Completing the CMS-2728 Form

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1 Completing the CMS-2728 Form Goal: Learn to complete a CMS-2728 Form for new ESRD patients in CROWNWeb. Estimated Time: 25 to 35 minutes PDF: Download a screen reader compatible version of this presentation

2 Table of Contents Click any section below to view that section, or click the Next arrow. Getting Started Course Goals Before You Begin FAQs Frequently Asked Questions on Completing the CMS-2728 Form Tutorial What Is a CMS-2728 Form? When Is Each Form Type Required? Accessing the CMS-2728 Section A, Parts 1-4 Sections B - F Save the CMS-2728 Delete the CMS-2728 Print the CMS-2728 Obtain Signatures Submit the CMS-2728 Supplemental and Re-Entitlement CMS-2728s Troubleshooting Summary How To Use This Tutorial Demonstration Access the demonstration for Completing the CMS-2728 Form Quiz Access the quiz on Completing the CMS-2728 Form More Info Quick Start Guides CROWNWeb Online Help Field-by-Field Descriptions

3 How to Use This Tutorial Getting Started Tutorial FAQs Demonstration Quiz More Info Click any section below to view that section, or click the Next arrow. Navigation HOME Description HOME Icon: Jump to Table of Contents Menu Bar: Click on any text to jump to that section Next Slide: Click to advance to next slide in tutorial Previous Slide: Click to return to last slide in tutorial Buttons: Click to perform an action in tutorial Red Highlights: Call out clickable action items in the tutorial Blue Highlights: Provide information on items in the tutorial Return to Tutorial

4 Getting Started Course Goals By completing this course, you will be able to: Complete an initial CMS-2728 Form for a new or existing patient. Print a copy of the CMS-2728 Form for required signatures, and submit the original copy to your Social Security Administration s office. Understand what the CMS-2728 Supplemental and Re-entitlement forms are and when they may be required.

5 Getting Started Before You Begin Before you can complete this procedure, the following conditions must be met: You must admit the patient to your facility in CROWNWeb. You must complete the Patient Mailing Address, Zip Code, City, Ethnicity, Race, and Employment Status fields in addition to the required attributes entered on the Patient Attributes screen. Let s get started!

6 What Is a CMS-2728 Form? The CMS-2728 Form is required by CMS for patient entitlement to Medicare benefits based on End Stage Renal Disease (ESRD). There are three types of CMS-2728 Forms:

7 When Is Each Form Type Required? Required for all new ESRD patients. Required when an Initial CMS-2728 has been previously submitted and: A patient transitions to self-care dialysis within the first three months of initial dialysis; -or- A patient has a transplant within the first three months of initial dialysis. Required when a patient resumes treatment after Medicare benefits have terminated. Patient restarts dialysis after one year or more of having recovered function or discontinued dialysis; -or- Patient restarts dialysis after three years or more following a transplant; -or- Patient has another transplant, three years or more following a transplant, with no dialysis in between.

8 Accessing the CMS-2728 Form The following interactive tutorial will guide you through accessing the CMS-2728 Form in CROWNWeb. View Tutorial Click View Tutorial to begin.

9 After you access the CMS-2728 Form, you ll need to begin to add the required information for your patient.

10 Warning Messages If you have not filled in some of the information on the patient attributes screen that will be required for the CMS-2728 Form, warning messages will display after clicking Add 2728.

11 Warning Messages You can click the checkbox to ignore the warnings, but this information will be required to submit the CMS-2728.

12 Warning Messages (CONT.) It is recommended that you go back to the patient s attributes (click on the View Patient Attributes hyperlink), enter the required data, then come back to complete the 2728 Form in CROWNWeb.

13 Section A Part 1 In Section A - Part 1 (Complete for All ESRD Patients), required values are: Form Type Patient Name Date of Birth Mailing Address The following interactive tutorial has more information on each of the form s fields. Click View Tutorial to begin. Ethnicity Patient s Sex Race View Tutorial Medicare Claim Number / Beneficiary Identifier

14 Section A Part 2 In Section A Part 2 (Complete for All ESRD Patients), required values are: Current Medical Coverage Height Dry Weight Primary Cause of Renal Failure View Tutorial The following interactive tutorial has more information on each of the form s fields. Click View Tutorial to begin.

