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

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~~Effective Dates: 05/11/2018 - Present~~
Effective Dates: 07/16/2018 - Present
TN 51 (12-17)
DI 11005.045 Completing the SSA-3367 (Disability Report – Field Office)
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
* interviewer observations.
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. 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)
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 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 alleges he or she became unable to work because of his or her medical condition, see DI 25501.210.
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.
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.
Make all AOD changes in the Modernized Claims System (MCS) and in the Modernized Supplemental Security Income Claims System (MSSICS).
c. Item 3: Potential Onset Date (see DI 25501.220 Potential Onset Date (POD))(check type of claim(s) and enter potential onset date)
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. The POD must be after the claimant meets all non-medical requirements. NOTE: For EDCS reconsideration level cases, enter the POD and the POD reason in the Remarks section.
* The FO does not have the capability to enter the POD on the 3367 in EDCS at the Appeals Council or Federal Court levels. NOTE: Although the EDCS 3367 appears on hearing level cases, EDCS does not require the form to be completed before transferring the case to the hearing office.
* 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.
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.
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 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.
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
Check the appropriate block for the reason for the POD.
NOTE: Check the “Other” block if the POD is the same as the AOD.
* SSI application date
* Date last insured
* Date first insured
* Controlling date
* Other (explain in item 5)
* Work before or after the AOD (check all that apply):
* UWA;
* SGA;
* Not SGA;
* 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).
Do not complete an SSA-821-BK or SSA-823 if the work is clearly not SGA per DI 10505.003.
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, 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.
* POD = AOD.
2. Item 6: MISCELLANEOUS INFORMATION
Provide the following information:
* 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
DI 25510.010 Establishing a Closed Period of Disability and Protecting a Closed Period Freeze Under Title II
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, 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 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.”
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.
Refer to detailed FO procedures on processing PD and PB claims in DI 11055.240.
5. Item 9: OBSERVATIONS/PERCEPTIONS
How was the interview conducted?
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
Document any development initiated by the FO.
For information about FO development, see
* DI 11010.485 through DI 11010.495 for medical evidence
* DI 22501.002B. for non-medical evidence.
CAPABILITY/REMARKS
7. Item 11: If medical evidence was brought in to the FO by the claimant, check here
Indicate whether the claimant submitted medical evidence of record (MER) to the FO.
8. Item 12: Is DDS capability development needed?
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.
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?
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.
a. Medicare for Qualified Government Employment (MQGE) claims
Enter the following information:
* 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 CE appointment, document the reason.
EXAMPLE: lack of transportation, home confinement due to disability, inability to read, no telephone to reach the claimant, or homelessness.
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-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 per DI 11005.020.
f. Blindness claims
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. Potential parent’s benefits claims
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. Fraud or Similar Fault cases
Describe any fraud or similar fault issues, see DI 11006.010.
i. Medicare Waiting Period cases
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.
For more information, see DI 11010.261 Field Office Applying Prior Entitlement Months to the Medicare Waiting Period
j. COBRA cases
Annotate “COBRA case” and the date the employee must notify the health plan administrator, see DI 11080.005.
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.
B. Form SSA-3367 supplemental instructions for specific claim types
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.
1. DIB and freeze claims with a non-blind DLI and an allegation of blindness, vision problems, or low vision
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
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.”
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 10515.000 Evaluation of Work Activity in Title II Blindness Cases – Table of Contents
* 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 81010.150 Processing Claims Appeals of Medical Decisions in Electronic Disability Collect System (EDCS)

POMS Reference

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