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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Network Patient Activity Report CMS Form 2728 CROWNWeb Network Reports CMS Form 2746 GFR Calculators Transplant Activity Report CMS Form 2744 FAQ Authorization to Release Medical Evidence Form 2728
Network Patient Activity Report (NPAR)
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.
Medical Evidence Report (2728 Form)
Medical Evidence Report (CMS Form 2728) (pdf - 6 pgs) - You may download and use this electronic version of the 2728 but Social Security Offices prefer the doctor and patient sign this electronically-generated 2728 in BLUE INK.When Is A 2728 Required?
- When a patient is diagnosed as ESRD and receives their first transplant or outpatient, chronic dialysis treatment
- "Initial" should be checked at top of 2728
- When an initial 2728 form has been previously submitted and the patient:
- Transitions to any type of home dialysis within the first 3 months after initial dialysis
- Has a transplant within the first 3 months after initial dialysis
- "Supplemental" should be checked at top of the 2728 for these patients
- When a patient resumes treatment after benefits have expired; that is, when the patient:
- Restarts dialysis after 1 year or more of having recovered function or discontinued dialysis
- Restarts dialysis after 3 years or more following a transplant
- Has another transplant, 3 years or more following a transplant, with no dialysis in between
- "Re-entitlement" should be checked at top of 2728
How Much Time do we Have to Complete the 2728?
- Network #17 MUST receive the 2728 within 45 days of the patient's starting treatment at your facility (#25 on the 2728.) It is acceptable to FAX the 2728 to the NW 17 Data Fax at 415-897-2443.
Where Can I Get Blank 2728 Forms?
- Obtain more 2728s from your local Social Security office or use this online 2728 (pdf 6 pgs) - but be sure to have the doctor and patient sign this electronically-generated form in BLUE INK. The original signed form goes to Social security and either fax or mail a copy to the Network.
Errors on Paper 2728 Forms Sent to Facilities
- In August 2010 CMS began shipping a supply of blank 2728 and 2746 forms to all ESRD facilities. Unfortunately, the shipped 2728 forms contain errors in two sections.
- The first errors are in boxes 22 and 23. Box 22, which lists dialysis “settings”, contains a second line, "CAPD, CCPD, and Other" that really should appear in box 23 as choices for dialysis “types”.
- Similar errors have been made in boxes 24 and 25. Specifically, the text which should be the second line of box 25 "Dialysis at Current Facility" instead appears in box 24.
- At the present time we do not know if or when CMS will correct these errors. We recommend that you use any correct paper forms you have on hand, and then make copies of this good form (or use this online 2728) until/unless CMS sends correct paper forms. Be sure to have the doctor and patient sign any photocopied versions of the 2728 in BLUE INK. The signed form showing the blue ink goes to Social security and you may fax a copy to the Network.
Race and Ethnicity on the 2728
- Both race and ethnicity must be "self-reported" by patient or patient's family when completing the 2728. If patient is unable to communicate this to the facility, then the staff person completing the form may enter race and ethnicity, but must indicate that they did this in the comments section of the 2728.
GFR Calculators
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 Plan
Death 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.
2010 2744 (Year-End Survey)
Every facility has now turned in a completed 2744 to Network #17. Copies of the 2744 should be kept on file at your facility for State Health Agencies to review.
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. You may fax both 2728 and 2746 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