DI 11005.601: The Disability Interview-- Identifying Terminal Illness (TERI) Cases

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~~Effective Dates: 11/07/2016 - Present~~
Effective Dates: 02/26/2018 - Present
TN 20 (01-08)
DI 11005.601 The Disability Interview-- Identifying Terminal Illness (TERI) Cases
A. TERI cases
Cases with an indication of a terminal illness (TERI) must be handled in an expeditious manner because of their sensitivity. These cases may be identified by the Teleservice Center (TSC), Field Office (FO), or the Disability Determination Services (DDS). TERI claims may share common traits with other types of cases but are distinct, as they are indicative of a terminal illness. Military Casualty/Wounded Warrior (MC/WW) cases are processed under expedited TERI procedures (see DI 11005.006), but cannot be classified as TERI without the indication of terminal illness. Other types of cases involve a high probability of allowance, but DO NOT necessarily meet the TERI criteria including:
* Quick Disability Determination (QDD) cases;
* Presumptive Disability/Presumptive Blindness (PD/PB) cases;
* Compassionate Allowance cases (CAL);
* Cases where the impairment meets or equals listing level severity; and
* Cases with a determination of less than sedentary capacity.
B. Identifying TERI cases
TERI cases are identified either directly by the claimant’s allegation or indirectly by the TSC, FO, or DDS staff by the use of TERI descriptors. All claims representatives and disability examiners must be alert to identify possible TERI cases. (See DI 11005.601C. in this section.)
Once designated as a TERI case, that designation remains on the case until all administrative appeals are exhausted. TERI case processing is expedited at each step in the process.
C. List of descriptors
Use the following criteria to identify a TERI case:
1. Situation—TERI cases
* An allegation (e.g., from the claimant, a friend, family member, doctor, or other medical source) that the illness is terminal;
* An allegation or diagnosis of Amyotrophic Lateral Sclerosis (ALS), known as Lou Gehrig’s Disease;
* An allegation or diagnosis of Acquired Immune Deficiency Syndrome or Acquired Immunodeficiency Syndrome (AIDS) (See DI 11055.241 – Processing Claims for Individuals with An Allegation of Human Immunodeficiency Virus [HIV] Infection); or
* The claimant is receiving inpatient hospice care or is receiving home hospice care, e.g., in-home counseling or nursing care.
2. Condition—TERI cases
The claimant alleges or medical records indicate an impairment which is untreatable, i.e., the impairment cannot be reversed and is expected to end in death. These impairments include, but are not limited to, the following list of descriptors:
* Chronic dependence on a cardiopulmonary life-sustaining device.
* Awaiting a heart, heart/lung, lung, liver, or bone marrow transplant (excludes kidney and corneal transplants).
* Chronic pulmonary or heart failure requiring continuous home oxygen and an inability to care for personal needs.
* Any cancer (malignant neoplasm) which is:
* Metastatic (has spread);
* Defined as Stage IV;
* Persistent or recurrent following initial therapy; or
* Inoperable or unresectable.
* An allegation or diagnosis of :
* Cancer of the esophagus;
* Cancer of the liver;
* Cancer of the pancreas;
* Cancer of the gallbladder;
* Mesothelioma;
* Small Cell or Oat Cell lung cancer;
* Cancer of the brain; or
* Acute Myelogenous Leukemia (AML) or Acute Lymphocytic Leukemia (ALL).
* Comatose for 30 days or more.
* Newborn with a lethal genetic or congenital defect.
The above list, shown on the back of the TERI Flag (i.e., SSA-2200 [TERI Case]), is not intended to be all-inclusive. Use it to provide general guidance in the identification of TERI cases. The remaining category of: Other: ____________ allows for cases, which are not identified in the list of descriptors, to be included as well, as long as the medical condition is untreatable and is expected to end in death.
D. TERI case procedure
1. Expedited appointment process
* Review the REFR screen for an indication of TERI status. The TSC will make an appointment for the claimant within 3 working days. If no appointment is available, the Teleservice Center Representative (TSR) notes “Appointment needed ASAP” on the referral to the FO.