15 Section A Part 3 In Section A - Part 3 (Complete for All ESRD Patients), required values are: Employment Status Co-Morbid Conditions View Tutorial The following interactive tutorial has more information on each of the form s fields. Click View Tutorial to begin.

16 Section A Part 4 In Section A - Part 4 (Complete for All ESRD Patients), required values are: Prior to ESRD Therapy Information Serum Creatinine Measurement The following interactive tutorial has more information on each of the form s fields. View Tutorial Click View Tutorial to begin.

17 Out-of-Range Labs If any of the labs on the CMS-2728 Form are outside of the valid range, you will get a warning message with a checkbox when submitting the If the lab value is correct, click the checkbox to ignore the warning, and you will be able to submit the CMS-2728 Form.

18 Section B In Section B (Complete for All ESRD Patients in Dialysis Treatment), all fields are required to have entries. View Tutorial The following interactive tutorial has more information on each of the form s fields. Click View Tutorial to begin.

19 Section C In Section C (Complete for All Kidney Transplant Patients), all fields are required to have entries if the patient is a Transplant patient. View Tutorial The following interactive tutorial has more information on each of the form s fields. Click View Tutorial to begin.

20 Section D In Section D (Complete for All ESRD Self-Dialysis Training Patients [Medicare Applicants Only]), all fields are required to have entries. Section D is completed for a Supplemental CMS-2728, and this is covered in the Supplemental CMS-2728 section of this tutorial.

21 Section E In Section E (Physician Identification), all fields are required to have entries. The following interactive tutorial has more information on each of the form s fields. View Tutorial Click View Tutorial to begin.

22 Section F In Section F (Obtain Signature From Patient), all fields are required to have entries. The following interactive tutorial has more information on each of the form s fields. View Tutorial Click View Tutorial to begin.

23 Save the CMS-2728 If all required fields have not been completed, you can save your work for completion later by clicking Save.

24 Save the CMS-2728 (CONT.) The View an ESRD Medical Evidence (2728) Saved screen displays. You can modify a CMS-2728 Form that is Saved.

25 Print, Obtain Signatures, and Submit a CMS-2728 Form The following interactive tutorial will help explain how to print, obtain signatures, and submit a CMS-2728 Form. View Tutorial Click View Tutorial to begin.

26 When a Patient Cannot Sign the 2728 Form What should be done if the patient is not able to sign the CMS-2728 (e.g., the patient is incapacitated or has expired)? For patients that are incapacitated, have a family member, guardian, or power of attorney sign the form for the patient. For patients that have expired, go into the patient s attributes and enter the Date of Death and Primary Cause of Death. That will remove the mandatory mark for the patient s signature on the CMS-2728 form in CROWNWeb. Enter remarks in the Remarks field as to why the patient was not able to sign, and the form can be submitted.

27 Supplemental and Re-entitlement CMS-2728s What are they, and how do you use them in CROWNWeb? The steps to complete the Supplemental and Re-entitlement CMS-2728 Forms are essentially identical to an Initial CMS However, the circumstances that require their completion are dependent on the patient s course of treatment. These variances are explained on the next few slides.

28 Supplemental CMS-2728 A Supplemental CMS-2728 is required when: An initial CMS-2728 has been previously submitted in CROWNWeb -and- A patient transitions to self-care dialysis; -or- A patient has a transplant within the first three months after initial dialysis.

29 Supplemental CMS-2728 (CONT.) Navigate to the Manage 2728 Forms screen. When a supplemental 2728 is required, CROWNWeb displays an additional Add 2728 button. Click Add The Add an ESRD Medical Evidence (2728) screen displays.

30 Supplemental CMS-2728, Section D The Supplemental CMS-2728 will be grayed out in the areas that are not affected by the change in modality. View Tutorial Complete Section D for Training (Change in Modality), then click Submit. The following interactive tutorial has more information on each of the form s fields. Click View Tutorial to begin.

31 Re-entitlement CMS-2728 Form CROWNWeb triggers the Re-entitlement CMS-2728 when a patient resumes treatment after Medicare benefits have terminated. Complete the admission process for the patient and proceed to the View Patient Attributes screen; click 2728 in the menu. The Manage 2728 Forms screen displays.

