The Network 8 Data Department has responsibilities for data processing, information management and reporting including the following:
- To effectively manage the collection, validation, storage, and use of data, including data provided by CMS, for review, profiling, pattern analysis, and sharing appropriate data with CMS and the State survey agency for use in their ESRD Medicare survey and certification activities;
- To ensure timely and accurate reporting by the facilities;
- To maintain and ensure the integrity, accuracy, and confidentiality of ESRD patient and facility databases;
- To ensure the quality and accuracy of the CROWNWeb database for inclusion in the ESRD Program Management and Medical Information System (PMMIS) and the United States Renal Data System (USRDS);
- To ensure current patient status is reported to CMS in a timely manner for appropriate enrollment and disenrollment into the Medicare program for ESRD benefits;
- To train facilities in the proper procedures for completing and transmitting forms electronically including establishing facilities’ access to Quality Net Exchange;
Network 8 collects data through the following forms for input into its data management systems:
Form 2728 - End Stage Renal Disease Medical Evidence Report | Medicare Entitlement and/or Patient Registration
An initial, re-entitlement, or supplemental form is due within 45 days
For all patients who initially receive a kidney transplant instead of a course of dialysis.
For beneficiaries who have already been entitled to ESRD Medicare benefits and those benefits were terminated because their coverage stopped 3 years post transplant but now are again applying for Medicare ESRD benefits because they returned to dialysis or received another kidney transplant.
|Supplemental||Patient has received a transplant or trained for self-care dialysis within the first 3 months of the first date of dialysis and initial form was submitted. A patient will only have one Supplemental 2728, if needed.|
Medicare certified dialysis facilities (this does not apply to VHA or transplant facilities) must enter 2728 forms into CROWNWeb. After the form has been completed, a copy must be printed and signed by the patient and physician. An original signed copy (blue ink) needs to be sent to the local Social Security Administration office. For information on how to get a CROWNWeb account go to the QualityNet website and select the ESRD tab.
For facilities that are not required to use CROWNWeb, please download the Form 2728 (opens in a new browser window). It must be submitted to the local Social Security office and a copy must be submitted to the Network within 45 days. Enter the patient's Zip code into the Social Security Administration Office Locator to determine which Social Security Office to submit the 2728 to. CMS instructions are included with the downloaded form.
Please review additional information regarding patient self-identification of race and ethnicity for Form 2728.
Form 2746 - End Stage Renal Disease Death Notification Form
For facilities that are not required to use CROWNWeb, please download the Form 2746 (opens in a new browser window). This form must be completed by the facility last responsible for the patient’s maintenance dialysis (or home dialysis) and submitted to the Network within 30 days of the date of death. CMS instructions are included with the downloaded form.
PAR Form - Patient Activity Report
Facilities using CROWNWeb no longer submit the monthly Patient Activity Report to Network 8. This form submission is replaced by the PART functionality within CROWNWeb. Please verify all patients at least every 30 days within CROWNWeb.
Dialysis facilities that are not required to use CROWNWeb will continue to submit the Patient Activity Report PAR (a small Excel file that opens in a new browser window). For each admission to your facility you need to complete the Network 8 Admission form. For each discharge you will need to complete the Network 8 discharge form. The PAR is due to the Network by the 10th of each month. Clinics are responsible for making copies of the blank form and for submitting a completed report each month.
Transplant facilities need to complete a Transplant Activity Report for each transplant and submit it to Network 8.
CMS-2744 Form – Annual Survey
Please review the Network 8 Annual Survey (CMS-2744) Process Guide for information on completing the annual survey.