DEPARTMENT OF HEALTH & HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Form Approved OMB No. 0938-0372 ESRD BENEFICIARY SELECTION (Home Patients Only) PLEASE READ INSTRUCTIONS ON REVERSE.
Open form follow the instructions
Easily sign the form with your finger
Send filled & signed form or save
How to fill out the CMS Form 382 - ESRD Network #15 online
Filling out the CMS Form 382 - ESRD Network #15 online is an essential process for Medicare beneficiaries undergoing home dialysis. This guide provides clear, step-by-step instructions to help users complete the form accurately and efficiently.
Follow the steps to complete the CMS Form 382 online.
- Click ‘Get Form’ button to access the CMS Form 382 - ESRD Network #15 and open it in your editor.
- In section 1, enter your name as it appears on your Medicare card, using your last name, first name, and middle initial.
- In section 2, provide your health insurance claim number, which is also your Medicare claim number.
- For section 3, input your date of birth in the specified format (month/day/year).
- In section 4, select your sex by checking either the ‘Male’ or ‘Female’ box.
- For section 5, enter the provider number of the facility where you will receive home dialysis training.
- In section 5A, provide the name and address of the facility providing your home dialysis training.
- Fill section 6 with the provider number of the facility that will provide your home dialysis support services.
- In section 6A, enter the name and address of the dialysis facility that will offer your support services.
- For section 7, indicate whether you are making an initial selection, cancellation, or a routine selection change.
- In section 8, check the box corresponding to the type of dialysis you will receive: Hemodialysis, CAPD, or CCPD.
- Complete section 9 by providing the date when your home dialysis training is completed.
- In section 10, check either Method I or Method II as per your preference for receiving dialysis supplies and services.
- If you selected Method II, fill in section 11 with the name and address of the durable medical equipment supplier.
- In section 12, by signing, certify that you have only one Method II supplier and understand the payment implications.
- Check the location in section 13, indicating where your home dialysis will be provided.
- Sign the form in section 14 to confirm your understanding and agreement with the selections made.
- In section 15, enter the date you are signing the form, followed by the effective date of any method exception in section 16.
- Once completed, ensure all sections of the form are filled, save your changes, and download or print a copy for your records.
- Submit the form as required, ensuring to follow any further instructions indicated for submission.
Complete your CMS Form 382 online today to ensure you receive the home dialysis service you need.
Experience a faster way to fill out and sign forms on the web. Access the most extensive library of templates available.
Related content
The Medicare End Stage Renal Disease (ESRD) Program, a national health ... Medical...
We used the Medicare dialysis facility compare, facility level impact and QIP files;...
Feb 16, 2019 — Version 1.2021 — July 15, 2020 ... The National Comprehensive Cancer...
Get answers to your most pressing questions about US Legal Forms API.
How often are ESRD services billed?
The physician or other practitioner can bill only one of three current procedural terminology (CPT) codes for ESRD-related visits of one per month, two to three per month, or four or more per month (CMS, Medicare Claims Processing Manual, Pub. No. 100-04, chapter 8, § 140.1).
What is the responsibility of ESRD networks?
The Role of ESRD Networks ESRD Networks are required to conduct specific quality improvement activities focused on patient care, maintaining a patient registry, providing educational materials, and investigating patient grievances. These activities are described in the CMS 2021-2026 ESRD Statement of Work (SOW).
What is a CMS 2728 U3 form?
The Form CMS-2728-U3 (End Stage Renal Disease Medical Evidence Report Medicare Entitlement and/or Patient Registration) is the primary documentation that a claimant has ESRD. It also provides statistical data for use in monitoring the ESRD program.
What is ESRD network support adjustment?
What is the ESRD Network Program? Congress enacted modifications of the Medicare ESRD Program on June 13, 1978 (PL 95-292) to improve cost-effectiveness, ensure quality of care, encourage kidney transplantation and home dialysis, and assist patients to return to work.
What are the CPT codes for ESRD?
Physician services providers should submit claims with CPT (Current Procedural Terminology) procedure codes 90951-90970 for professional ESRD (end-stage renal disease) -related services. These services may be reimbursed once per calendar month per member.
What is ESRD in medical billing?
End-Stage Renal Disease (ESRD) is a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life. Beneficiaries may become entitled to Medicare based on ESRD.
Use professional pre-built templates to fill in and sign documents online faster. Get access to thousands of forms.
If you believe that this page should be taken down, please follow our DMCA take down process here.