TN 49 (08-08)

A. Procedure – Retirement Survivor Insurance (RSI) claimant not insured for Disability Insurance Benefits (DIB)

The Field Office (FO) forwards Retirement Insurance Benefits (RIB) cases to the Program Service Center (PSC) when there is a concurrent filing of a retirement claim with a disability claim, or when there is an allegation of disability under the following conditions:

• The claimant does not meet the insured status requirements for Disability Insurance Benefits (DIB); or

• An earlier onset is not possible; and

• There is no prior period of disability ending within 5 years before the month the current disability began.

• Use the Document Processing System (DPS) to prepare the notice. See General Notice Policy - Title II and Title XVI - NL 00603.001 for FO notice instructions.

B. Procedure - Childhood Disability

When there is a denial on a claim for Childhood Disability Benefits (CDB), an SSA-L236 (Notice of Disapproved Claim for Child 22 or Older) or SSA-L236A (Notice of Disapproved Claim to Child 18 to 22) is notice of the determination. Also prepare an SSA-4268 (Disability Determination Rationale) in this situation and attach it to the SSA-L236 or SSA-L236A.

If a disability determination is made for a child age 15 1/2 to 17 1/2 to permit entitlement of a spouse, mother or father, send the notice to the spouse, mother or father.

C. Procedure - initial Title II, initial Title XVI and concurrent Title II/Title XVI SGA denials

1. General procedure

Prepare a notice in DPS with proper attachments containing required personalized information in every initial and reconsideration Title II, Title XVI and concurrent Title II/Title XVI Substantial Gainful Activity (SGA) denial. Instructions for notifying attorneys, representatives, or third parties, for disclosing information and returning documents are contained in Designating Notice Information on Disability Determination Form - NL 00603.025. In concurrent initial and reconsideration Title II/Title XVI SGA denials, and in initial Disability Insurance Benefits/Disabled Widow(er) Benefits (DIB/DWB), Disability Insurance Benefits/Childhood Disability Benefits (DIB/CDB) SGA denials, it is necessary to prepare a separate notice and personalized disability explanation for each claim.

2. FO-prepared personalized disability explanation

a. Required Title II/Title XVI SGA personalized disability explanation contents

The personalized disability explanation must contain the following elements:

• A list of the reports evaluated;

• A brief description of the findings to support the determination of the SGA denial and the conclusion that the claimant is not disabled because he or she is engaging in SGA;

• An explanation which includes the period of work evaluated, the employer's name, claimant's job title and a brief description of job duties, hourly rate of pay and average monthly earnings as well as the number of hours worked per week, a statement concerning subsidy, impairment work-related expenses (IRWEs) or absence of same; and

• A statement regarding the SGA determination, including a definition of SGA.

b. Example of personalized disability explanation

EXAMPLE: Initial SGA Denial language. The following language may be used in a personalized disability explanation.

The following reports were considered in evaluating your claim:

• Your statement about your job duties and earnings dated 08/16/99;

• A report of a telephone conversation between you and the Pasadena, California District Office dated 09/01/07; and

• A report of a telephone conversation dated 09/03/07 between the Pasadena, California District Office and your employer, the Pasadena Trucking Company.

  You said that you have been unable to work full-time as a truck driver since you injured your back on 01/05/05. You also said that you do not earn the wages paid to you. The evidence shows that you have worked 20 hours per week since 01/11/05 and you performed all the normal duties of your job, such as loading your truck and making necessary deliveries within the city. You earned $15.00 per hour for a total of $300.00 per week or more than $1200.00 per month during that time. Your employer indicates that you fully earn the wages paid to you.

  Work activity for earnings that average more than $900.00 per month is generally considered substantial gainful activity. Before January 2005, work averaging more than $830.00 a month was generally considered substantial gainful activity. Your claim must be denied because you are working and fully earning more than $900.00 per month.

  (Refer to Tables of SGA Earnings Guidelines and Effective Dates Based on Year of Work Activity - DI 10501.015 for the current SGA amounts.)

D. Procedure - release of personalized notices

Use the following procedure:

• The personalized notice consists of a form notice, a rider when necessary, and a personalized disability explanation. Do not date the notice if the Office of Disability Operations (ODO) releases it.

• In Title II or Title XVI SGA denials, the FO prepares the personalized notice and releases it. Place a copy of the notice in the official folder. For CEFs, if the notice is not stored in the Online Retrieval System (ORS), fax a copy into the electronic folder.

• In concurrent initial Title II/Title XVI SGA denials, the FO prepares and releases both the Title II/Title XVI personalized notices to the claimant. For CEFs, if the notice is not stored in ORS, fax a copy into the electronic folder. When the official folder is paper, place a copy of each notice in the official folder.

E. Procedure - special situations

1. Escalated claims

Use the following procedure:

• When a Title II claim in a concurrent Title II/Title XVI claim is escalated to the reconsideration level, include paragraph 585. See Numbered Paragraphs - NL 00708.100 in the notice.

