DI 12001.005: Handling Appeals Pending on SDW Cases – Additional Workflow Information

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~~Effective Dates: 05/24/2018 - Present~~
Effective Dates: 06/08/2018 - Present
TN 2 (05-05)
DI 12001.005 Handling Appeals Pending on SDW Cases – Additional Workflow Information
Citations:
Regulations No. 4, Subpart J, Section 404.900 ff. Regulations No. 16, Subpart N, Sections 416.1400 ff.
A. Introduction
This section provides guidance regarding the processing of appeals on Special Disability Workload (SDW) cases. All SDW cases must be mapped by an SDW Cadre member. The map is a document which serves as an important source of information, including critical factors of entitlement. If a case was not mapped at the initial level, it must be mapped at a later point based on the instructions below.
This section contains instructions on SDW appeal workflow for FOs/Cadres, DDS offices, OHO, Office of Appellate Operations (OAO) and PSCs.
B. Procedure - FO/Cadre Actions on SDW Appeals
If an SDW case was mapped, and tracked on the SDW website through the initial decision, no further mapping, tracking, or special FO/Cadre handling is required when an appeal request is filed.
1. Reconsideration on SDW Cases That Were Not Mapped at The Initial Level
If the FO discovers that a "Request for Reconsideration" is filed on an SDW case that has not been mapped, the case will be sent to the Cadre for mapping. The Cadre will forward the case to the DDS for a reconsideration decision. The Cadre will update the SDW website questionnaire when the case is mapped. The reconsideration case will be returned to the Cadre to effectuate the DDS decision.
If the DDS or the Cadre discovers that a reconsideration request is pending on an SDW case which has not been mapped, the case will be cleared from the DDS as a "No Decision (ND)" case and forwarded to the Cadre via FedEx or Priority Mail for mapping. The Cadre will give priority to mapping the case and returning it to DDS via FedEx. The Cadre will update the SDW questionnaire when the case is mapped. After the DDS decision, the reconsideration case will be returned to the Cadre to effectuate the decision.
2. ALJ Hearing on SDW Cases That Were Not Mapped at The Initial Level
If the FO/Cadre discovers that a request for hearing is pending on an SDW case that has not been mapped, the FO/Cadre will request the case for mapping before the hearing is held. The Cadre will map the case and update the SDW questionnaire. The Cadre will forward the case to the Hearing Office for a hearing decision.
3. SDW Cases at OAO That Were Not Mapped at The Initial Level
When the Administrative Law Judge (ALJ) issues an unfavorable decision, claim files go to the SSA National Records Center in Independence, MO to await a potential request for review. The Office of Analytics, Review and Oversight (OARO) should be queried to determine the appeal status, i.e. to determine whether a request for review has been filed by the claimant.
a. Request for Review Has Not Been Filed
If the OARO shows that a request for review has not been filed, the Cadre will request the claim folder via an email at |||OARO OAO SDW Referrals, to the SDW Program Analyst in the Executive Director’s office. The email will contain the name and Social Security Number of the claimant, the date of the ALJ ’s decision and the reason for the claims folder request. The SDW Program Analyst will contact the SSA National Records Center and request release of the claims file to the Cadre member. The Cadre will map the case, update the SDW questionnaire and forward the claim folder to OAO.
If a request for review is filed after the case has been sent to the Cadre, the OAO staff will contact the Cadre member and the Cadre member will immediately return the claim folder to OAO for processing via FedEx or Priority Mail.
The Cadre will put a SDW flag on the front of the claim folder and indicate on the SDW flag whether OAO needs to diary the case to await additional mapping documentation from the Cadre (if subsequent filing apply). The Cadre will map the case, update the SDW questionnaire and fax the map to the OAO.
b. Request for Review Filed
If the OARO CCS shows that a request for review has been filed, the Cadre will fax a Memorandum to the SDW Program Analyst at 703-605-7101. The SDW Program Analyst will contact the OAO Branch with jurisdiction of the case. The Branch staff will photocopy the requested documentation and fax it (or if too voluminous, mail it via Priority Mail) to the requesting Cadre member.
4. Questionable ALJ/AC Decision Recognized During Mapping
When a case is first mapped, if a questionable ALJ/AC decision is recognized, the Cadre will contact the SSA Regional Office to determine if a request for reopening under the SSA regulations is appropriate. If appropriate, the SSA Regional Office will prepare a protest memorandum stating the grounds for the protest or request for reopening to the Executive Director, OAO. If OHO reopens and revises the decision, the favorable decision will be routed to the PSC of SDW jurisdiction (see DI 11010.285) for effectuation, unless otherwise instructed by regional procedures.