* If the TSC did not make the appointment, the FO will contact the claimant within 2 days to arrange the appointment.
* Mail a disability packet to the applicant, if one has not been received from the TSC when TERI status is established.
2. Designating TERI cases
* Identify potential TERI cases based on the claimant's allegation or through information from the claimant using descriptions in this section at DI 11005.601C as a guide.
* Verify TSR TERI case designations and disregard if requirements in DI 11005.601C in this section are not met, except where the designation is based on the claimant's or the claimant's representative's direct statement.
3. FO identification of TERI case
Once the FO has identified a TERI case, proceed as follows.
a. Flagging -- TERI cases
For information about adding a TERI flag to a Certified Electronic Folder (CEF), see DI 81010.080.
For Electronic Disability Collect System (EDCS) exclusions:
* Attach a TERI flag to the front of the modular disability folder (MDF). Do not use a photocopy of this form. This form is a different color to bring attention to the case. Also, place a TERI flag on the FO-retained, non-disability folder, if any. (If all non-disability development was completed before transmittal to DDS, the FO does not retain a non-disability folder.)
* Indicate the reason for the TERI designation by checking the appropriate box on the reverse of the flag.
NOTE: Disability Determination Services (DDS) legacy systems may only identify one type of priority case when multiple priority flags are present (e.g., Suicide Risk, Terminal Illness [TERI], and PD). The disability examiner must review the certified electronic folder (CEF) or the paper modular disability folder (MDF) to ensure the case is developed and processed appropriately.
b. Development -- TERI cases
Title II
If possible, process cases through the Earnings Computation (EC) system.
* Immediately request a pre-adjudicative EC. This usually provides a record of earnings and a computation.
* If the EC request gives you an Office of Earnings Operations (OEO) feedback condition, request feedback immediately.
* Check the Field Office Case Status Query in the Modernized OCRO System (MOS) to ensure that your request is being controlled. See EM 063.002, OCO Case SSN Status (OTMS).
* If the EC request results in an exception or limitation, use a certified earnings record to process the case (A101). You will need an interactive computation to obtain a Primary Insurance Amount (PIA).
Title XVI
Use simultaneous development to process these cases following the instructions in “Explanation of Deferred and Simultaneous Development” (SI 00603.002C) and “Simultaneous Development Application Process” (SI 00603.004).
NOTE: Although a priority case, prior to transferring a claim to DDS the FO is responsible for Substantial Gainful Activity (SGA) development and documentation. For more information on SGA documentation, refer to DI 10505.035 Documenting Employment Cases Using Forms SSA-821 and SSA-823. For information on providing an accurate potential onset date (POD) refer to DI 25501.220 Potential Onset Date (POD) and DI 11005.045-Completing the SSA-3367 (Disability Report-Field Office.)
c. Transmittal of TERI cases
* Annotate the form that is used to transmit the folder (e.g., EDCS remarks section or SSA-831 [Disability Determination and Transmittal]), as applicable, with the words “TERI CASE” in all caps in the remarks section of the form.
* Send EDCS exclusions to the DDS in a separate priority mail envelop with a TERI designation clearly marked on the outside of the envelop.
d. Tracking TERI cases
Establish a manual management tracking system when automated systems are not available. For information about tracking and EDCS transfer see, DI 81005.030, DI 80550.200, and DI 81010.085. Under either system:
* For Modernized Claims System (MCS) cases, automated tracking is accomplished by entering the issue “TERI” on the Development Worksheet (DW01).
* For Modernized Supplemental Security Income Claims System (MSSICS) cases, create an issue on the DW01 (Modernized System Operations Manual MSOM MSSICS 022.004 ). For non-MSSICS cases, code the SZ field on the SSA-450SI (SSI Data Input and Determination) so that the system can generate a TZ diary for control purposes. (See SM 01005.466.)
