Missing Forms

CMS Form 2728 – Entitlement Form

Background: This form is not just to get Medicare benefits for the patient. It has a dual use for listing the patient in the ESRD Patient Registry (via CROWNWeb) even if they are private pay and specifically not signing up for Medicare ESRD benefits at this time.

DUE DATE – must be submitted within 45 days of admission

CROWNWeb is programmed to look for a 2728 form under the following reasons:

• A “New ESRD” admission reason exists, but no 2728 form has been generated.
• A Supplemental 2728 form will show missing when a treatment record has been created in the Admit/Discharge section of CROWNWeb that shows self-care training dates for PD or Hemo within the first 90 days of admission.  Note: this will waive the 90 day waiting period for Medicare benefits if the patient is doing self-care once completed.
• A Re-entitlement 2728 form will show missing if a patient previously had a discharge reason of “Recovered Function”  and was later admitted as a “Restart” after their initial benefits period had ended.
• A Re-entitlement 2728 form will show missing if a transplant occurs after the first 36 months of dialysis benefits. This generally only applies to missing forms due from a transplant unit.

If for some reason it is physically impossible to create the form such as an undocumented patient returning to his/her home country, or the patient has gone missing for an extended period of time, then please note that on the spreadsheet report that came with the Missing Forms email and send it back to the Network so that we can suppress it from future reports. Otherwise you will keep getting the patient emailed to you each month.

Occasionally the CROWNWeb reports will show that a Re-entitlement or Supplemental 2728 is due, but the 2728 link on the Patient Attributes screen says “No Form 2728 is required for this patient” , then please note that on the monthly emailed spreadsheet and return to the Network. We will suppress it from future emails.

CMS Form 2746 – Death Notification

The 2746 is fairly straightforward. Enter the cause of death. If you do not know the cause of death, enter code 99 in box 12a. For questions 14-16 if you do not know, then answer “Unknown” or “Not Applicable”.

If the patient died within 30 days of discharge, your unit is responsible to complete the 2746.  If the patient died greater than 30 days after discharge, then note on the email spreadsheet and send it back to the Network so that we can suppress it from future reports.

If the patient died within 30 days of discharge, your unit is responsible to complete the 2746. If the patient died greater than 30 days after discharge, then note on the email spreadsheet and send it back to the Network so that we can suppress it from future reports.

DUE DATE – must be submitted within 14 days of date of death. If the patient died greater than 30 days after the discharge date in CROWNWeb, then you do NOT need to complete a 2746 form.