DI 45001.065 Processing ESRD Medicare Disallowances

SM 00380.001 should be reviewed for MADCAP processing (SSA-3428-U2). The disallowance notice is shown in DI 45001.076 and it must be manually prepared. Also see DI 45010.050 for diary action and folder maintenance. Procedures for review of DOFA disallowances are shown in DI 45001.005.

Be alert to an ESRD denial of a claimant age 65 or older who does not have age 65 HI/SMI. Regardless of the claimant's insured status, if there is no indication that the FO is developing either HI or SMI based on age 65, notify the FO (and send them a copy of the HCFA-43 and the SSA-831-U5) that protective filing exists for claimant. Tell them if it has not been done, the claimant should be given an explanation of and an opportunity to file for age 65 (premium if uninsured) HI and/or SMI if he or she meets all of the eligibility requirements.