POMS Reference

Table of contents Recent changes
Contact
Back
This change was made on Dec 12, 2017. See latest version.
Text removed
Text added

DI 11005.045: Completing the SSA-3367 (Disability Report – Field Office)

changes
← * →
  • Effective Dates: 06/05/2017 - Present
  • Effective Dates: 12/12/2017 - Present
  • TN 48 (05-16)
  • TN 51 (12-17)
  • DI 11005.045 Completing the SSA-3367 (Disability Report – Field Office)
  • The field office (FO) is responsible for completing Form SSA-3367 (or the Electronic Disability Collect System (EDCS) 3367 Disability Report) before transferring jurisdiction of a claim to the disability determination services (DDS). The SSA-3367 or EDCS 3367 entries provide the DDS information about the:
  • * current filing including the potential onset date (POD), work after the alleged onset date (AOD), and blind date last insured (DLI), if applicable;
  • The field office (FO) completes Form SSA-3367 or the Electronic Disability Collect System (EDCS) 3367 Disability Report for initial claims, reconsiderations of initial claim, escalated claims, and continuing disability reviews (CDRs). Complete the SSA-3367 or EDCS 3367 before transferring jurisdiction of a claim to the disability determination services (DDS).
  • This information alerts the DDS to factors that could affect entitlement and guides case development. The entries provide the DDS with information about:
  • * current filing including the potential onset date (POD);
  • * work before or after the alleged onset date (AOD);
  • * non-blind and blind date last insured (DLI), if applicable;
  • * prior filings;
  • * presumptive disability and presumptive blindness (Title XVI only); and
  • * observations made by the interviewer.
  • This information alerts the DDS to non-medical factors that could affect entitlement and helps guide DDS case development. The FO completes the SSA-3367 or EDCS 3367 for initial claims, reconsiderations of the initial claim and escalated claims, and continuing disability reviews (CDRs), including expedited reinstatements (EXR).
  • * interviewer observations.
  • REMINDER: Claims excluded from EDCS make up a small number of disability claims and you rarely need a paper form SSA-3367.
  • EXCEPTIONS: Although EDCS supports electronic CDR processing, complete the paper SSA-3367 for EDCS exclusions i.e., expedited reinstatements (EXRs). For additional EDCS exclusions, complete the paper SSA-3367 as detailed in DI 81010.030.
  • A. Completing the SSA-3367
  • For multiple or concurrent EDCS exclusion claims, fill out one complete paper form SSA-3367 and duplicate copies of page 1, items 1 through 6, for each additional claim.
  • A. FO completes the SSA-3367
  • * Complete one entire paper form for multiple or concurrent EDCS exclusion claims.
  • * Complete page 1, items 1 through 6 for each additional claim.
  • * Complete form EDCS 3367 as detailed in DI 81010.025.
  • 1. IDENTIFYING INFORMATION (items 1-5)
  • Complete the following information.
  • For data propagation into EDCS, see DI 81010.035. Complete the following information on the SSA-3367.
  • a. Item 1: Name, Social Security number, gender, date of birth
  • Enter the full name and social security number (SSN) of the number holder (NH). Enter the full name, gender, date of birth, and SSN of the claimant, if different from the NH.
  • For auxiliary or survivor claims (e.g., a disabled widow(er) beneficiary (DWB) filing on the deceased spouse’s record, or a disabled minor child (DMC) filing on a parent’s record), enter the claimant’s name and SSN.
  • * Enter the number holder’s (NH) full name and social security number (SSN).
  • * Enter the claimant’s full name, gender, date of birth, and SSN, if different from the NH.
  • * Enter the claimant’s name and SSN for auxiliary or survivor claims (e.g., a disabled widow(er) beneficiary (DWB) filing on the deceased spouse’s record, or a disabled minor child (DMC) filing on a parent’s record).
  • b. Item 2: Claimant’s Alleged Onset Date (AOD)
  • Enter the AOD. The AOD is the date the claimant says that he or she became unable to work because of his or her medical condition (see DI 25501.210).
