TN 64 (09-09)

If the Title XVI claim is a MSSICS limitation or exclusion, prepare the SSA-831 (Disability Determination and Transmittal) to transmit the case to the Disability Determination Services (DDS).

The following section contains FO procedures for completing the paper SSA-831 in disability claims that are Electronic Disability Collect System (EDCS) exclusions or limitations (see DI 81010.030).

A. Procedure for completing items 1-10 on the SSA-831

For claims involving MSSICS limitations or exclusions, manual completion of the SSA-831 is necessary. In those instances, the FO must complete Items 1-14 on the SSA-831 for Title XVI claims transmitted to the DDS for a disability determination.

If a presumptive disability or presumptive blindness (PD/PB) determination is made in the FO, complete additional items on the same SSA-831 as specified in DI 11055.240D.

Item 1 - destination

Check the "DDS" or "DQB" block, as appropriate, for all Title XVI disability claims requiring a disability determination that are routed to the DDS or the Disability Quality Branch (DQB).

Concurrent claims (Title II and Title XVI) may have the DDS, ODO, DRS (PSC), DQB, or OIO blocks checked.

For further jurisdiction and routing instructions for certain foreign Title II disability claims, see DI 11055.060.

Item 2 - DDS code

Enter the appropriate three-digit DDS code listed in the Detailed Office/Organization Resource System (DOORS).

Item 3 - filing date

Enter the earliest of the following dates:

• The actual month, day, and year of filing of the current application;

• The protective filing date established based on an oral or written intent (for protective filing policy and procedures, see GN 00204.010; for multi-category requests, see SI 00501.300); or

• The earliest filing date, if there are two or more current applications.

NOTE: If the claimant dies before filing an application, but submits a written statement to file, or if the FO received an oral inquiry with intent to file, someone eligible to receive the deceased claimant's underpayment may file the application. For underpayment policy and procedures, see GN 00204.005.

Item 4 - SSN

Enter the disabled person's own Social Security Number (SSN) for Title XVI claims. This is the primary SSN, even though the individual may have used a different SSN to file a Title II claim.

NOTE: If the claimant does not have an SSN, do not delay sending the Title XVI claim to the DDS. Instead, take the following steps:

• Process an application for a new Social Security Number (for data entry instructions for Form SS-5, see RM 00407.000);

• Enter "Applied For" in this block;

• Immediately alert the DDS of the claimant's SSN by phone, fax, or mail when the new SSN is generated, which is normally the following day.

Reference:

SI 00604.016, Name, Sex, Birthdate, and SSN - Question 1(a)

Item 5 - name and address of claimant

Enter the name and mailing address of the claimant.

If a proper applicant has filed on behalf of the claimant, enter the applicant's name followed by “for,” and then the claimant's name, and the applicant’s mailing address (see Proper Applicant GN 00204.003). Enter the name of the disabled person and proper applicant, if appropriate, in this item exactly as shown on the disability claim.

If two or more proper applicants have filed on behalf of the claimant, the name and address entries for the applicant should be for whichever of the applicants is the preferred payee (see Payee Preference Lists GN 00502.105).

In situations involving a Title XVI disability claim filed after the claimant's death, show the applicant's title and name followed by "On behalf of (claimant's title and name) Dec'd."

Items 6 and 7

Leave blank. (Not applicable in Title XVI cases.)

Item 8 - type claim (title XVI)

Check the appropriate block as follows:

NOTE: At no time should the FO check the following blocks:

Even though the claim is based on an alleged visual impairment, indicate "DI," "DS," or "DC" for all alleged visual impairments. If blindness is established, the DDS changes this field accordingly.

Item 9 - date of birth

Indicate the established date of birth by noting the month, day, and year of birth, e.g., 03/17/67. If the FO has not established the date of birth, use the date of birth by which the disabled individual or child is the oldest.

Item 10 - prior action

Check the “PD” block when the last determination for the same type of benefit was a denial. Check the “PT” block when the last determination for the same type of benefit was a termination of entitlement. (Include the prior disability file, if in the FO, or as shown in DI 11010.260B, and complete the information on the SSA-3367 [Disability Report – Field Office], Item 7).

B. Procedure for completing item 11--remarks

1. Cases requiring a DDS determination

For cases requiring a DDS determination:

• Always enter the contact telephone number of the claimant (including the area code). If the claimant gives as a mailing address, “general delivery” or the address of a hospital or institution, enter the claimant's home address or the address of a friend or relative with whom they keep in touch.

• If the claimant's mailing address is in one State, but he or she resides in another State, also enter “Resides in (name of State).” Show the county if the DDS indicates need for this information.

• Enter the alleged onset date.

2. Procedure for situations requiring additional remarks involving title XVI claims

Use the “Remarks” section to bring other situations to the attention of the component making the disability determination. See also DI 11010.205A.11., Completing the SSA-831.

Here is a list of additional remarks involving Title XVI claims.

a. Concurrent title II - title XVI disability claims

When concurrent Title II or Title XVI disability claims are filed, enter the remark “Concurrent Title II and Title XVI claim”, as appropriate, on each SSA-831.

b. Title XVI couples’ claims

If a couple files for Title XVI simultaneously and both members of the couple are disabled applicants, enter a remark on either Electronic Disability Collect System (EDCS) or SSA-831, Remarks section to cross-refer couples claims, e.g., “See SSI claim for John Smith on SSN 000-00-0000DS.”

