Completing a CMS-2728 Form in CROWNWeb 12-Apr-17 [Title of the course] Completing a CMS-2728 Form in CROWNWeb Submitting CMS-2728 forms using the CROWNWeb system Whether your facility information was imported from a previous application, or a Network Facility Editor added the facility, one of the first tasks you must perform as a Facility Editor is to update your facility information. www.projectcrownweb.org Copyright © 2004-2009. All rights reserved. Copyright © 2004-2005 NameOfTheOrganization. All rights reserved.

Background Information 12-Apr-17 Background Information [Title of the course] Things to know before you get started: 2728 is required for all dialysis patients that will be submitted for reimbursement through Medicare. Must admit patient before you can complete a 2728 form. Only a Facility Editor can add a 2728.  Note: You can view a workflow of the Completing a 2728 Process in the Appendix of your handout. The first thing you must do is perform a search and select the desired facility. As a Facility Editor, you can see any facilities and their information nationwide, but the only facilities you can edit are the ones that your Network Administrator has granted your scope over. Copyright © 2004-2005 NameOfTheOrganization. All rights reserved.

12-Apr-17 Let’s Take a Look! [Title of the course] Let’s take a look at how we’ll admit and discharge patients in CROWNWeb! Live (link to CROWNWeb Application) Next Slide (continue PPT) Questions? The first thing you must do is perform a search and select the desired facility. As a Facility Editor, you can see any facilities and their information nationwide, but the only facilities you can edit are the ones that your Network Administrator has granted your scope over. Copyright © 2004-2005 NameOfTheOrganization. All rights reserved.

The Procedure From the CROWNWeb home page, select Patients. The Search for Patients screen displays. Enter search criteria to find the desired patient and click Search. The Search Results screen displays. Click the CROWN UPI Number hyperlink for the desired patient. The View Patient Attributes screen displays. On the View Patient Attributes screen, click 2728. The Manage 2728 screen displays. Click the Add 2728 button. The Add a 2728 screen displays.

Searching for Patients From the CROWNWeb home page, select Patients. The Search for Patients screen displays. Enter search criteria to find the desired patient and click Search. The Patient Search Results screen displays.

CROWN UPI Number Click the CROWN UPI Number hyperlink for the desired patient. The View Patient Attributes screen displays.

Adding a 2728 for the Patient On the View Patient Attributes screen, click 2728. The Manage 2728 screen displays. Click the Add 2728 button. The Add a 2728 screen displays.

The 2728 Form in CROWNWeb Tip: You can hover over some form items to get more info on that field!

12-Apr-17 Saving Incomplete 2728s [Title of the course] You can save incomplete forms to complete later. Click Save. The View ESRD Medical Evidence Submitted screen displays. Note: A saved 2728 form can be modified – submitted forms cannot. Saving the 2728 Click Save. The View ESRD Medical Evidence Submitted screen displays. Note: A saved 2728 form can be modified. Copyright © 2004-2005 NameOfTheOrganization. All rights reserved.

Deleting Saved 2728s Click the 2728 Link Open the saved 2728 form 12-Apr-17 Deleting Saved 2728s [Title of the course] Click the 2728 Link Open the saved 2728 form Click the Edit 2728 link to open the saved 2728 form for editing (and deleting). Scroll to the bottom of the page and click the Delete button. Click Yes on the confirmation box that appears to confirm. Saving the 2728 Click Save. The View ESRD Medical Evidence Submitted screen displays. Note: A saved 2728 form can be modified. Copyright © 2004-2005 NameOfTheOrganization. All rights reserved.

12-Apr-17 Print the 2728 Form [Title of the course] Before submitting a saved 2728, you need to print copies and obtain patient and physician signatures (in blue ink). Social Security requires that these signed forms be sent in by mail. To print the completed 2728, open the saved 2728 and click Print. The form displays in PDF format, allowing you to print for signatures. Print the 2728 Form Before submitting a saved 2728, you need to print copies and obtain patient and physician signatures (in blue ink). Social Security requires that these signed forms be sent in by mail. To print the completed 2728, open the saved 2728 and click Print. The form displays in PDF format, allowing you to print for signatures. Copyright © 2004-2005 NameOfTheOrganization. All rights reserved.

