Saved But Not Submitted 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.

2728 DUE DATE – must be submitted within 45 days of admission

The form has been started in CROWNWeb but not completed for one or more of the following reasons:

• The user completed the form but forgot to click “Submit”. RESOLUTION – click on “Submit”.
• The user found unresolved submission errors that must be addressed. RESOLUTION – resolve the error messages and Submit.
• The user started, but forgot about the form. RESOLUTION – finish the form and Submit.
• The user found that the patient was an acute patient, so no form is required. RESOLUTION– Delete the saved 2728 and discharge the patient with a discharge reason of “ACUTE”. Be sure your medical record system has the same change or it will overwrite CROWNWeb on the next batch submission upload and cause you to get a Missing Form email next month.
• The user started the form, but cannot get a patient signature because the patient moved or has died. RESOLUTION – If the patient died before signing, we recommend that you use the same signature data as the physician in box 50, and note in the Remarks in box 53 “Patient died before signing”. If you see in CROWNWeb that the patient has moved to another clinic, then fax the form to them for the patient’s signature, and when you receive it back, enter that date into CROWNWeb.

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.

 

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.

2746 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.