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CMS 2728 - Medical Evidence Report Form
CMS 2746 - Death Notification Form
Patient Activity Report
Reject Report
Missing Forms Report
Network Definitions
CMS 2728 - Medical Evidence Report Form
Q. Do the lab values on the Medical Evidence Report (CMS 2728) have to be within 45 days before the Date Regular Dialysis Began (Section B, Item #23)?
A. Yes, the lab values MUST be within 45 days BEFORE the Date Regular Dialysis Began.
Q. If a patient is not applying for Medicare benefits at the time the 2728 is completed do I still send the form to the local Social Security office?
A. No, however; keep a copy in the patient's file so that when he/she applies you can send that form to the Social Security office.
Q. There are three colored copies of the 2728. Which colored form goes to the Network?
A. The green form goes to the Network, the blue form goes to Social Security, and the white form should stay with the patient's records on file at the facility.
Q. How long does the Network keep 2728s on file?
A. Copies of 2728 forms are maintained at the Network office for two years after receipt. After this time, forms are shredded.
Q. Can I request a 2728 from the Network for a patient who has transferred into my facility?
A. No, the Network is only authorized to send a copy of a 2728 form to the patient or to the facility that completed the form.
Q. Do I have to complete a 2728 if a patient returns to dialysis after transplant failure?
A. A facility only needs to fill out another 2728 if a patient returns to dialysis after transplant failure when the transplant functioned for 36 months (3 years) or more.
Q. Do I complete a 2728 for all my first starts at my dialysis facility?
A. You should complete 2728 forms for chronic ESRD patients only.
Q. What do I do if a patient cannot sign the 2728?
A. A patient signature is required on all 2728 forms. If the patient is unable to sign, a family member or someone authorized to act on the patient's behalf should be asked to sign.
Q. On the 2728, Item #2 asks for Health Insurance Claim Number. If a patient does NOT have Medicare, should I list other insurance numbers here?
A. Only list a Medicare number in this field. If the patient does not have Medicare then you can leave this field blank. Please note : If you write that the patient has Medicare (field #10 on the 2728), you must report the patient's Medicare number in field #2 of the 2728.
CMS 2746 - Death Notification Form
Q. If a patient from an outpatient dialysis center is hospitalized and dies while in the hospital, who is responsible for completing the CMS 2746 form?
A. It is the facility's responsibility to complete the 2746. However, if the death is more than 30 days from the last treatment AND occurs while the patient received treatment at a non-Medicare provider, it is considered a CMS death and the facility does not need to complete the 2746.
Q. If the patient did not have a Health Insurance Claim Number (HIC), do I leave the field blank on the 2746?
A. No, if a patient does not have a HIC number, then write/type the patient's Social Security Number in that field.
Patient Activity Report
Q. What chronic start date do I use for a patient starting dialysis for the first time ever on the Patient Activity Report?
A. Use the date the patient started chronic dialysis at your facility (#24 on the 2728 form).
Q. What if I have made a mistake or omitted something on the Patient Activity Report?
A. Add the omission or note the correction on the next month's report. It is not necessary to send us immediate notification of an error.
Q. If a patient has been gone from my facility for more than 30 days and dies under the care of a non-Medicare provider, is my facility responsible for filling out the 2746 form?
A. No. If patient has been gone for more than 30 days from a Medicare facility, then dies while under the care of a non-Medicare provider, this event is classified as a CMS death. With CMS death events, the prior Medicare facility is NOT responsible for completion of the 2746 Death Notification. However, we understand that some facilities may want to continue to track deaths of patients previously under their care. In May 2004, Network 5 began notifying facilities via fax of CMS death events. This is provided as a courtesy. No action is required by CMS for these events.
Q. What's the difference between an Interruption in Service event and a Transfer Out event?
A. An Interruption in Service is used only if patient is receiving planned, temporary dialysis at a non-Medicare provider (rehab centers or acute care centers). If a patient receives dialysis at a Medicare facility and he/she has been gone for more than 30 days, then this would become a Transfer Out.
Reject Report
Q. What needs to be returned to the Network office?
A. All corrections should be made directly on the Reject Report and the report (or a copy) should either be faxed or mailed back to the Network office by the due date on the report.
Missing Forms Report
Q. What needs to be done with this report?
Network DefinitionsA. This report lists patients for whom the Network has not received the proper forms. This report is based on the Patient Activity Reports and UNOS reports. This report allows the Network to notify facilities of what specific information is needed. Updated forms should be mailed to the Network office. If one has already been completed, it should then be forwarded to the Network office.
Q. What is the definition of a transient patient?
A. The Network operational definition for transient is a chronic patient who dialyzes at a facility for less than thirty days.
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