To view form CMS-2728-U3 see HI 00801.902.
Item 1-14 should be completed in all cases, but non-completion of these items does
not preclude entitlement.
Items 15 a-d or 16 a-d must be completed if the claimant received a regular course
of dialysis. If 15d or 16d is marked “yes” , 15e or 16e, as appropriate, must be completed pre-adjudicatively.
Item 19-25 should be completed, as appropriate, if the claimant had a kidney transplant.
If early entitlement based on transplantation (HI 00801.221) is a factor, item 22 must be completed and the hospital must appear as an approved
facility on the current Renal Provider List.
Item 26 must be completed. If the question in the first block in unanswered or in
answered “no” and there is an entry in item 15a-c, 16a-c, or 19, develop for clarification through
the district office to resolve the discrepancy between the claimant’s allegation and
the information shown on the Form CMS-2728-U3. If the discrepancy is not resolved
by the development response, forward the case to the Office of Disability, Division
of Vocational Rehabilitation and Special Programs, Special Programs Branch, 3-M-25
Operations for possible referral to CMS, BERC, OEP, DMEP, Medicare Entitlement Branch,
349 EHR. If the signature of the physician is not shown, but a signature is shown
in item 32, follow the development and, if necessary, the referral procedure shown
immediately above. If no signature appears in either item 26 or item 32, redevelop
for a new Form CMS-2728-U3 through the FO. (Adjudication should not be precluded because
only the date signed is not completed.)
Items 27-32 must be completed if the claimant received self-care dialysis training
(see DI 45001.015F., below). If items 27-31 are completed but a signature is not entered in item 32,
redevelop for a signature post-adjudicatively if entitlement can be establish DI 45001.015 see DI 45001.015F.2., below).