EQRS

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

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.​

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)