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Basic (05-11)

DI 11052.020 Adjudication Considerations for Initial End-Stage Renal Disease Case Processing

A. Unable to process claim via Earnings Computation (EC) or A101

Whenever you do not process the claim via EC or A101, you must manually clear (MANCLR) the claim to close and lock the segment you have established in Modernized Claims System (MCS).

B. Equitable relief in initial ESRD Medicare cases

1. Premium arrearage

The Centers for Medicare & Medicaid Services (CMS) collects Supplementary Medical Insurance based on ESRD(R-SMI) premiums in the same manner as other SMI premiums.

R-SMI coverage ordinarily begins with the first month of hospital insurance based on ESRD (R-HI). If the beneficiary’s R-HI is retroactive, the R-SMI can also be retroactive causing difficulty in paying the retroactive R-SMI premiums. The equitable relief provisions apply to premium arrearage situations of six or more months of retroactive R-SMI coverage. The Social Security Administration (SSA) informs the beneficiary, or his or her responsible representative, when there appears to be a six or more month premium arrearage because he or she has an option of when the R-SMI begins. The beneficiary has the following options for the R-SMI effective date:

  • •

    first month of R-HI if the enrollee elects and is able to pay all the past-due premiums,

  • •

    the month of filing for R-HI/R-SMI, or

  • •

    the month of processing.

If any of the above situations apply, the equitable relief item on the HIHI screen in MCS must be “Y”.

If the file does not reflect a clear election for the R-SMI effective date when retroactive coverage applies, the SMI coverage is prospective (i.e., coverage begins with the month of processing) and the claimant is notified of his/her right to have earlier coverage.

SSA can amend the SMI award to give retroactive coverage if we receive a timely request and payment.

2. When equitable relief does not apply

Equitable relief does not apply in the following situations:

  • •

    premium-free HI;

  • •

    merely because of hardship or because of “good cause” for failure to enroll. There must be a Government error or inaction;

  • •

    the beneficiary refuses Part B, voluntarily withdraws, or is terminated for non-payment of premiums; or

  • •

    the beneficiary is enrolled in state buy-in or elects to pay the premium arrearage.

However, if the State buy-in agreement is effective with the first possible month of R-SMI entitlement and continues for all following months to the current operating month (COM), equitable relief is not an issue as the State pays the premiums.

References:

C. State buy-in agreement

Many ESRD beneficiaries are eligible for State buy-in because they are eligible for Medicaid as well as for Medicare. We process ESRD cases for State buy-in as any other Medicare case.

References:

  • •

    HI 00801.251, SMI Enrollment

  • •

    HI 00801.257, State Buy-In Considerations

  • •

    HI 00815.000, State Enrollment of Eligible Individuals

  • •

    SM 03040.040, State Buy-in on Initial Awards

D. Closed period of coverage cases

A closed period of coverage is appropriate if one or more of the following situations apply:

  • •

    a transplant occurred 33 months or more before adjudication, but not more than 48 months before the month the ESRD patient filed the application;

  • •

    cessation of regular dialysis occurred 10 months or more before adjudication, but not more than 24 months before the month the ESRD patient filed the application;

  • •

    the ESRD patient dies before we adjudicate the claim and establish entitlement.

In a closed period, take care to insure that you apply the proper policy regarding coverage. If there is an indication that we should establish a closed period of coverage, be certain that the claimant has not had a later transplant, or subsequently has not begun dialysis. Either of these latter situations indicates entitlement to a continuous period, or perhaps multiple periods of Medicare coverage. Separate SSA-892s (End-Stage Renal Disease (ESRD) Medicare Determination) are necessary for each of the multiple periods of coverage. Prepare and process these forms normally per HI 00801.308, Form SSA-892-U3 (End-Stage Renal Disease (ESRD) Medicare Determination.

Closed period of coverage cases are District Office Final Authorization (DOFA) exclusions. Route DOFA exclusions to the Office of Disability Operations (PC7) for final authorization via A101. Enter NON DOFA reason 2 on the DECI screen. In this case, complete items 1 through 18 of Form SSA-892. PC7 completes the remaining items when processing final authorization.

E. Diaries

The field office (FO) must prepare a diary whenever an ESRD claimant is on dialysis throughout the qualifying period but discontinues treatments and does not resume dialysis or receive a kidney transplant and cessation occurred less than 10 months before adjudication, prepare a diary for notification of termination. Prepare a diary to mature in PC7 for the first day of the 10th month from the month of cessation. Use diary code 41.

F. Remarks for SSA-3601 (Claims Routing Form)

When processing award or denial via A101 or EF101, ESRD claims require additional remarks. Consider the following remarks:

1. Mandatory remarks

  1. a. 

    Route to Benefit Authorizer for Processing - Priority Handling

  2. b. 

    “See SSA-5002 in file for notice.” On the SSA-5002, Report of Contact, request the necessary paragraphs or dictated language (MH-16 (if Medicare entitlement is based on transplant), or MH-17 (if Medicare entitlement is based on dialysis));

  3. c. 

    See CEF for documentation (if you have faxed anything into CEF)

2. Conditional remarks

Use the following remarks if they apply to the situation:

  1. a. 

    Annotate ESRD Medicare entitlement dates (if earlier than HI/ SMI currently on the MBR). Include the following information:

    • •

      The remark “ESRD CLAIMANT” Establish on SSN/BIC

    • •

      R-HI - (coverage start date)

    • •

      R-SMI - (coverage start date), if the claimant elects SMI, or “R-SMI – Refused”

    • •

      The date dialysis began or the transplant date (including the date of hospitalization in preparation for transplant), whichever results in the earlier entitlement;

    • •

      “See SSA-5002 for Buy-in effective date” if buy-in applies;

    • •

      If beneficiary's SMI premium is higher than base SMI rate, include the remark “ADJUST SMI PREMIUM TO BASE RATE EFF  (MOE TO SMI based on ESRD)”

    • •

      If R-SMI is elected but aged SMI or D-SMI was previously refused, withdrawn, or terminated for premium non-pay - Include the remark “CONCURRENT SMI – PROCESS PER SM 00850.600”

  2. b. 

    If you are sending an age 22-26 claim to ODO that required a disability determination by the Disability Determination Services (DDS), include the following information:

    • •

      Non-DOFA – Manual Award Action Required

    • •

      TOEL “CLAIM ESRDINT”

    • •

      Uninsured ESRD claimant AGE 26 OR OVER; BIC T (or BIC TC)

    • •

      Filing for ESRD based on insured status of mother / father SSN XXX-XX-XXXX

    • •

      See disability documents attached. Determination of disability prior to age 22 completed by the DDS.

References:

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0411052020
DI 11052.020 - Adjudication Considerations for Initial End-Stage Renal Disease Case Processing - 05/31/2011
Batch run: 12/18/2024
Rev:05/31/2011