Check the appropriate box for type of claim or action.
-
a.
Check “A” (Initial) if:
-
•
it is an initial ESRD Medicare claim (allowance or denial), or
-
•
it is a new ESRD Medicare claim after a prior period of coverage terminated (see d.
below).
-
b.
Check “B” (Recon) for a reconsideration request of an initial determination.
-
c.
Check “C” (Continuing) if the action is based on an alert.
-
d.
Check “D” (Other) if:
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•
the action is based on an appeal higher than a reconsideration, or
-
•
the action is a reopening at any level, or
-
•
the action is a subsequent period of entitlement processed at the same time as cessation;
or
-
•
the action is taken to revise a prior determination, to establish either an earlier
date of entitlement, to affirm a prior determination, etc.
If “D” is checked, write the type of action to the right of block D (e.g., Affirmation,
Reversal, etc.). Show more than one type of action, (e.g., an ALJ Reversal) if necessary.
Check more than one block in item 19 if necessary, e.g., if bullet 3 above applies,
check blocks A. and D. Also, specify “term/ent. same month.”