If the dates of dialysis, early transplant procedures, transplant, or self-dialysis
training given by the patient on the CMS-43/MCS application differ from those on the
CMS-2728-U3 completed by the facility and could affect the date of R-HI entitlement, resolve discrepancies by contacting the
patient and/or facility, as appropriate. If the dates shown on the CMS-2728-U3 are
found to be correct, document the file with a Report of Contact and process the claim.
If the date(s) on the CMS-2728-U3 are incorrect or missing, make a photocopy of the
CMS-2728-U3 for the file and return the original blue copy to the facility for correction.
Follow up in two weeks, if the corrected copy has not been received.
If a response is still not received, and there is no question that treatment was received
at least as early as the date(s) documented on the existing CMS-2728-U3, and these
dates(s) permit immediate entitlement, establish R-HI entitlement based on the available
If the corrected CMS-2728-U3 is received after adjudication, forward it to ODO, 1500
Woodlawn Drive, Baltimore, MD 21241.