2728 Form Instructions

Updated 2/26/2024

The 2728 Form (END STAGE RENAL DISEASE MEDICAL EVIDENCE REPORT MEDICARE ENTITLEMENT AND/OR PATIENT REGISTRATION) Is required to add a patient to the ESRD registry and help them apply for Medicare benefits.

There are 3 types of 2728 Forms:

• Initial 2728: submitted only once after a patient's 'New ESRD' admission into EQRS

• Supplemental 2728: available only within the first 90 days of a 'New ESRD' admission to help a patient's Medicare benefits start sooner than the usual 90 days, if:
  • Patient starts training for a Home Modality
  • Patient is admitted for a Transplant
• Re-Entitlement 2728: submitted if patient is reapplying for Medicare coverage due to the following Admit Reasons:
  • Restart: after not treating at a dialysis facility for +1 year (coverage ends after 1 year)
  • Dialysis After Transplant Failed: returning to dialysis after living with a functional kidney transplant for +3 years (coverage ends after 3 years)
    • If the 2728 does not appear right away please contact the Network and we will change the Transplant Status to Non-Functioning so that you may complete the 2728.
  • Transplant: receiving a transplant immediately after a Transplant Failed event after living with a functional kidney transplant for +3 years OR after not treating at a dialysis facility for +1 year

To EDIT a Submitted 2728 Form: https://help.esrd.ipro.org/support/solutions/articles/9000230058-editing-a-submitted-2728-form-2746-form

AKI(Acute) versus Recovered Function Instructions: https://help.esrd.ipro.org/support/solutions/articles/9000233007-2728-forms-acute-aki-and-recovered-function

2728 Facts

• 2728 Forms are to be submitted in EQRS: https://eqrs.cms.gov/.
• Due within 45 days of the Admit Date (Field 24).
• Due for all ESRD patients (not AKI patients).
• A Supplemental/Re-Entitlement is not required if the patient already has Medicare coverage due to age (>65) or due to another medical condition.
• Submitted 2728 Forms are required by transplant centers to add patient to their kidney transplant waitlist.
  Patients who received treatment outside the country must be admitted as "New ESRD" for their first  admission into a dialysis facility or transplant center in the U.S.
  
• If a patient is discharged as "Death" then their signature is no longer required for 2728 to be submitted.
• If a 2728 does not appear in the Form 2728 section consider:
  • the Admit Reason may be wrong, preventing a 2728 from being triggered
  • the facility where this patient should be "New ESRD" did not admit them in EQRS, or they did not submit the 2728 yet
    • Contact that facility to ask if they have another UPI for the patient OR if they need your help getting the patient's signature
• If a patient refuses to sign or is unable to sign the 2728 Form, and there is no with a power-of-attorney, then the 2728 cannot be submitted
• Serum Creatinine is the only required clinical value on the 2728 Form. It must be within 45 days prior to the patient starting treatment as 'New ESRD.'

Download detailed CMS Instructions here: https://www.cms.gov/medicare/cms-forms/cms-forms/downloads/cms2728.pdf