TN 4 (10-08)

DI 81010.144 Processing End Stage Renal Disease (ESRD) Cases

A. ESRD Claim

When a claimant contacts the Field Office (FO) about filing for ESRD benefits, or the FO receives Form CMS-2728-U3 End Stage Renal Disease Medical Evidence Report, the Claims Representative (CR) determines whether:

  • The case is ESRD only,

  • There is an existing CEF, or

  • The Number Holder is filing concurrently for disability benefits (Title II and/or Title XVI) for which a CEF will be established in addition to the ESRD claim.

B. ESRD — only case (No CEF exists)

Stand-alone claims for ESRD benefits are exclusions to Electronic Disability Collect System (EDCS) processing because they are claims for Medicare only, not disability benefits. Process ESRD-only cases according to current procedures found in HI 00801.300 District Office Final Authorization (DOFA) of ESRD Medicare Awards and Disallowances.

See DI 11052.035B for handling the paper claim and documentation when there is no CEF .

C. ESRD claim and existing CEF case

If there is an existing CEF (pending or closed), the CR verifies ESRD entitlement and processes the claim according to current procedures. Additionally, the CR:

  • Completes the End Stage Renal Disease (ESRD) Medicare Determination Form SSA-892-U2 per HI 00801.308 Preparing the SSA-892-U2;

  • Creates a barcode coversheet for Form SSA-892-U2 using document type code 0113 – ESRD Medicare Determination;

  • Creates a barcode coversheet for Form CMS-2728-U3 using document type code 0114 – ESRD Medical Evidence Report;

  • Faxes both the SSA-892-U2 and the CMS-2728-U3 into the CEF using the barcode coversheets per DI 81010.090 Faxing Documents into the Certified Electronic Folder (CEF) Using Barcodes;

  • If ODO action is needed fax form SSA-3601 Claims Routing Form to PC7 via the Paperless Processing Center (PPC) system using Fax number (877) 385-0643; and

    NOTE: This alerts ODO that there is an issue pending. The faxed Form SSA-3601 should display the proper TOEL – “CLAIM ESRDINT” and a remark – “Manual Action Required. See SSA-892 in Section A and CMS-2728 in Section F of eView”.

  • Inputs the adjudicative decision and PC-7 jurisdiction on the Decision Input (DECI) screen.

NOTE: Use Non-EC Clearance when transferring the MCS segment to PC-7 for manual processing of the ESRD award.

In some cases, a CEF exists for a claimant in a terminated status (e.g., LAF – T8, or X7). If the ESRD award action can be processed to completion (LAF change to “U”) by the Field Office via MCS EC, skip the 5th and 6th bullets as shown in DI 81010.144C. above, as this requires no ODO MACADE action.

D. Concurrent ESRD with Title II and/or Title XVI claim

If taking an ESRD claim concurrently with a Title II and/or Title XVI claim, the CR:

  • Establishes the disability claim(s) in Modernized Claims System (MCS) and/or Modernized SSI Claims System (MSSICS);

  • Establishes the Title II and/or Title XVI case in EDCS;

  • Transfers the MCS and/or MSSICS, and EDCS disability claim(s) for medical determination;

  • Verifies ESRD entitlement and processes the claim according to current procedures; and

  • Follows the additional steps outlined in DI 81010.144C. above to store the documents in the CEF.

REMINDER: Process the ESRD award via MCS-EC after securing all requirements and evidence. Do not delay the ESRD award action pending DDS determination of the disability claim.

NOTE: Do NOT create and send a paper folder to ODO if you can input the ESRD documents to a CEF.

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DI 81010.144 - Processing End Stage Renal Disease (ESRD) Cases - 04/17/2015
Batch run: 11/07/2023