DI 45005: Processing Reconsideration, Hearings, and Appeals Medicare ESRD Cases
Requests for reconsideration of entitlement issues will all be handled by reconsideration examiners in the appropriate ODO Modular Processing Group. The basic interpretations of ESRD policies and provisions are provided in HI 00801.186 through HI 00801.325 and HI 00820.030. Adjudicative and processing instructions for ODO earnings reviewers are shown in the chapters DI 45001.001 through DI 45001.210 and DI 45010.001 through DI 45010.050. Except as shown in A. below, the reconsideration examiner is responsible for all aspects of the determination, although advice and/or nonmedical decisions and forms preparation may be obtained as required from authorizers, earnings reviewers, etc.
A. Referral of certain ESRD reconsideration cases to CMS
Cases which require review of unclear or irreconcilable conflicts in the medical information (i.e., neither clearcut affirmations nor reversals of medical denials or cessations) will be forwarded via SSA-559 to CMS, BPP, OEP, DMEP, Medicare Entitlement Branch, Room 349 East High Rise without development. On the transmittal, show “ESRD Reconsideration Claim.” Cite the issue and/or evidence which makes the case other than a clearcut denial or cessation or other than a clearcut reversal of such. Place a self-addressed SSA-559 under the SSA-559 to CMS. On the second SSA-559, indicate that the folder should be returned to your office. An acknowledgement of receipt of the reconsideration request must be sent to the requester for cases referred to CMS. If the requester is a third party, send a copy of the acknowledgement letter to the claimant or beneficiary. Send cases to CMS via OD, SPB, 3-M-25 Operations Building.
After review, CMS may on its own secure medical clarification or return the claim and indicate what, if any, additional medical development is needed. CMS will also indicate the proper course of action and necessary language for the notification to the claimant.
B. Completion of determination
1. Prior ESRD denials
If it is now determined that the initial ESRD denial determination should be reversed to an allowance, complete an SSA-892-U3, and SSA-101-U3 or SSA-559 (see DI 45001.030). If the reversal is based on a transplant in other than a closed period situation, also prepare a Form SSA-1598. As appropriate, select (and modify for reconsideration decision purposes) a notice from DI 45001.077 through DI 45001.098. If the denial should be affirmed, complete the SSA-892-U3 and send notice to the claimant as described in DI 45005.900. Appropriate fill-in language explaining the evidence and the reasons why the ESRD claim was denied should be included.
2. Prior cessations
If it is determined that the cessation should be revised to a continuance, prepare an SSA-892-U3 as described in DI 45010.025. See HI 00805.240H. for equitable relief procedures, if six or more months premiums are due based on the cessation reversal. Route the folder to a benefit authorizer, to reinstate the Medicare annotation on the MBR. If the cessation action is affirmed, prepare a new SSA-892-U3, send a notice, as described in DI 45001.098 through DI 45001.099 and provide the appropriate modifications for reconsideration and fill-in language explaining the evidence and reasons for affirmation of the cessation, along with the hearing paragraph.