32 Re-entitlement CMS-2728 (CONT.) CROWNWeb displays an additional Add 2728 button when a re-entitlement is required. Click Add 2728.

33 Re-entitlement CMS-2728 (CONT.) The Add an ESRD Medical Evidence (2728) screen displays. Continue adding data to the Re-entitlement 2728 the same as an Initial 2728 Form.

34 Re-entitlement CMS-2728 (CONT.) Supplemental and Re-entitlement CMS-2728s must also be signed and submitted to the Social Security Administration.

35 Delete a Saved CMS-2728 If you need to delete a CMS-2728 Form, you can only do so if it s in a saved status. The following interactive tutorial will help explain how to delete a saved CMS-2728 Form. View Tutorial Click View Tutorial to begin.

36 Delete a Submitted CMS-2728 What do you do if you discover a patient s social security number is wrong, their name not correct, or the wrong reason for the ESRD diagnosis was listed, and the CMS-2728 has been submitted? Once you submit the CMS-2728 and send the signed hardcopy to the Social Security Administration, it can only be deleted in CROWNWeb by calling the QualityNet Help Desk. The Help Desk confirms the deletion with CMS. The facility would submit a new CMS-2728 in CROWNWeb and forward to the Social Security Administration a new, signed hardcopy. Older CMS-2728 Forms cannot be deleted by the Help Desk; only forms that are more recent can be deleted.

37 Troubleshooting If you re having difficulty completing the CMS-2728 Form, the following tips might help you out: Ensure that the mandatory fields are completed on the Patient Attributes screen before creating a CMS This prevents having to navigate back and forth between the screens. A patient must be admitted as New ESRD Patient in order to add the Initial CMS-2728 Form. The Initial 2728 Form must be submitted by the facility the patient first dialyzed with.

38 Troubleshooting (CONT.) If you re having difficulty completing the CMS-2728 Form, the following tips might help you out: An Initial 2728 Form must be submitted before the patient s modality can be changed in CROWNWeb, and before CROWNWeb triggers the Supplemental 2728 Form. Labs that are not in range will display a warning message. Click the checkbox to ignore the warning and continue with entering data.

39 Summary To complete a CMS-2728 Form: 1. From the Home Page, click Patients. 2. Enter criteria to search for the patient, click Search. 3. Click the patient s CROWN UPI. 4. Click Click Add Complete Sections A-F of the CMS-2728 Form. 7. Click Save. 8. Print a copy(ies) of the CMS-2728 Form. 9. Get signatures from the attending physician and patient (in blue ink). 10. Enter dates the attending physician and patient signed the form in CROWNWeb. Click Submit.

40 Summary (CONT.) To complete a CMS-2728 Form: 11. Store a copy of the completed, signed form in the patient s medical records file based on your state s medical record archival rules. 12. Mail the printed and signed CMS-2728 Form to the Social Security Administration.

41 Frequently Asked Questions (FAQ) To view Frequently Asked Questions for this topic, click the following link: Access FAQs Enter the words 2728, supplemental, re-entitlement, or any other applicable keyword to view FAQ content for that topic.

42 Demonstration The Completing the CMS-2728 Form demonstration will allow you to watch the task of completing a CMS-2728 Form in CROWNWeb. Click the View Demonstration button below; -or- Click the Bypass Demonstration button to skip the demonstration and advance to the Completing the CMS-2728 Form Quiz. View Demonstration Bypass Demonstration To Quiz

43 Quiz The Completing the CMS-2728 Form Quiz will test your knowledge on completing the CMS-2728 Form in the CROWNWeb system. Click the Take Quiz button below; -or- Click the Bypass Quiz button to skip the quiz and advance to the end of the tutorial. Take Quiz Bypass Quiz End Tutorial

44 For More Information Quick Start Guides The CROWNWeb Quick Start Guides provide short and simple instructions on tasks users can perform in CROWNWeb, including admitting new patients. Click the link below to access the CROWNWeb Quick Start Guides. Online Help The CROWNWeb Online Help is a resource that contains instruction on all facets of the CROWNWeb system, including admitting new patients. Click the link below to access the CROWNWeb Online Help. Go To Quick Start Guides Go To Online Help Thank you for taking this tutorial! This material was prepared by HSAG, the CROWNWeb Outreach, Communication, and Training contractor, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.

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