Data Collection

A Medical Evidence Reporting Form (CMS-2728) should be completed for all patients undergoing regular dialysis after receiving a diagnosis of ESRD and a prescription has been written for a regular course of dialysis treatment.

• Facilities have 45 days from the date a patient started at current facility to submit a completed Form CMS-2728.
• A Form CMS-2728 is required even if the patient chooses not to apply for or will not qualify for Medicare.
• The Form CMS-2728 should be signed by both the physician and the patient before it is submitted in EQRS.
• If the patient is applying for ESRD Medicare Coverage this signed copy should be sent to your local Social Security Office.
• A signed copy should also be kept in the patient’s file in the event they apply later.
• Facilities not using EQRS (i.e. Veterans Administration, Military, and Prison units) should fax a signed copy of the form to the Network at 877-725-9998

Updating Information in EQRS

It is very important that all facilities maintain current facility information in EQRS. The Network uses this information fax and email you about QIA measures, missing data, educational opportunities, breaking news, emergency events, etc. You should review your facility’s information regularly and check it for accuracy.

• Changes in address, phone, and fax numbers should be made immediately in EQRS, so that the information always remains up-to-date and we can always reach you.
• Hours of operation and shift times should also be updated regularly, so that information is reflected properly on the Dialysis Facility Compare website and Networks can more easily coordinate emergency efforts with your facility staff.

All facility changes can be made in EQRS under the Facility Module:

• Log in to EQRS, choose Facilities from the main EQRS page,
• Search for your facility by CCN
• Select your facility from the results by clicking on it, and then,
• Choose Edit Facility from the available options on the page.

Most fields can be edited; you can save your changes by clicking the Submit button at the bottom of the page. If you have any questions, contact our Data Department or view the training materials at the https://eqrs.cms.gov/resources website.

The Form CMS-2744 was designed to collect Medicare-certified dialysis facility (2744A) and transplant hospital (2744B) information regarding patient activity, treatments, training days and staffing. The Centers for Medicare and Medicaid Services (CMS) require all Medicare-certified dialysis facilities and transplant hospitals to review all data for accuracy, correct discrepancies, and submit to the local ESRD Network for approval.

The Form CMS-2744 lists:

• Patients receiving care at the beginning of the reporting period
• Patients added to the facility during the reporting period
• Patient losses at the facility during the reporting period
• Number of patients present at the facility at the end of the reporting period
• Patients Medicare enrollment status
• Hemodialysis patients dialyzing four or more times per week
• Vocational rehabilitation status of patients aged 18 to 64
• Number of Hemodialysis and Other treatments in center
• Number of days spent training home patients
• Staffing

You cannot delete the Form CMS-2744 once you create it. Once submitted, the ESRD Network will review the Form CMS-2744 and accept it or reject it.

Forms and Instructions

• CMS-2744a (For Dialysis Units)
• CMS-2744b (For Transplant Units)

The ESRD Death Notification Form (CMS-2746) is a one-time form completed when a dialysis patient dies. The purpose of the form is to notify Medicare of the date and cause of a patient's death. The Form CMS-2746 form is to be completed by the Medicare-certified dialysis facility or transplant hospital that was last responsible for the care of the patient on an ongoing basis, regardless of the place of death.

Important Tips

• The ESRD facility last responsible for the patient's ongoing care is responsible for completing and submitting the Form CMS-2746 if:
  • a patient discontinues treatment or transfers to a "non-ESRD" provider and dies within 30 days
  • a patient dies within 30 days after being admitted to hospice, a hospital, long term care facility, nursing home or rehab
  • a patient dies while dialyzing as a transient patient at another facility
• Facilities using EQRS: The data from the form is entered into EQRS
• Facilities not using EQRS (i.e. Veterans Administration, Military, and Transplant units) should fax a signed copy of the form to the Network at 877-725-9998.​