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DI 11005.604: Processing Compassionate Allowances (CAL) in the Field Office (FO)

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  • Effective Dates: 01/09/2017 - Present
  • Effective Dates: 02/26/2018 - Present
  • TN 38 (11-12)
  • DI 11005.604 Processing Compassionate Allowances (CAL) in the Field Office (FO)
  • A. CAL cases
  • The CAL initiative is designed to quickly identify diseases and other medical conditions that invariably qualify under the Listing of Impairments based on minimal, but sufficient, objective medical information. If the condition does not meet these strict criteria, it is not designated as a CAL case. For a complete list of CAL conditions, see DI 23022.080.
  • All CAL identified conditions are entered into the Predictive Model (PM) and are selected for CAL processing based solely on the claimant’s allegations listed on the SSA-3368 (Disability Report—Adult) or SSA-3820 (Disability Report--Child).
  • Like Quick Disability Determinations (QDD), CAL cases receive expedited processing within the context of the existing disability determination process.
  • CAL cases are similar to Terminal Illness (TERI) claims, however, not all CAL cases involve terminal illness. For example, a person with a spinal cord injury could qualify for a CAL – even if he or she is expected to live for many years.
  • B. CAL and QDD similarities and differences
  • Process CAL cases in the same manner as QDD cases. Before processing a CAL case, review QDD procedures in DI 11005.603 (Processing Quick Disability Determinations (QDD) Cases—Field Office (FO) Instructions).
  • 1. Similarities of CAL and QDD cases include:
  • * Most CAL cases are identified by the PM upon Electronic Disability Collect System (EDCS) transfer to the disability determination services (DDS) at the initial claim adjudicative level. CAL and QDD do not apply to Continuing Disability Review (CDR) classification cases.
  • * CAL cases are processed in the DDS by adjudicators who meet the qualifications set forth in DI 23022.020.
  • * Expedited processing applies to all CAL-identified cases.
  • * CAL cases can be removed from the CAL process; however, the reasons for taking such action on a CAL case are very limited, as set out in DI 23022.055B.
  • * Cases removed from the CAL process, can be reinstated in certain circumstances, as set out in DI 23022.055C.
  • * Cases determined to be CAL could also meet the criteria for QDD, and would be designated both QDD and CAL. For example, the case could meet the scoring criteria for QDD and also have an allegation of a CAL condition.
  • If the PM identifies a case as both QDD and CAL, the case can be removed from QDD yet maintain its CAL status, and vice versa.
  • 2. Differences of CAL and QDD include:
  • * The PM criteria for CAL are simpler than the criteria for QDD. A CAL case is identified solely on a claimant’s allegation of a disease or other medical condition that matches a disease or condition loaded in the PM (by name, synonym or abbreviation). No scoring or threshold criteria are necessary for CAL selection. For example, a case must have a high enough score from the PM to be considered a QDD. For CAL, the PM only needs to see the allegation of a condition on the CAL list.
  • * Designated employees in the DDS, the Office of Quality Review (OQR), and the Office of Disability Adjudication and Review (ODAR) can manually add a CAL indicator to a case, which is not an available function in the QDD process. However, FO employees cannot add or delete CAL cases.
  • * Designated employees in the DDS, the Office of Quality Review (OQR), and the Office of Hearings Operation (OHO) can manually add a CAL indicator to a case, which is not an available function in the QDD process. However, FO employees cannot add or delete CAL cases.
  • NOTE: The FO workload management information (WMI) listings do not capture these manual additions, reinstatements, or removals. For CAL cases that are not already identified as QDD, the FO is automatically notified when a case is added, reinstated, or removed from the CAL process via an EDCS action item for electronic claims. FOs regularly monitor EDCS action lists to identify any case where a CAL indicator is set after transfer to initiate a full non-medical development of the case.
  • * Unlike QDD, there are very few reasons for removing a case from CAL processing (these are addressed in DI 23022.055). The most significant difference is a CAL case can be processed to a denial.
  • * If a case is identified as CAL and QDD, continue to follow expedited QDD processing guidelines, even if the DDS removes the case from QDD processing. For example, if you have a QDD case that you cannot complete within the QDD timeframe, or if the claimant moved out of State, you do not need to remove the case from CAL processing.
  • * A new Compassionate Allowance page can be accessed by selecting a hypertext link labeled [CAL] in the top right hand frame of the Electronic Folder (EF) in eView. The CAL link will display [CAL: Y] or [CAL: N.]
  • * CAL cases can be identified at the Initial, Reconsideration, Hearing, and Appeals Council adjudicative levels.
  • C. Screening for CAL at the initial interview or when reviewing an iDIB claim
  • Unlike QDD, there is a pre-determined list of conditions/diseases that qualify as CAL.
