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Data Policy and Procedure

Background

Completion of several Centers for Medicare & Medicaid Services (CMS) data forms is a condition of participation in the Medicare End-Stage Renal Disease (ESRD) Program (42 CFR [Condition of Federal Regulation], Subpart U, sections 405.2133 and 405.2134). ESRD Networks work with ESRD facilities to ensure the accurate and timely submission of data. Network 11 also uses a few additional forms. Data from the CMS and Network 11 forms constitute Network 11’s patient data registry used for quality improvement, consumer services, and health care planning.

CMS Forms and Deadlines

CMS-2728, ESRD Medical Evidence Report/Medicare Entitlement and/or Patient Registration—This form is to be completed once the patient is diagnosed as having ESRD. It is due 45 days after the first ESRD treatment (dialysis or transplant) at your facility. The form requires a physician’s signature certifying that the patient has ESRD. It also requires the patient’s signature. The information on this form is required to determine the Medicare medical eligibility of ESRD claimants. It also provides data for research and policy on this population. Network 11 provides an initial supply of these forms to new facilities. Additional supplies are obtained from your local social security office or may be downloaded from the CMS Website .

An additional 2728 (known as a supplemental form) is required when:

1. Patient uses any type of home dialysis within the first thee months after initiating in-center dialysis.
2. Patient has transplant within the first 3 months after initial dialysis.

When a patient resumes treatment after Medicare benefits have expired, a re-entitlement 2728 is required. This situation occurs when:

1. Patient returns to dialysis after 1 year or more of having recovered function or discontinued dialysis.
2. Patient returns to dialysis after 3 years or more after a transplant.
3. Patient has another transplant 3 years or more following a transplant, with no dialysis in between.

CMS-2744, ESRD Facility Survey—Form completed annually by all Medicare approved renal providers. Network 11 sends each provider a survey form in February. (2009 Annual Survey is due on March 1st!)

CMS-2746, ESRD Death Notification—Form completed by the primary provider of care and due within 30 days of the date of death of an ESRD patient, regardless of where the death occurred. These forms should be available at all Medicare approved renal providers; if not, they may be obtained by calling the Network 11 office.

Patient Activity Report (PAR)—Facilities send Network 11 a completed PAR each month in order to maintain current and accurate dialysis data. PARs are due to Network 11 on the 10th of each month.

** If you are unable to obtain certain data elements or meet CMS required deadlines, please call your Network 11 Data Specialist to discuss options. They will consider the matter on a case-by-case basis, and ask you to put a note on the form you eventually submit to document the conversation. **

Other Federally Mandated Forms

Occasionally, Networks may be asked or required by other organizations or CMS to process other surveys or forms.

Network 11 Required Forms

Quarterly Transplant list—To collect current and accurate transplant data and to help verify data received from the United Network for Organ Sharing (UNOS), Network 11 transplant facilities are required to note all changes and return the updated list to the Network within two weeks of receipt.

Address Updates—Facilities must submit Patient Change of Address forms whenever a patient transfers in from another state, or otherwise changes their address. The form is posted on the Network 11 website and may be completed electronically or by hand. Completed forms may be faxed to 651-644-9853. Also, a consumer newsletter is sent to over 33,700 ESRD patients in Network 11. At least once each year, Network 11 may ask for address updates to ensure that the bulk-mailed newsletters are being received by patients.

Data Clean-Up—Network 11 will follow-up with facilities when data they submit is incomplete or unclear. Also, CMS periodically reconciles it’s data with Network 11 by notifying us of records that do not match other sources. In both instances, we send you a fax, list the record in question, and ask for clarification. The turnaround time for these requests is typically between 1–7 days, depending upon urgency.

Data Compliance Policy

CMS has established performance goals for the submission of Medical Evidence (2728) and Death Notification (2746) forms. A rate of 90% or better for data timeliness and accuracy is expected by facilities. Twice a year, Network 11 issues CMS Forms Compliance Reports to all units, detailing performance outcomes. These reports are also forwarded to Network 11’s CMS Project Officer.

About the compliance reports: The first section lists patient forms submitted by your facility to Network 11 for a specified time period (usually six-month or one-year intervals). Any forms completed erroneously or submitted late will be noted here. (Late is defined as more than 45 days after the patient’s first ESRD treatment for the 2728, and more than 30 days from the patient’s death for the 2746.) The second section reports your facility’s overall compliance. CMS defines non-compliance as:

• An annual average compliance rate of less than 90 percent for timeliness, completeness/accuracy.

CMS requires Network 11 to monitor and report providers not in compliance with Network goals. We work with non-compliant facilities to identify barriers to effective reporting and offer educational resources to promote improvement. Facilities that do not improve are asked to submit a corrective action plan. Chronically non-compliant facilities may be noted in the Network 11 Annual Report. Per CMS policy, a list of all facilities that do not achieve the 90% compliance rate must be reported to the CMS Regional Project Officer for Network 11.

Form	Description	Completed By	CMS Deadlines
CMS-2728	Medical Evidence	Designated facility staff member & attending physician.	Within 45 days from date of first ESRD treatment at your facility (dialysis or renal transplant).
CMS-2746	Death Notification	Transplant center or dialysis unit last responsible for care of patient on an on-going basis, regardless of place of death.	Within 30 days of date of death.
PAR	Patient Activity Report	Facility-designated PAR Contact	Due to Network office on the 10th of each month.
CMS-2744	Annual Survey	Transplant & dialysis units.	Network sends surveys to facilities in February; Network must submit completed & verified forms to CMS by April 5.

Revised: 7/6/2007
A printable version of this policy and procedure document is available.