  • If the AOD conflicts anywhere in the file (e.g., the AOD is different on the application from what is recorded on the SSA-3368-BK (Disability Report - Adult)), resolve the conflict with the claimant, enter the date selected by the claimant, and explain it in the remarks section on the SSA-3367.
  • NOTE: Even if the claimant never worked, enter the date when he or she believes the condition(s) became severe enough to keep him or her from working. (Refer to the work activity section on the SSA-3368-BK.)
  • Enter the AOD.
  • c. Item 3: Potential Onset Date (POD)
  • The AOD is the date the claimant alleges he or she became unable to work because of his or her medical condition, see DI 25501.210.
  • For detailed instructions on completing items 3 through 6 for specific claim types, refer to DI 11005.045B in this section.
  • If the claimant never worked, enter as the AOD, the date he or she believes the condition(s) became severe enough to keep him or her from working.
  • The POD alerts the DDS examiner of work issues, insured status, and other non-medical factors that may affect the EOD. The POD is claim specific.
  • If the AOD conflicts anywhere in the file (e.g., the AOD is different on the application from the date on the SSA-3368-BK (Disability Report - Adult)):
  • * resolve the conflict with the claimant,
  • * enter the date selected by the claimant, and
  • * explain why the AOD conflicts in the Remarks section on the SSA-3367.
  • For Title II disability insurance benefit (DIB) claims, the POD is the earliest possible date that we can establish onset based on non-medical factors. The POD may be the same as, earlier, or later than the AOD.
  • Make all AOD changes in the Modernized Claims System (MCS) and in the Modernized Supplemental Security Income Claims System (MSSICS).
  • Enter the POD for each disability claim at the initial and reconsideration levels, including escalated claims, after the claimant meets all non-medical requirements.
  • c. Item 3: Potential Onset Date (see DI 25501.220 Potential Onset Date (POD))(check type of claim(s) and enter potential onset date)
  • For both FO and DDS instructions for determining the POD, see DI 25501.220.
  • The POD alerts the DDS examiner of work issues, insured status, and other non-medical factors that may affect the established onset date (EOD). The POD is claim specific.
  • * Before transferring jurisdiction of a claim to the DDS, the FO must enter the POD for each Title II disability claim at the initial and reconsideration levels, including escalated claims, and continuing disability review claims (CDRs). The POD must be after the claimant meets all non-medical requirements.
  • * The FO does not have the capability to enter the POD on the 3367 in EDCS at the Appeals Council or Federal Court levels.
  • * For Title II disability insurance benefit (DIB) claims, the POD is the earliest possible date that the DDS can establish onset based on non-medical factors. The POD may be the same as, earlier, or later than the AOD. For guidance on how to consider the POD in Title II claims, see the chart in DI 25501.220C.1.b.
  • * Enter the POD for Title XVI supplemental security income (SSI) claims only if the POD is different from the protective filing date or the filing date;
  • * Consider the POD separately for each disability claim type in concurrent or multiple Title II claims.
  • Enter the POD for Title XVI cases if it is different from the protective filing date or the filing date if there is no protective filing.
  • To complete items 3 through 6, follow detailed instructions in subsection B. Supplemental instructions for Form SSA-3367 for specific claim types:
  • * DIB and freeze claims with a non-blind DLI prior to filing date and an allegation of blindness, vision problems or low vision;
  • * MQGE claims; and
  • * DWB claims.
  • For instructions on how to enter the POD in Title II cases, see the chart in DI 25501.220C.1.b.
  • NOTE: Be aware that the POD may be in a previously adjudicated period; including a period decided by an administrative law judge (ALJ).
  • For concurrent cases, consider the POD separately for each disability claim type (see DI 25501.220A.3.).
  • If the FO sets a POD in a previously adjudicated period decided by an ALJ, the DDS does not have the authority to reopen the case but must consider whether reopening and revising a prior determination or decision is appropriate.