NOTE: If both the individual and spouse file at the same time, indicate "DI" in Item 8 for the older spouse and "DS" for the other disabled spouse.

c. Title II or title XVI claim pending

If a Title II or Title XVI claim is pending on the same SSN or on another SSN, enter “(Type of Claim) claim pending on (SSN)” on EDCS or SSA-831, Remarks section. This alerts the DDS not to send closeout language if the initial disability claim has been denied on the other program while there is another claim still pending.

d. Title XVI claimant institutionalized

If a Title XVI claim filing is by or for an institutionalized individual, enter “Title XVI institutionalized case” on the SSA-831 for the DDS to properly identify the case. If this is also a Title XVI prerelease case, enter the additional remark “Prerelease case.” For remarks in prisoner cases, see DI 10105.094.

e. Title XVI multi-category case

If a Title XVI claimant elects consideration for more than one category, enter “Title XVI multi-category disabled (or blind) (enter the month/year of application, onset, State agreement, or election, whichever is later).” See Multicategory Eligibility – General Information SI 00501.300.

f. Systems limitation or exclusion is involved

For non-MSSICS claims, enter “No MSSICS input,” followed by “systems limitation” or “exclusion” (whichever is applicable).

g. Title II claim pending in DDS or prior title II denial

If any of the following situations apply, enter the appropriate remark on the SSA-831 for the Title XVI claim:

• “Title II initial (or reconsideration) filed (date) pending in the DDS;” or

• “Prior Title II denial (or cessation) (date).”

h. Title XVI noncitizen case

Enter “Non-Citizen case - date of U.S. admission (date).” Obtain the date of U.S. admission from immigration documents submitted by the claimant.

For information about authorization and proof of noncitizen U.S. residency, refer to Authorized Alien Status GN 00303.400 and Non-Citizen SSI Disability Claims DI 11055.105.

NOTE: As of 08/22/96, noncitizens applying for SSI based on disability or blindness must be in a qualified alien category and meet an exception condition for qualified aliens. For basic alien eligibility and development requirements, see SI 00502.100.

i. Non-Medical development deferred

If the criteria in DI 11010.025 for deferring nonmedical development are met, enter “Deferred case.”

j. Retroactive substantial gainful activity (SGA) cessation with possible current entitlement

When a retroactive SGA cessation is being processed and there is possible current entitlement without a new application, enter “SGA cessation (date) - possible current entitlement.”

See Details:

• DI 13001.001 – The Obligation to Review Continuance of Disability

• DI 13001.005 – Events Which May Initiate a CDR

• DI 13001.010 – Component Responsibilities

k. Claimant does not want to pursue claim

If the claimant submitted medical evidence to the FO and does not want to complete the development or has written or orally stated that they do not wish to pursue the claim, enter “Claimant does not want to pursue claim” in the Remarks section. Refer to the procedure for discontinuing development when a claimant does not wish to pursue the claim in DI 11055.085F.

l. Visual impairment alleged

In those cases where a visual impairment or blindness is alleged, enter “Alleges visual impairment.”

m. Emergency clause case

When transmitting an emergency clause Title XVI claim to DQB, enter “Emergency clause case: (name of DDS).” See Emergency Clause that Allows Transferring Jurisdiction of the Medical Determination to the Disability Quality Branch (DQB) in DI 11055.110.

n. Spanish notice required

If a Spanish notice is required, enter “Spanish notice required.”

o. Braille notice requested

Handle requests for Braille notices in accordance with NL 01001.120.

p. Title XVI start-date record

If a start-date record is being input, enter “SSI start-date record.”

q. Aged individual under section 1619(b)

If an individual, age 65 or over, wishes to establish eligibility under section 1619(b), enter the remark, “Aged individual - 1619(b) eligibility determination P.L. 101-508 Section 5032.”

For FO responsibilities, see SI 02302.010B.2. and SI 02302.030C.5.a.

For SSI eligibility under more than one SSI category (multi-category), see SI 00501.300.

r. Aged noncitizen (age 65 or older)

Enter “Title XVI Aged Non-Citizen case - blindness/disability alleged - systems limitation” if an aged noncitizen alleges disability or blindness and:

• Lawfully residing in the U.S. on, or prior to, 08/22/96; and

• A qualified alien.

s. Homeless with no permanent address

When the claim is for a homeless individual, enter "Homeless-no permanent address."

t. FO unable to adopt prior claim

In this situation, when a subsequent Title II or Title XVI disability claim is being sent to the DDS, enter "FO unable to adopt prior disability determination" per DI 11011.005.

u. Claims that are CEF exclusions forwarded at different times

If the FO is not forwarding the claims material for both claims to the DDS at the same time, enter one of the following remarks:

• “Title XVI (or Title II) claim pending in FO” on the first SSA-831 being sent to the DDS.

• “Title XVI (or Title II) material on claim # (specify SSN and type of claim) forwarded (specify date first claims material was forwarded to the DDS) please associate” on the SSA-831 of the second claim being sent the DDS.

v. Common issues

In cases involving common issues, indicate the status of both claims in the Remarks section of the SSA-831, e.g., “Title XVI claim escalated to the reconsideration level with initial Title II claim.” (Indicate the filing or appeal dates for both claims as well as prior denial or allowance dates, if applicable.)

For detailed information on common issues, see DI 12045.000.

C. Procedure for completion of Items 11A-14 on the SSA-831

Items 11A and 11B

For completing Items 11A and 11B, PD/PB, see DI 11055.240D.1.a.

Item 12 - District-Branch Office Address/DO-BO Code

Enter the FO mailing address (City, State, and ZIP code) in all cases. In the block labeled DO-BO Code, enter the FO three-digit office code.

Item 13 - FO-BO Representative

The FO employee who transmits the claim should enter their name and title in this block.

Item 14 - Date

Enter the date the file is transmitted to the DDS, Office of Disability Operations (ODO), Disability Quality Branch (DQB), or Office of International Operations (OIO).