• In a Title II only claim, if a claim for one benefit under Title II is escalated to the reconsideration level because a claim for another Title II benefit is at the reconsideration level, include paragraph 587. See Numbered Paragraphs - NL 00708.100.

• If a claimant for a Title II benefit files for reconsideration before notification of the initial determination, include paragraph 586 in Title II cases and the appropriate closeout paragraph on the combined initial-reconsideration notice. See Numerical Index of Automated and Manual Paragraphs - NL 00804.100.

2. Statutory blindness alleged (Title II only)

When a claimant alleges statutory blindness (stat blind) and is engaging in work activity and earning above the regular SGA level, the FO sends the claim to the DDS for a medical determination and advises the DDS that a determination regarding stat blind is needed. If the DDS determines that the claimant is not stat blind, the DDS continues to complete the Disability Determination and Transmittal (SSA-831) and processes the claim in accordance with existing instructions. The FO prepares a personalized SGA denial notice for claims where the eligibility requirements to receive benefits as a statutorily blind individual are not met.

The FO prepares the personalized disability explanation based on the instructions in DI 11010.345C.2. (in this section). The FO mails a copy of the personalized disability explanation with the manually prepared notice to the claimant. For CEFs, if the notice is not stored in the Online Retrieval System (ORS), fax a copy into the electronic folder.

If the official folder is paper, place a copy of the personalized disability explanation and a copy of the form notice in the official file.

If the DDS determines a claimant does meet the requirements for stat blind and makes a determination for “freeze only” purposes, the FO must send a notice to address the non-medical requirements. This type of case situation may be complex, varied, and infrequent, therefore, use independent judgment to decide what information must be included and use approved language (or follow the style of similar approved language) from stock paragraphs, exhibit letters, or model letters.

References:

• NL 00603.020 - Preparing a Notice for Situation Not Fully Covered by Instructions

• NL 00705.015 - Model Letter "L" - Freeze Allowance

3. Spanish notices

Spanish language versions of Title XVI notices are available. See NL 00801.025, Spanish Language Notices.

In cases where the claimant meets the criteria for receiving Spanish language notices, the FO sends the Spanish language version of the appropriate notice and Medicaid/State supplementation attachment.

If the FO has determined that Spanish language notification is required for claims that have been entered into EDCS, see Alerts, Flags, and Messages in the Electronic Disability Collect System (EDCS) - DI 81010.080 to notify DDS by adding a limited English Proficiency Flag. The information concerning Spanish notices should be placed in remarks of the 3367. If the official folder is paper, the remark "Spanish Notice Request” appears in item 34 of the SSA-831 or item 29 of the SSA-833 (Cessation or Continuance of Disability or Blindness Determination and Transmittal (Title II). Send an English notice with a Spanish cover sheet or an English and Spanish notice.

Prepare an English and Spanish notice if a Spanish version of an English language form notice is available. Use the single copy Spanish form with English forms while supplies last. Insert any additional paragraphs in English on the personalized disability explanation, an "O" Rider (Paragraph 800), or the Medicaid/State supplementation attachment. If a claimant moves to another State and a Spanish Medicaid/State supplementation attachment is not available, enter the appropriate paragraphs in English on the personalized disability explanation or an "O" rider (Paragraph 800). The completed English and Spanish notice is assembled in the following order:

• English form notice;

• English Medicaid/State supplementation rider (if applicable);

• Personalized disability explanation;

• Spanish form notice; and

• Spanish Medicaid/State supplementation attachment.

F. Procedure - other Disability notices

The SSA-L237 (Disallowance Letter Disability Denied) is the standard manual disallowance notice for most DIB cases processed in the PSC, ODO, or OIO (Office of International Operations). When the claim is denied for lack of severity, item 29 of the SSA-831 is completed with the appropriate paragraph numbers. The Claims Authorizer (CA) is responsible for including the paragraphs shown on the SSA-831 in the notice to the claimant (P. L. 96-265, section 305) before release.

When a DIB claimant dies while the disability determination is pending, send a denial notice regarding the DIB to the survivor if he or she filed a survivor claim before adjudicating the disallowance, regardless of the reason for disallowance. Notice about the disposition of the Number Holder’s (NH's) claim is included in the notice to the survivors in these cases.

In cases where the claimant dies within 5 months of the alleged onset date, and no earlier onset date is established, a personalized disability explanation is not needed. The PSC uses Form SSA-L237B (Disallowance Notice to Survivors of DIB Claimant) to notify the survivor in cases not processed through the Modernized Claim System (MCS) Earnings Computation (EC) when the claimant dies within 5 months of onset and no earlier onset can be established.

In similar cases processed by MCS EC, the FO inserts paragraph DDDR11 (see MCS Universal Text Identifiers (UTI) (NL 00725.005)) on the survivor's notice and forwards the file to the PSC after releasing the notice. In cases where the claimant dies within 5 months of the established onset date due to an unfavorable onset date determination, the DDS prepares a personalized disability explanation.

If a denial is applicable, and the claimant had filed an application but dies after the waiting period but before adjudication, the PSC is responsible for the preparation and release of the notice including a personalized disability explanation to the survivor.