  • NOTE: Be aware that the POD may be in a previously adjudicated period; including a period decided by an administrative law judge (ALJ). If the FO sets a POD in a previously adjudicated period, the DDS must consider whether reopening and revising a prior determination or decision is appropriate (see DI 27501.005).
  • The DDS only has authority to reopen if the prior determination is below the ALJ hearing level, see DI 27510.005C.1.
  • * If the DDS believes reopening is appropriate, the DDS completes action on the subsequent claim and refers the prior and subsequent claims to the State or Federal Disability Hearing Unit (DHU) or the Office of Disability Operations (ODO) to consider reopening. See DI 27510.005C.2.
  • * In some situations, the DDS can establish onset within the prior period without reopening. See DI 27510.005D and DI 27510.005E.
  • d. Item 4: Reason for Potential Onset Date
  • Complete this item if you entered a POD in item 3 in DI 11005.045A.1.c. in this section.
  • Check the appropriate block for the reason for the POD.
  • * Supplemental Security Insurance (SSI) application date
  • * SSI application date
  • * Date last insured
  • * Date first insured
  • * Controlling date
  • * Work before or after the AOD (check appropriate reason):
  • * UWA (unsuccessful work attempt);
  • * SGA (substantial gainful activity);
  • * Other (explain in item 5)
  • * Work before or after the AOD (check all that apply):
  • * UWA;
  • * SGA;
  • * Not SGA;
  • * SSA-823 (Report of SGA Determination – For SSA Use Only) in file. (For EDCS claims, when you select the “823 in file” option, you must also select if work is UWA, SGA or Not SGA. This will allow for the transfer of the claim to the DDS; see MSS15-083 EDCS.)
  • * Other – explain in item 5.
  • * SSA-823 in file
  • IMPORTANT: You must complete Form SSA-823 (Report of SGA Determination - For SSA Use Only) in all initial claims that require an SSA-820-BK (Work Activity Report - Self-Employment) or an SSA-821-BK (Work Activity Report - Employee).
  • IMPORTANT: You must complete the Form SSA-823 (Report of SGA Determination- For SSA Use Only) in all initial claims that require an SSA-820-BK (Work Activity Report - Self-Employment) or SSA-821-BK (Work Activity Report - Employee). Do not complete an SSA-821-BK or SSA-823 if the work is clearly not SGA; see DI 10505.003.
  • Do not complete an SSA-821-BK or SSA-823 if the work is clearly not SGA per DI 10505.003.
  • For more detailed information on work activity reports, (SSA-820-BK and SSA-821-BK), see DI 10510.025 and DI 10505.035.
  • For detailed information on work activity reports, see:
  • * DI 10510.025 Documenting Self-Employment Cases Using the SSA-820-BK (Work Activity Report-Self-Employment) and the SSA-823 (Report of SGA Determination- For SSA Use Only)
  • * DI 10505.035 Documenting Employment Cases Using Forms SSA-821-BK (Work Activity Report-Employee) and SSA-823 (Report of SGA Determination-For SSA Use Only)
  • e. Item 5: Explanation for Potential Onset Date, when applicable
  • If you check “Other” in item 4, explain the reason for the POD. Provide an explanation if:
  • * The POD and the AOD are inconsistent. (The FO must resolve and explain any inconsistencies in work activity or other non-medical factors that may affect the onset date.)
  • * The claimant’s work is clearly not SGA (see DI 10505.003).
  • * The date first insured (DFI) is indicated as a reason for the POD, then enter the DFI.
  • * In blindness and visual impairment paper claims, enter the following statement on the SSA-3367 in item 5, Explanation for Potential Onset Date, when applicable: “If claimant is found statutorily blind, the blind DFI is MM/DD/YYYY and the blind DLI is MM/DD/YYYY.” For EDCS claims, see DI 11005.045A.9.g.