12-Apr-17 Submit the 2728 Form [Title of the course] Once you obtain physician and patient signatures, you are ready to Submit the form to CROWNWeb Open the saved form, then click the Submit button at the bottom of the page. The form will be submitted for processing. Note: You can no longer delete the 2728 from the patient’s record once you submit it. Submit the 2728 Form Once you obtain physician and patient signatures, you are ready to Submit the form to CROWNWeb Open the saved form, then click the Submit button at the bottom of the page. The form will be submitted for processing. Note: You can no longer delete the 2728 from the patient’s record once you submit it. Copyright © 2004-2005 NameOfTheOrganization. All rights reserved.

Supplemental and Re-Entitlement 2728 Forms 12-Apr-17 [Title of the course] Supplemental and Re-Entitlement 2728 Forms What are they, and how to use them in CROWNWeb Supplemental and Re-Entitlement 2728 Forms What are they, and how to use them in CROWNWeb Copyright © 2004-2005 NameOfTheOrganization. All rights reserved.

Supplemental and Re-entitlement 2728s 12-Apr-17 Supplemental and Re-entitlement 2728s [Title of the course] Supplemental/Re-entitlement 2728s Steps are identical to completing an Initial 2728. Circumstances where required depend on the patient’s course of treatment. Supplemental and Re-entitlement 2728s The steps to complete the Supplemental and Re-entitlement 2728 forms are essentially identical to an Initial 2728. However, the circumstances that require their completion are dependent on the patient’s course of treatment. These variances are explained on the next 4 slides. Copyright © 2004-2005 NameOfTheOrganization. All rights reserved.

Supplemental 2728 – About Required when: 12-Apr-17 Supplemental 2728 – About [Title of the course] Required when: an initial 2728 has been previously submitted and a patient transitions to self care dialysis or a patient has a transplant within the first 3 months after initial dialysis. When modality changes (Hemodialysis to home dialysis or the patient receives a transplant), change the modality, return to the patient page, and select the 2728 button. The Add an ESRD Medical Evidence (2728) screen displays. Supplemental 2728 A Supplemental 2728 is required when: an initial 2728 has been previously submitted and a patient transitions to self care dialysis or a patient has a transplant within the first 3 months after initial dialysis. When modality from Hemodialysis to home dialysis or the patient receives a transplant upon the selection of the modality change the end user will navigate back to the patient page and select the 2728 button and the Add an ESRD Medical Evidence (2728) screen displays. Copyright © 2004-2005 NameOfTheOrganization. All rights reserved.

12-Apr-17 Supplemental 2728 [Title of the course] The Supplemental 2728 will be grayed out in the areas that are not affected by the change in modality. Complete the Section C for Transplant and Section D for Training (Change in Modality) and click Submit. Supplemental 2728 The Supplemental 2728 will be grayed out in the areas that are not affected by the change in modality. Complete the Section C for Transplant and Section D for Training (Change in Modality) and click submit. Copyright © 2004-2005 NameOfTheOrganization. All rights reserved.

12-Apr-17 Re-entitlement 2728 [Title of the course] Click on the Add 2728 button. The View ESRD Medical Evidence (2728) screen displays. Re-entitlement 2728 Click on the Add 2728 button and the View ESRD Medical Evidence (2728) screen displays. Copyright © 2004-2005 NameOfTheOrganization. All rights reserved.

Re-entitlement 2728 - Access 12-Apr-17 Re-entitlement 2728 - Access [Title of the course] Required when a patient resumes treatment after benefits have terminated. Complete the admission process for the patient, proceed to the View Patient Attribute screen, and click on the 2728 link. Re-entitlement 2728 A Re-entitlement 2728 is required when a patient resumes treatment after benefits have terminated. Complete the admission process for the patient and proceed to the View Patient Attribute screen and click on the 2728. Copyright © 2004-2005 NameOfTheOrganization. All rights reserved.

12-Apr-17 Troubleshooting [Title of the course] If you’re having difficulty completing the 2728 form, the following tips might help you out: Ensure that the 2728 mandatory fields are completed on the Patient Attribute Page before creating a 2728 to prevent having to navigate back and forth between the pages. Ensure that the Reason for Admission for a new patient is “ New to ESRD” to complete a 2728. Troubleshooting If you’re having difficulty completing the 2728 form, the following tips might help you out: Ensure that the 2728 mandatory fields are completed on the Patient Attribute Page before creating a 2728 to prevent having to navigate back and forth between the pages. Ensure that the Reason for Admission for a new patient is “ New to ESRD” to complete a 2728. Copyright © 2004-2005 NameOfTheOrganization. All rights reserved.

Appendix Alert! In the Appendix section of your handout, you can view a printed version of the CMS-2728 form that is available in CROWNWeb

Questions on the 2728 Form