Place the SSA-4268 in the appropriate official folder. The document is filed in Folder Section A, the front yellow (payment documents/decisions) section of the Modular Disability Folder (MDF) or in corresponding section of the CEF.

G. Procedure - DIB disallowed but period of Disability established

When a period of disability is established, but no disability benefits are payable, give the applicant notice of the dual action. An E3905 may be used with the appropriate paragraphs. See Disallowance – Miscellaneous Fill-in Letter - NL 00703.905. If Railroad (RR) compensation is involved, see DI 44005.005, Joint Freeze Processing. In prisoner cases where a period of disability is established, but disability benefits are not payable because of an incarceration-related impairment, use prisoner Model Letter "U." See Prisoner Model Letter “U” – Incarceration-Related Impairment – DIB Freeze Established - NL 00705.530. For procedures involving fugitive felons, see Initial Claims – Determining Fugitive Status - GN 02613.050.

H. Procedure - Disability cases routed directly to the PC

The FO has the primary responsibility for disability denial notices for DIB-RIB, DWB, and CDB claims. This includes MCS EC automated notices and manual notices. However, the PC must review the folder to determine if a copy of the manual notice is in the folder.

If the FO did not send a notice, refer to item 29 of the SSA-831 to determine if the PC should send one of the notices listed in DI 11010.345A, DI 11010.345B or DI 11010.345G (in this section).

I. Procedure - denial notices for spouse's, mother's/father's claims when the youngest child in care is age 16 to 18

Use the following procedure:

• Use Form SSA-L4954 (Notice of Disapproved Claim) along with the personalized disability explanation in these cases.

• Disallow the spouse, mother, or father using code 42 Disability Denial Codes - SM 00380.100 and suppress the generated notice.

• Attach the SSA-4268 to the SSA-4954 before sending the notice.

• The claims authorizer places the SSA-4268 with the SSA-831 in the official folder before sending the case for denial notice action.

J. Procedure - Lump Sum Death Payment disability denial notices

The Social Security Act specifies who may qualify for the Lump Sum Death Payment (LSDP). For deaths on or after 09/01/81, the LSDP is paid only to:

• A spouse living in the same household; or

• A widow(er) or child who is entitled to, or is eligible for, benefits on the deceased's earning record for the month the number holder died.

If a widow(er) or child is not already on the number holder’s record, a disability determination is needed to entitle a spouse (age 50 to 60 and not living with the worker) or a child of the worker to the LSDP.

Special denial language is required in these cases because a disability determination is necessary. A manual denial notice must be prepared. See Introduction - NL 00708.001.

Use the following procedure:

• Include SSA Pub. No. 05-10041, “The Appeals Process,” as an enclosure; and

• Place the SSA-4268 with the SSA-831 in the official folder.

K. Procedure – preparing interim disability notices in capability/payee issue cases

The Social Security Act requires that unfavorable disability determinations contain a statement of the case (rationale) in understandable language. The DDS prepares the personalized rationale for total and partially unfavorable medical determinations on the SSA-4268. Since it is not practical to associate the personalized rationale with a systems-generated award notice, use an interim notice SSA-L1157 (DI Social Security Notice for Title II Cases) and/or SSA-L1157-SI (DI Social Security Notice for Title XVI Cases) to send the rationale to the party who receives the award notice. The DDS is able to send the interim notice unless the FO has determined the claimant to be incapable or capability is in question. If the DDS is unable to send the interim notice because a capability issue is raised, the FO places the personalized rationale in the file for release (for official paper files). For CEF cases, the notice is located in the (red) Jurisdictional Documents/Notices. After resolving capability and payee issues, the FO prepares the SSA-L1157--DI and/or SSA-L1157-SI as appropriate, attaches the personalized rationale and sends the notice to the party who receives the award notice.

L. Procedure - date of birth established different than alleged

Use the Universal Text Identifier (UTI) AGE008 in the Modernized Claim System (MCS) when a DOB has been established which is different from that alleged on the application. AGE008 requires fill-ins. See MCS Universal Text Identifiers (UTI) (NL 00725.005).

M. Procedure - auxiliary notices - disability denials - auxiliary protective filing only

Due to the deferral of non-disability development, when the claimant lists auxiliaries on the MCS claim or SSA-16 (Application for Disability Insurance Benefits), an auxiliary application is not taken unless there is a favorable disability determination. If the disability claim is a denial, do not send a notice to the auxiliaries. Paragraph 245 (see Numbered Paragraphs - NL 00708.100) is included on the claimant's denial notice informing the claimant that the auxiliary(ies) are not eligible for payment unless he or she is entitled. If the claimant lists a spouse who is living in a separate household, the spouse must receive separate notification regarding the fact that they cannot receive benefits. Prepare and release an SSA-445 to the spouse.

NOTE: Some DIB notices used by the PSC or ODO do not contain a preprinted paragraph 245. Add this paragraph to the notice whether or not auxiliaries are living in the same household as the NH.

N. Using pamphlets with notices

See Use of Pamphlets With Disability Notices - NL 00603.115 for the procedure on using pamphlets with notices