  • If you check “Other” in Item 4, explain the reason for the POD, for example:
  • * The POD and the AOD are inconsistent. (You must resolve and explain any inconsistencies in work activity or other non-medical factors that may affect the onset date.)
  • * The claimant’s work is clearly not SGA per DI 10505.003.
  • * The date first insured (DFI) is the reason for the POD. Enter the DFI.
  • 2. Item 6: MISCELLANEOUS INFORMATION
  • Provide the following information:
  • * Enter the protective filing date.
  • * For DIB and Freeze claims, enter the non-blind date last insured (DLI).
  • * For DWB claims, enter the prescribed period and controlling date. For detailed guidance, see DI 11005.050.
  • * Enter the blind DLI, if applicable. For EDCS claims, see DI 11005.045A.9.g.
  • * Check “yes” or “no” for a closed period of disability case. For more information on closed periods, see DI 25510.001, DI 25510.010, and DI 25510.015.
  • * Enter the protective filing date. Find the protective filing date in the electronic folder under the case data tab in eView.
  • * Enter the non-blind DLI for DIB and Freeze claims.
  • * Enter the blind DLI if the claimant is insured for blind benefits, and alleges blindness, a visual impairment, or low vision. For claims involving potential blindness, see Remarks Section, 9.f.
  • NOTE: It is possible that a claimant will be insured for blindness only and therefore, not be insured for non-blind benefits.
  • * Enter the prescribed period and controlling date for DWB claims, see subsection B.3. For EDCS cases, verify that the propagated prescribed period and controlling date are correct. For detailed guidance, see DI 11005.050.
  • * Check “yes” or “no” for a closed period of disability case.
  • See also:
  • DI 25510.001 Closed Period of Disability
  • NOTE: For instructions on cases involving potential blindness, see DI 11005.045B.1. in this section.
  • DI 25510.010 Establishing a Closed Period of Disability and Protecting a Closed Period Freeze Under Title II
  • 3. Item 7: PRIOR FILING INFORMATION
  • DI 25510.015 Closed Period of Disability Under Title XVI
  • 3. Item 7: PRIOR FILING INFORMATION – Use Remarks, if additional space is needed
  • List ALL prior filings with a medical determination or decision and SGA denials on the SSA-3367 (or the EDCS 3367). Use the Remarks section, if you need additional space. The DDS does not need filing information for technical denials (e.g., N13, N04, N18, 090).
  • Indicate whether the claimant has a prior filing(s).
  • If yes, provide the following:
  • * Claim type(s);
  • If yes, and you are not sending the prior folder(s) to the DDS, provide the following information:
  • * Type of prior claim(s);
  • * SSN(s) of prior claim(s);
  • * Date of last decision (MM/DD/YYYY);
  • * Level of last decision (initial, reconsideration, etc.);
  • * Outcome of last decision (allowance or denial);
  • * Date of prior decision(s) (MM/DD/YYYY);
  • * Level of prior decision(s) (initial, reconsideration, etc.);
  • * Outcome of prior decision(s) (allowance or denial);
  • * Location of prior folder; and
  • * Prior folder requested; if “yes” include the date requested or “no.”
  • IMPORTANT: List ALL prior filings with a medical decision and SGA denials on the SSA-3367 (or the EDCS 3367). The DDS does not need filing information for technical denials (e.g., N13, N04, N18, 090).
  • For instructions on prior filings, see Prior Claims Activity in DI 11005.085.
  • 4. Item 8: PRESUMPTIVE
  • Check the block(s) for any presumptive disability (PD) or presumptive blindness (PB) criteria that apply in SSI (Title XVI) claims. For detailed FO procedures on processing PD and PB cases, see DI 11055.240.
  • Check the block(s) for any presumptive disability (PD) or presumptive blindness (PB) criteria that apply in SSI (Title XVI) claims.
  • Refer to detailed FO procedures on processing PD and PB claims in DI 11055.240.
  • 5. Item 9: OBSERVATIONS/PERCEPTIONS
  • Observations are very valuable because DDS examiners do not have face-to-face contact with claimants.
