505
San Marin Dr. Bldg. A, Suite 300, Novato, CA 94945
Phone: 415-897-2400
Administration Fax: 415-897-2422
Data Fax: 415-897-2443
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on Forms CompliancePatient totals by County (Xcel - from 2006 Annual Report)
Medical Evidence Report (2728 Form)
The 2728 is required for all first-time chronic dialysis patients; required for all patients initially receiving kidney transplant instead of dialysis; required for patients who stopped dialysis for more than 12 months, or for patients who a had functioning transplant for over 3 years but are now returning to dialysis or are receiving another transplant.
The green copy should be submitted to Network #17 within 45 days of patient's first course of "regular dialysis" at the chronic facility, or 45 days after patient receives a transplant. In some cases the 2728 is completed by an acute care hospital that also does chronic dialysis treatment. HOWEVER, it is the ultimate responsibility of the chronic outpatient dialysis facility to ensure that such a form has been completed and mailed to Network #17. The blue copy goes to Social Security.
Revised 2728
At this time ONLY the newest version of the 2728 (dated EF 03/2005 at the bottom of form) will be accepted by Network #17. If you run out of these new forms you may get more from your local Social Security office. In the meantime, you may use this online 2728 (pdf 4 pgs) - but be sure to have the doctor sign this electronically-generated form in BLUE INK. Send the original form with the signatures in blue ink to Social Security.
2005 Algorithm for GFR (pdf - 1 pg) - This summarizes the CMS criteria to determine eligibility for the ESRD program and should be used when determining the chronic status of a patient. The GFR value does not need to go on the 2728 form, but should be calculated to ensure that 2728 forms are submitted only for truly chronic patients.
Below are additional resources regarding the basis for the MDRD formula and how to calculate a GFR using this formula:
www.nkdep.nih.gov/GFR-cal.htm
www.hdcn.com/calcf/gfr.htm
http://nephron.com/mdrd/default.html
www.kidney.org (K/DOQI Clinical Practice Guideline Tab) - Has downloadable GFR calculator and CKD Clinical Action PlanDeath Notification Form (2746)
Death Notification Form (CMS Form 2746) (pdf - 2 pgs) - You may download and use this form --and remember there is no need to send more than one copy of a 2746 to Network #17, and you do NOT need to send the second sheet (codes).
The 2746 should be submitted within 30 days of death by last facility responsible for permanent chronic dialysis. If patient has discontinued dialysis and dies within 30 days, the last chronic dialysis facility is still required to submit a 2746. If patient's last event was a transplant, the transplant clinic is responsible for submitting 2746.
Network Patient Activity Report (NPAR)
This NPAR was revised in June of 2005.
All NPARs should be faxed to Network #17 by the 10th day of the month. NEVER email NPARs (or any other patient information). The following NPAR documents will be available soon to downloaded if you need extra copies:
Guidelines to follow when completing the NPAR:
Top Portion of the Report
- Enter your facility's Provider Number (the Medicare number assigned to you by CMS), your Provider Name (the name of your facility), the Reporting Month (the month in which activities occurred), and your facility's telephone number.
- Be sure to print your name on the form so we know who to contact if we have questions.
- You do not need to do anything with the "Activity Summary" section.
Reporting Activities
- Enter the patient's Last Name and First Name, Social Security Number, Date of Birth, Gender, and ZIP Code.
- Enter the date of the activity you are reporting.
- Record the specific type of event under the appropriate category for additions, losses, or neutral events. Note: We have added 5B - "Transfer Out for Transplant outside of US"
- If the event is an addition or modality change, be sure to include what type of treatment (Modality) you are providing.
- If you are reporting a Transfer In or Transfer Out, enter the provider number, name, or city and state (or country) of the facility from which the patient has come or to which he/she is going.
- Remember that neutral events (numbers 11, 15, and 16) do not change your facility's overall population.
Transplant Activity Report (TAR)Each transplant facility in Network #17 needs to turn in a TAR every month to report all kidney transplants that have taken place. The TAR should be faxed to 415-897-2443 and is due by the 10th of the month. The TAR should NEVER be emailed.
- TAR - in Microsoft Word so that you may save it and type directly onto the form or make a copy to write on.
- You may generate a report out of your own data system as long as it contains the required elements on the TAR form.
Please call if you need more information about doing this.
Network #17 Reports That are Sent to Dialysis Facilities
Compliance Reports - (aka: Timeliness and Accuracy Reports) CMS mandates that 90% of required forms (2746s and 2728s) are submitted on time and complete. This report shows the percentage of forms received that meet this standard. Report is sent to facilities semiannually and is reviewed by CMS to determine if sanctions against facilities are warranted.
Missing Forms Report - 2746 missing forms report is sent monthly at first of month. The 2728 missing forms report is sent monthly about 15th of month. Forms may appear on a report for two months; after that a letter requesting the form is sent to unit administrator.
Quarterly Roster - Alphabetical list of patients the Network shows to be currently dialyzing at a facility (grouped by modality.) Sent out quarterly, the roster needs to be reviewed by the facility and returned with a list of any additions, losses, or modality changes.
CMS Data Element Reconciliation Report: Sent when there is a discrepancy between patient data at the Network and at CMS. The date elements include first name, last name, birth date, Social Security number. The report must be returned within five working days.
Frequently Asked Questions
Q: The State Survey Agency has assigned our unit a provider number with "23" as the middle number, but Network #17 is telling us not to use this number. Why?
A: CMS has issued this letter confirming the policy requiring hospital-based units to use their hospital provider number with 00-08 in the middle rather than the "23" in all correspondence with the ESRD Networks or CMS.Q: What happens if a patient enters a long-term care center (i.e. VENCOR) or a hospital?
A: That event is now considered an "Interruption in Service" and may be reported via the Network Patient Activity Report. That patient is still considered a part of the population, and any status change (death, recover function, transfer to chronic facility) needs to be reported via the NPAR.Q: Where do facilities obtain blank 2728 and 2746 forms?
A: Local Social Security offices have blank 2728 forms. The Network has blank 2746 forms, or, better yet, you may download the 2746 form here.Q: Do facilities need to attach copies of death certificates to 2746 forms?
A: No.Q. Can facilities fax forms?
A: Yes. If you fax both forms. If you fax, do not mail a copy of the same form.
505 San Marin Dr. Bldg. A, Suite 300, Novato, CA 94945
Phone: 415-897-2400
Administration Fax: 415-897-2422
Data Fax: 415-897-2443