CMS Pub. 100-16, ch. mc86c17d, § 40.3

Please refer to §20.2 of this chapter for information on when a beneficiary with ESRD

may be eligible to enroll in a cost plan.

If a cost plan is aware that an individual electing a plan has received a kidney transplant

(e.g., the individual informs the cost plan this has occurred), then the plan should request

that the individual submit medical documentation that he or she no longer has ESRD (i.e.,

a letter from the physician that states the individual has received a kidney transplant and

no longer requires a regular course of dialysis to maintain life). Upon receipt of this

documentation, the cost plan should enroll the beneficiary.

If an individual indicates on the enrollment form that he or she does not have ESRD but

the cost plan receives a reply listing containing a “code 45” or “code 15” rejection (an

explanation of reply listing codes is contained in Chapter 19), the cost plan should

investigate further to determine whether the individual is eligible to enroll. To determine

eligibility, the cost plan should contact the individual and request medical

documentation. Contact can be made orally, in which case the cost plan must document

the contact and retain the documentation in its records.

If the cost plan learns that the individual has received a kidney transplant which has

restored kidney function and that the individual no longer requires a regular course of

dialysis to maintain life, then the individual must be permitted to enroll in the plan if

other applicable eligibility requirements are met. When this occurs, the cost plan must

contact its RO to override the system rejection. The following documentation must be

submitted to the RO:

1. Evidence of contact with the individual after the system rejection, including the

individual’s explanation for rejection (i.e., successful transplant) and medical

documentation, i.e., a letter from the physician that documents that the individual

has received a transplant that has restored kidney function.

2. A copy of the Reply Listing or, if using the services of a CMS subcontractor, a

report indicating the cost plan’s attempts to enroll the individual and the resulting

rejection.

Once received and approved, the Regional Office will override the enrollment rejection

for the individual.