  • All adjudicators should be familiar with the current CAL criteria, found in the CAL list in DI 11005.604G. Information on the Calculate CAL button on the Illness and Onset page of EDCS (3368 and 3820) and guidelines for its use is found in DI 81010.085. Immediately initiate QDD procedures, including full development of non-medical evidence and completion of a full Title XVI claims path for SSI cases, if you recognize a potential CAL condition during your disability interview or review of an online application.
  • NOTE: Diseases or conditions are frequently added to the CAL list, therefore, refer to the list on a regular basis to verify that you have updated information.
  • D. Processing initial claims involving CAL
  • If you identify a potential CAL case during your interview or review of an online application, follow these steps:
  • * Follow instructions for processing QDD cases in (DI 11005.603C. – DI 11005.603F.).
  • * If the claimant alleges cancer, obtain the type and stage (if known) and record this information on the ADIB screens on the Disabling Condition section of the Modernized Claims System (MCS) DISB or Modernized Supplemental Security Income System (MSSICS), or both.
  • * After transferring the case to the DDS in EDCS, if CAL has been identified, return to MCS/MSSICS and annotate CAL as an issue on the DW01 with a tickle date of 20 days.
  • * For Title XVI cases, revisit the possibility of Presumptive Disability/Blindness (PD/PB) payments if one of the PD/PB conditions is met. (For PD/PB instructions, see DI 11055.230 and DI 11055.240)
  • NOTE: When transferring a case in EDCS, the PM software determines whether the case qualifies for processing as a QDD or CAL case, or both. The FO receives one of the following on-screen message boxes in EDCS:
  • * “This case has been marked as a Compassionate Allowance case. Full non-medical development required.”, or
  • * “This case has been marked as a Quick Disability Determination and Compassionate Allowance case. Full non-medical development required.”
  • E. CAL identified or removed after FO transfer
  • Unlike the QDD process, the DDS, OQR, and ODAR can add cases to CAL processing.
  • Unlike the QDD process, the DDS, OQR, and OHO can add cases to CAL processing.
  • If a case has not already been identified as a QDD case, an electronic alert will be sent to the FO when CAL is added to (or removed from) a case.
  • If the FO receives an EDCS Action Item that a case has been added to CAL processing:, they take the following action:
  • * For Initial Claims, the FO updates the MCS/MSSICS DW01 with CAL as an issue using a tickle of 20 days. For appeals, a 20 day tickle is not needed.
  • * Initiate full non-medical development.
  • Conversely, if the FO receives an EDCS Action Item that a case has been removed from CAL processing; update the MCS/MSSICS DW01 CAL issue receipt line with the date the Action Item was received and add the remark “removed from CAL”
  • If the FO receives a report of what appears to be a previously unreported CAL condition (from the claimant or representative) while the claim is at the DDS, the FO should:
  • * Send an Update After Transfer (UAT) message via EDCS to the DDS concerning the allegation of a possible CAL condition.
  • * If the condition alleged by the claimant also qualifies as a TERI case, add an electronic TERI flag.
  • * Consider PD/PB payments for Title XVI cases.
  • * Update the MCS/MSSICS DW01 with CAL as an issue and set a tickle for 20 days for initial claims.
  • * Initiate full non-medical development.
  • F. Appeals processing for CAL cases
  • If a CAL case is denied, it retains priority status at all levels of adjudication.
  • To determine if a denied claim was processed as CAL, look for the CAL: Y indicator on the eView header or the issue CAL on the MCS/MSSICS DW01.
  • When processing an appeal in a CAL case:
  • * Follow processing guidelines in the following sections:
  • * DI 12005.000--Reconsiderations-Initial Claims,
  • * DI 12010.000--Hearings Level Review-Initial Claims, and
  • * DI 81010.150--Processing Claims Appeals of Medical Decisions in Electronic Disability Collect System (EDCS).
  • * Fax additional medical records of up to 15 pages, if they are in the claimant’s possession, into eView per (DI 11005.603C.4).
  • * Notify DDS/ODAR of the need for CAL processing by annotating the remarks section of the EDCS Transfer page.
  • * Notify DDS/OHO of the need for CAL processing by annotating the remarks section of the EDCS Transfer page.
  • G. Request for review at Appeals Council (AC) and a subsequent claim is filed that is CAL identified
  • If a case is pending at the AC and a CAL identified claim is subsequently filed, and identified, upon transfer of the new claim through EDCS to the DDS, the AC is notified via the following message:
  • “Another case with this SSN: (insert SSN) has been identified as Compassionate Allowance because of the following conditions: <insert conditions>.”
  • Conversely, if a case is pending at the AC and a subsequent case is removed from CAL processing by the DDS, the AC is notified via the following message: “Another case with this SSN: (insert SSN) has been removed from the Compassionate Allowance process.”
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