Welcome.
The Data Department of Network #15 tracks patient events at your facility and reports that information to CMS. The data collected helps ensure that Medicare accurately covers patient expenses for dialysis and allows researchers to better understand ESRD trends in order to improve treatment for this devastating disease.
If your facility is new, please notify Network #15 as soon as you start dialyzing patients. At that time Network #15 will assign you a temporary provider number to use on all forms until you receive your permanent Medicare-assigned provider number. You will also need to begin submitting the following patient-related forms (at right):
- End-Stage Renal Disease Medical Evidence Report (2728) – Submitted to Network #15 within 45 days of patient’s FIRST CHRONIC DIALYSIS TREATMENT at your dialysis facility. It is acceptable to fax this form to Network #15, but you must mail a hard copy to your local Social Security field office.
- ESRD Death Notification (2746) – Due at NW #15 within 30 days of a patient’s death. You can fax these forms to Network #15 at 303-860-8392.
- Patient Activity Report (PAR) – Completed at the end of each month and due to NW 15 by the 10th of the following month. Lists all patient events (transfers, new starts, deaths, etc.) Please review all of the PAR Instructions and Tips to ensure that you are completing the PAR correctly.
Additional forms that Network #15 will send you periodically for completion:
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Network #15 Facility Roster is mailed to each facility for review on a quarterly basis (January, April, July, October). The roster helps to ensure that the NW #15 database accurately reflects the location where patients are receiving dialysis.
If you have questions about any of the above-mentioned forms or data requirements, please call Cynthia Nelson, Virginia Nelson, or me, Matthew Howard at 303-860-1515. You will also find more detailed information about data requirements on the "Data Collection" page of our website.
Thank you,
Matthew Howard, Director of Information Systems
Intermountain End-Stage Renal Disease Network
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Data Forms and Reports
Data WebEx Presentations
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Understanding 2728
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2746 Forms
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Compliance (28 min) A tutorial on the CMS Medical-Evidence Form (2728) and the Death Notification Form (2746). Highlights fields that are frequently confusing and emphasizes the importance of accuracy and timeliness. Appropriate for Social Workers and Data Contacts who work on these two forms
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