* Obtain a Disability Determination Service Query (DDSQ) to verify receipt 2 days (7 days for non-EDCS cases) after transmittal of the case. If not on the DDSQ, and an eView query cannot confirm DDS acceptance of the case, contact DDS by telephone or fax for receipt.
* Contact the DDS examiner when the DDS has not completed its actions within 30 days after receipt of case. Offer FO assistance, as needed.
* Contact the DDS management when the DDS has not completed its actions within 60 days after receipt of the case. Offer FO assistance, as needed.
* Ask the regional office (RO) for assistance if the FO and DDS cannot resolve the problems of the delayed case.
* For Foreign cases, follow TERI identification and flagging procedures outlined above and expedite transmittal of the case to the Office of International Operations (OIO).
e. Allegation of TERI after transmittal of the case to DDS
When there is a subsequent allegation of TERI, request the DDS to attach a TERI flag and handle under TERI processing instructions (see DI 23020.045). Proceed as in this section at DI 11005.601D.3.b.
Fax medical evidence of record (MER) submitted to the FO into the CEF, and alert the DDS.
4. DDS identification of TERI case
Upon receipt of DDS notification of TERI status, the FO should proceed as follows:
* Initiate simultaneous development of non-disability factors.
* Establish a tracking system and proceed as in this section at DI 11005.601D.3.d.
5. Allowance -- TERI cases
* The FO continues FO tracking control until all payment actions are completed.
* The DDS mails EDCS exclusions to the FO or the designated Processing Center (PC) in a separate envelop with a TERI designation.
Title II
After receiving the case from the DDS:
* Verify any DDS-triggered Title II payment actions.
* Trigger payment actions as appropriate.
* Send Title II cases to the PC. Place EDCS exclusions in a specially marked TERI Case envelop if PC payment actions are needed. Place the TERI flag on top of the Form SSA-3601 (Non-CAPS Routing) with the PC destination clearly visible.
* After 20 days, obtain a PCACS (Processing Center Action Control System) or Paperless Read Only Query System (PPL ROQS) query and MBR (Master Beneficiary Record) to obtain the status of the case.
* If necessary, telephone the Inquiries & Expediting (I&E) Staff in the PC to ensure expedited payment actions.
Title XVI
To effectuate payment, follow the procedures in SI 00603.031 and SI 00603.033.
6. Appeals of TERI cases
a. TERI processing
* Identify TERI cases using DWO1 screens and by the TERI flag in eView or on the case folder.
* Annotate the transmittal form with “TERI CASE” when any level of appeal, i.e., a request for reconsideration, hearing, or Appeals Council (AC) review is filed.
b. Hearing/AC TERI cases – EDCS exclusions
For EDCS exclusions:
* Annotate the TERI flag with the date sent to Office of Disability Adjudication and Review (ODAR).
* Annotate the TERI flag with the date sent to Office of Hearings Operation (OHO).
* Send a copy of the annotated TERI flag to the RO to initiate RO tracking.
E. Procedure -- Special handling of TERI cases in the PC
1. Title II--TERI allowances, EDCS exclusions
For paper “E101” awards and other manual awards, process as follows:
* Separate the TERI case from regular mail when received in the mailroom.
* Hand-carry TERI cases to the Inquiry and Expediting (I&E) Staff for payment processing.
* Control and monitor these cases through completion.
* The manager ensures that these cases are properly read into the system with a special event indicator.
* The technical assistant performs a consistency check on the Form SSA-101-U3 (Determination of Award) per GN 01010.285 and GN 01010.220 prior to issuing the case for review by the specialist.
2. Title XVI--TERI allowances
Follow the procedures in SI 00603.011 and SI 00603.015 when a favorable determination is made at any level of appeal.
F. Exhibit - SSA-2200 -- TERI flag
See OS 15020.301 for the TERI Flag.

POMS Reference

DI 11005.601: The Disability Interview-- Identifying Terminal Illness (TERI) Cases