  • How was the interview conducted?
  • Record the following information:
  • * type of interview (teleclaim, face-to-face, or no contact with the claimant);
  • * difficulties with any of the activities listed (check “yes,” “no,” or “not observed”);
  • * explanation or comments about your observations in the space provided; and
  • * description of the claimant’s behavior, appearance, grooming, or degree of limitations in the space provided.
  • Observations are very valuable to DDS examiners for both face-to face and telephone interviews. Record the following information:
  • * type of interview
  • * teleclaim with claimant,
  • * face-to-face with claimant, or
  • * no contact with claimant;
  • * if claimant communicated in a language other than English, record that language;
  • * difficulties with any of the activities listed (check “yes,” “no,” or “not observed/perceived”);
  • * description of the claimant’s behavior, appearance, grooming, or degree of limitations; and
  • * any additional comments about your observations.
  • 6. Item 10: FO DEVELOPMENT
  • Completely document any development initiated by the FO.
  • Document any development initiated by the FO.
  • For information on FO development of medical evidence, see DI 11010.485 through DI 11010.495.
  • For information about FO development, see
  • * DI 11010.485 through DI 11010.495 for medical evidence
  • * DI 22501.002B. for non-medical evidence.
  • For information on FO development of other non-medical evidence, see DI 22501.002B.
  • CAPABILITY/REMARKS
  • 7. Item 11: MEDICAL EVIDENCE
  • 7. Item 11: If medical evidence was brought in to the FO by the claimant, check here
  • Indicate if the claimant submitted medical evidence of record (MER) to the FO.
  • Indicate whether the claimant submitted medical evidence of record (MER) to the FO.
  • 8. Item 12: CAPABILITY DEVELOPMENT
  • 8. Item 12: Is DDS capability development needed?
  • If you cannot make a capability determination, but capability is questionable (e.g., allegation of mental disorder(s) or noticeable abnormal behavior of the claimant), request the DDS to give an opinion on the issue of capability and explain in the remarks section on the SSA-3367.
  • If capability is questionable and you cannot make a capability determination, (e.g., allegation of mental disorder(s) or noticeable abnormal behavior of the claimant),
  • * ask the DDS to provide a capability opinion, and
  • * explain in the Remarks section on the SSA-3367.
  • NOTE: While the DDS may provide an opinion regarding the evidence of capability, the FO is responsible for the final determination of capability.
  • While the DDS may provide an opinion regarding the evidence of capability, the FO is responsible for the final determination of capability. For more detailed information, see
  • * DI 11055.215A. Policy for an FO request for DDS capability development
  • * GN 00502.040A.3. How much consideration should I give to medical evidence?
  • For policy about FO requests for DDS capability development, see DI 11055.215A.
  • 9. Remarks Section:
  • 9. REMARKS SECTION
  • Use the Remarks section
  • * to add explanations, descriptions, expansion of the answers to questions, or
  • * to record other pertinent information about the claim for the DDS.
  • Use the remarks section to add explanations, descriptions, or expansion of the answers to questions. Use this area to record other pertinent information about the claim for the DDS.
  • See the following examples of when to use the remarks section.
  • a. Medicare for Qualified Government Employment (MQGE) cases
  • a. Medicare for Qualified Government Employment (MQGE) claims
  • Enter the following information:
  • * When applicable, enter a remark to advise the DDS that the claimant filed an application with the Office of Personnel Management for an annuity based on disability, or is receiving an annuity based on disability. Include the Civil Service annuity claim number;
  • * When forwarding MQGE cases to the DDS for a disability determination, annotate the remarks section “MQGE claim for Medicare entitlement only;”
  • * When developing disability for MQGE claims and there are differences in the DLI or the prescribed period for MQGE and cash benefits, annotate the remarks section to notify the DDS to avoid unnecessary development; and
  • * If a claimant is potentially entitled to both MQGE and DIB benefits with different DFIs, DLIs, and PODs, the FO must indicate this in the remarks section to alert the DDS to develop evidence based on multiple onset dates.
