/depts/,/depts/uwmf/,/depts/uwmf/patient-resources/,/depts/uwmf/patient-resources/social-guide/,/depts/uwmf/patient-resources/social-guide/manual/,/depts/uwmf/patient-resources/social-guide/manual/population-specific/,/depts/uwmf/patient-resources/social-guide/manual/population-specific/transplant/,/depts/uwmf/patient-resources/social-guide/manual/population-specific/transplant/kidney-transplant/,/depts/uwmf/patient-resources/social-guide/manual/population-specific/transplant/kidney-transplant/2728-forms/,

/depts/uwmf/patient-resources/social-guide/manual/population-specific/transplant/kidney-transplant/2728-forms/

20150105

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UWHC,

Patient Services,

UW Medical Foundation,Patient Resources,Social Work Services Quick Guide,Social Work Manual,Population Specific,Transplant,Kidney Transplant

2728 Forms

2728 Forms - UW Medical Foundation, Patient Resources, Social Work Services Quick Guide, Social Work Manual, Population Specific, Transplant, Kidney Transplant

Focus

2728 forms are filled out by dialysis units in order to communicate certain information with CMS.

These forms are important to obtain so that we can correctly calculate a patient's EPTS score as well as when their 30 month coordination of benefits period will begin. 

Of note, if a patient has a transplant, and returns to dialysis within 3 years of surgery, the dialysis unit is not required to fill out a second 2728 form. In that case, Network 11 should be contacted to verify dialysis re-start date. 

Checking to see if we have the 2728

  1. Click on Snapshot/2728 Documentation
  2. Check “Pending and Completed Tasks – Documentation”
  3. Check to see if “Verify Receipt of Form 2728 and Dialysis Start Date”task is complete.
  4. If it is complete, nothing further needs to be done.
  5. If it is not complete, and they are on dialysis, please go to “Need 2728”
  6. If it is not complete, and they are not on dialysis, please go to “No 2728 Needed”

Need 2728

  1. Fax
    1. Fill out fax request form, and give to SW Assistant to send to dialysis unit
  2. Checklist
    1. In section J, click on “Verify Receipt of form 2728 and dialysis start date”
    2. Type .2728, then hit enter.
    3. Push “F2” button on keyboard
    4. Choose “Need 2728 . . . “
    5. Hit Accept
    6. DO NOT CLICK THE COMPLETE BUTTON
  3. Patient List
    1. Under Shared Patient Lists, choose “Need 2728”
    2. Click “Add Patient”, enter pt’s MR#

No 2728 Needed

  1. Checklist
    1. In section J, click on “Verify Receipt of form 2728 and dialysis start date”
    2. Type .2728, then hit enter.
    3. Push “F2” button on keyboard
    4. Choose “No 2728 on file as pt not on dialysis . . . “
    5. Hit Accept
    6. Click the Complete Button

Receipt of 2728 Forms

  1. Checklist
    1. In section J, click on “Verify Receipt of form 2728 and dialysis start date”
    2. Erase “Need 2728 . . . “
    3. Type .2728, then hit F2
    4. Choose “Per 2728, patient began dialysis on *** . . . “
    5. Enter the start date as indicated on the form in #24/Date Chronic Dialysis Began
    6. Click Accept
    7. Click Complete
  2. History
    1. Click Amb Enc
    2. Click on patient name
    3. New
    4. Type = Abstract; Provider = your name; Dept = UWH Tx Medicine
    5. Click on History
    6. Correct start date as needed
    7. In comments section, delete “need 2728” and type “per 2728/HL/” at the beginning of the field
  3. Patient List
    1. Under Shared Patient Lists, choose “Need 2728”.
    2. Highlight patient name, then click on “Remove” button.
  4. Scanning
    1. Place “Medicare Form” sticker on top right corner of document
    2. Fill in MR#
    3. Give to SW Assistant to scan
  5. Double Check
    1. When Jackie gives back, open patient’s chart.
    2. Click on “Media” then search for document. Type will be “Certification/Participation” and Description will be “Medicare Form”
      1. If the description "Medicare Form" is missing, email HIS-ScanningCorrec@uwhealth.org to have them add

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