  • For more information on MQGE policy and procedures, see DI 11035.001, DI 11035.005, and DI 25501.365.
  • * When applicable, alert the DDS that a claimant filed an application with the Office of Personnel Management for an annuity based on disability, or is receiving an annuity based on disability; include the Civil Service annuity claim number, see DI 11035.010;
  • * When forwarding MQGE only claims to the DDS for a disability determination, annotate “MQGE claim for Medicare entitlement only”;
  • * If a claimant is potentially entitled to both MQGE and DIB benefits with different DFIs, DLIs, and PODs, alert the DDS to develop evidence based on multiple onset dates.
  • See MQGE policy and procedures:
  • * DI 11035.001 Medicare for Qualified Government Employment (MQGE) Claims Based on Disability
  • * DI 11035.005 Developing Medicare for Qualified Government Employment (MQGE) Claims Using the Electronic Disability Collect System (EDCS)
  • * DI 25501.365 Established Onset for Medicare Qualified Government Employment (MQGE) Claims
  • b. Consultative examination (CE) appointment
  • If the claimant expects difficulties in keeping a possible CE appointment (e.g., lack of transportation, home confinement due to disability, inability to read, no telephone where claimant can be reached, or homelessness), document the reason in the remarks section.
  • If the claimant expects difficulties in keeping a CE appointment, document the reason.
  • c. Prisoner cases
  • EXAMPLE: lack of transportation, home confinement due to disability, inability to read, no telephone to reach the claimant, or homelessness.
  • For applicable remarks to document prisoner cases, refer to Field Offices Identifying and Documenting Prisoner Status for Title II Disability Benefits in DI 10105.094B.2.
  • c. Prisoner claims
  • For applicable remarks to document prisoner claims, refer to
  • * DI 10105.094B.2. Documenting the SSA–3367
  • * DI 23530.001B.1. FO actions upon receipt of referral
  • d. Recontacting the claimant
  • If re-contact with the claimant is difficult (e.g., when the claimant is homeless, will be difficult to contact by telephone, or will be on an extended trip and unavailable for contact), document the reason in the remarks section. For more information, see DI 11005.001A.2.
  • If re-contacting the claimant is difficult, document the reason, see DI 11005.001A.2.
  • EXAMPLE: Telephone contact with a homeless claimant may be difficult, or a claimant may be on an extended trip and unavailable for contact.
  • e. Curtailing completion of Form SSA-3368-BK (Disability Report – Adult) or SSA-3820-BK (Disability Report – Child)
  • If you curtail completion of the SSA-3368-BK or SSA-3820-BK, explain why in the remarks section. See details in DI 11005.020.
  • If you curtail completion of the SSA-3368-BK or SSA-3820-BK, explain why per DI 11005.020.
  • f. Earnings that are clearly not SGA
  • f. Blindness claims
  • Document the monthly earnings allegations and write “clearly not SGA” in the remarks section per DI 10505.003B.1.a.
  • In blindness, visual impairment, and low vision claims,
  • * enter “If the claimant is found statutorily blind, the blind DFI is MM/DD/YYYY.”
  • * you may need to provide two DFIs and two DLIs (non-blind and blind) if the claimant alleges both a physical impairment and blindness or a visual impairment, see DI 11005.071.
  • g. Blindness claims (EDCS 3367 only)
  • g. Potential parent’s benefits claims
  • In blindness and visual impairment claims, enter the following statement: “If claimant is found statutorily blind, the blind DFI is MM/DD/YYYY and the blind DLI is MM/DD/YYYY.”
  • If the DIB claimant alleges providing half support to a parent at the time of onset, enter the following statement: “Potential Parent’s Benefits - Do not use the DIB expedient when establishing the EOD,” see DI 25501.300.
  • h. Potential parent’s benefits claims
  • h. Fraud or Similar Fault cases
  • If the DIB claimant alleges providing half support to a parent at the time of onset, enter the following statement: Potential Parent’s Benefits - Do not use the DIB expedient when establishing the EOD.” (See DI 25501.300.)
  • Describe any fraud or similar fault issues, see DI 11006.010.
  • 10. INTERVIEWER INFORMATION
  • i. Medicare Waiting Period cases
  • Print the interviewer’s name or the name of the person completing the form (if different from interviewer), the interviewer’s area code and phone number, and date the form.
  • If onset is more than five years after the prior termination, enter
  • * “Medicare Waiting Period Determination Needed,”
  • * the diagnosis code from the prior entitlement, and
  • * the month of prior termination.
  • B. Supplemental instructions for Form SSA-3367 for specific claim types
  • For more information, see DI 11010.261 Field Office Applying Prior Entitlement Months to the Medicare Waiting Period
  • You need supplemental claim information regarding insured status, prescribed period or controlling date, or both, for the claim types described in DI 11005.045B in this section. If you fail to document this information properly, it could affect the claimant’s entitlement to benefits.
  • j. COBRA cases
  • 1. DIB and freeze cases with a non-blind DLI prior to the filing date and an allegation of blindness, vision problems, or low vision
  • Annotate “COBRA case” and the date the employee must notify the health plan administrator, see DI 11080.005.
  • When an applicant alleges blindness, vision problems, or low vision, the blind date first insured (DFI) and the blind date last insured (DLI) could be material to the established onset date for blindness.
  • INTERVIEWER INFORMATION
  • * Print the interviewer’s name, area code, and phone number
  • * Print the name of the person completing the form (if different from the interviewer)
  • * Date the form.
  • Provide the blind DLI when the non-blind DLI is in the past or is likely to expire before DDS or the Office of Disability Adjudication and Review (ODAR) renders a decision (e.g., will expire within six months of the filing date or the date of appeal). In these cases:
  • * In item 3, Potential Onset Date, check the “OTHER” block. Enter NONE and explain in Item 5 (no disability entitlement, blindness entitlement only) in the space provided.
  • * In item 5, Explanation for Potential Onset Date, when applicable, enter the following statement for paper claims: “If claimant is found statutorily blind; the blind DFI is MM/DD/YYYY.
  • * In item 6, Miscellaneous Information, “Date last insured (DIB/Freeze case)” field, enter the non-blind DLI in the space provided.
  • * In item 6, Miscellaneous Information, enter the blind DLI in the “Blind date last insured (if applicable)” field.
  • B. Form SSA-3367 supplemental instructions for specific claim types
  • NOTE: For EDCS blindness claims, see DI 11005.045A.9.g. in this section.
  • Document information properly as it could affect the claimant’s entitlement to benefits for the claim types described in this section. For each of the following claim types provide the following:
  • * supplemental claim information regarding insured status, and
  • * prescribed period or controlling date, or both.
  • 2. MQGE cases
  • 1. DIB and freeze claims with a non-blind DLI and an allegation of blindness, vision problems, or low vision
  • There may be a second, more recent DLI for Medicare purposes when the claimant meets insured status. For MQGE cases:
  • * In item 4, Reason for Potential Onset Date, check the “Date Last Insured” block.
  • * In item 5, Explanation for Potential Onset Date, when applicable, enter the following statement: “Possible later DLI for Medicare purposes only due to claimant being a Medicare Qualified Government Employee”.
  • * In item 6, Miscellaneous Information, “Non-blind date last insured (DIB/Freeze case)” field, enter the DLI (the non-blind DLI). For further instructions for MQGE cases, refer to DI 11005.045A.9.a. in this section.
  • The blind DFI and blind DLI could be material to the established onset date for blindness when applicant alleges:
  • * blindness,
  • * vision problems, or
  • * low vision
  • 3. DWB cases
  • When there are both non-blind and blind allegations, provide the non-blind DLI and the blind DLI. In these claims:
  • * In item 6, Miscellaneous Information,
  • * Enter the non-blind DLI in the “Non-blind date last insured (DIB/Freeze case)” field.
  • * Enter the blind DLI in the “Blind date last insured (if applicable)” field.
  • * Enter in the Remarks section, “If the claimant is found statutorily blind, the blind DFI is MM/DD/YYYY.”
  • For DWB cases, provide the following information:
  • * In item 6, Miscellaneous Information, always enter the protective filing date.
  • * In item 6, Miscellaneous Information, enter the beginning and ending dates of the prescribed period and the controlling date. To determine these dates, see the guide in DI 11005.050C.
  • * In item 6, Miscellaneous Information, in a Medicare-only claim filed by a mother or father beneficiary, enter “Not yet started” in the line for “End of Prescribed Period,” because the prescribed period has not yet begun; see DI 11005.050B.1.
  • 2. MQGE claims
  • There may be a second, more recent DLI for Medicare purposes when the claimant meets insured status. For MQGE claims:
  • * In item 4, Reason for Potential Onset Date, check the “Date Last Insured” block.
  • * In item 5, Explanation for Potential Onset Date, when applicable, enter “Medicare Qualified Government Employee, DLI for Medicare purposes only is XX/XX/XXXX.”
  • * In item 6, Miscellaneous Information, “Non-blind date last insured (DIB/Freeze case)” field; enter the non-blind DLI in the space provided.
  • * If a claimant is potentially entitled to both MQGE and DIB benefits with different DFIs, DLIs, and PODs, you must indicate this in the Remarks section to alert the DDS to develop evidence based on multiple onset dates. Similar remarks regarding the DFI, POD, and prescribed period may be required if the claimant is potentially entitled to both MQGE and DWB benefits.
  • * For additional instructions for MQGE claims, refer to Capability/Remarks in this section.
  • 3. DWB claims
  • In item 6, Miscellaneous Information, for DWB claims
  • * enter the protective filing date;
  • * enter the beginning and ending dates of the prescribed period and the controlling date per DI 11005.050C;
  • * verify that, for EDCS cases, the systems derived controlling date is correct.
  • * in a Medicare-only claim filed by a mother or father beneficiary, enter “Not yet started” in the line for “End of Prescribed Period,” because the prescribed period has not yet begun; see DI 11005.050B.1.
  • C. References
  • * DI 10505.003 Evaluating and Developing Earnings that Clearly are or are not Substantial Gainful Activity (SGA)
  • * DI 10505.035 Documenting Employment Cases Using Forms SSA-821-BK (Work Activity Report-Employee) and SSA-823 (Report of SGA Determination-For SSA Use Only)
  • * DI 10510.025 Documenting Self-Employment Cases Using the SSA-820-BK (Work Activity Report-Self-Employment) and the SSA-823 (Report of SGA Determination- For SSA Use Only)
  • * DI 10515.000 Evaluation of Work Activity in Title II Blindness Cases – Table of Contents
  • * DI 25501.220 Potential Onset Date (POD)
  • * DI 25501.380 Establishing the Established Onset Date (EOD) of Statutory Blindness in Title II Disability Insurance Benefits (DIB) Claims
  • * DI 27500.000 Reopenings, Adoptions and Refilings – Table of Contents
  • * DI 81010.025 Completing Electronic Disability Collect System (EDCS) Forms for Initial Claims
  • * DI 81010.150 Processing Claims Appeals of Medical Decisions in Electronic Disability Collect System (EDCS)
  • * AM–14047 REV Potential Erroneous DLI Propagation in EDCS
The materials available at this web site are provided free of charge, for informational purposes only, and without warrant by True Link Financial, Inc., and are not legal advice or Social Security benefits advice. You should contact your attorney to obtain advice with respect to any particular issue or problem, or the Social Security Administration with any general inquiries. Click here to view this section of the POMS on the Social Security Administration website.