When a case is first mapped, if a questionable ALJ/AC decision is recognized, the Cadre will contact the SSA Regional Office to determine if a request for reopening under the SSA regulations is appropriate. If appropriate, the SSA Regional Office will prepare a protest memorandum stating the grounds for the protest or request for reopening to the Executive Director, OAO. If OARO reopens and revises the decision, the favorable decision will be routed to the PSC of SDW jurisdiction (see DI 11010.285) for effectuation, unless otherwise instructed by regional procedures.
C. Procedure - DDS Actions on SDW Appeals
1. SDW Cases That Have Been Mapped, Then Denied, Then Sent for Reconsideration
If reconsideration is requested on an SDW denial, the DDS will follow its standard procedures for handling reconsiderations. At closure, the case will be returned to the office of jurisdiction, as reflected on the case transmittal. Mandatory cadre involvement ended with the tracking and annotation of the initial denial to the SDW website. Each region has the discretion of determining whether cadre involvement is needed to process allowances decided at reconsideration level. However, the initial determination coded on website remains unchanged.
2. Unmapped SDW Cases That Are Denied, and Reconsideration Requested, Before Being Mapped
If the FO/Cadre/DDS discovers that a reconsideration request is pending at the DDS for an SDW case that has not been mapped, initial contact will be made via telephone, email or fax to obtain the information necessary to map the case. DDS has the option of clearing cases as a no-decision (ND), if they decide to return the case to the Cadre. If DDS returns the case to the Cadre, once the map and any additional development is completed, the case will be sent back to the DDS for its action, via FedEx or Priority Mail.
If the DDS completes a reconsideration decision on an SDW case without realizing the case was SDW, the case will follow regular DDS reconsideration procedures and workflow. When the case is eventually mapped by the Cadre, the Cadre will consider all the decisions that have already been made at that point, including the reconsideration.
D. Procedure - OHO Actions on SDW Appeals
1. Handling SDW Hearings That Were Mapped at The Initial Level
In hearing SDW cases which have been mapped, the map is located in the Jurisdictional Documents/Notices (Red) section of Electronic Disability Collect System (EDCS) or modular claims folder (MDF),or prong filed on the right side of the brown Kraft folder. The “SDW map” will serve as information and guidance for the ALJ when making a decision. These cases also contain an SDW flag on the outside cover of the claims folder, or an electronic flag in EDCS.
2. Handling SDW Hearings That Were Not Mapped at The Initial or Reconsideration Level
Hearing Offices (HOs) may receive SDW cases with requests for hearing that have not been mapped. Proceed as usual, unless contacted by the SDW Cadre as described in DI 12001.005C.2. At a later point in time the Cadre will map the case, taking into consideration the prior decision. The Cadre will map the case and update the SDW questionnaire. During the mapping, if a case has a questionable ALJ decision, the Cadre will contact the SSA Regional Office to determine if a request for reopening under the SSA regulations is appropriate. If appropriate, the SSA Regional Office will prepare a protest memorandum stating the grounds for the protest or request for reopening to the Executive Director, OAO . If OARO reopens and revises the decision, the favorable decision will be routed to the PSC of SDW jurisdiction (see DI 11010.285) for effectuation, unless otherwise instructed by regional procedures.
The HO may receive a Memorandum from the SDW Cadre requesting the claim folder or documents from the file if the Cadre discovers that a request for hearing is pending on an SDW case that has not been mapped. When the HO staff receives the Cadre Memorandum, they should run a CPMS query to determine the case status.
a. If hearing has not yet been scheduled:
* Forward requested information outlined in the Memorandum to the Cadre within 3 workdays via fax, FedEx or Priority Mail.
* Code the case status in the Case Processing Management System (CPMS) as PRE, UNWK, WKUP, etc., as appropriate, and enter in the Remarks section: "SDW Cadre (and Cadre code)".
* Place a copy of the SDW request in the case file.
* Diary the case in CPMS for 30 days.
* If the SDW Cadre does not provide the map and/or other necessary development by the end of the diary period, the HO staff should:
* Contact the SDW Cadre listed on the Memorandum for a status
* Document the claim file of the follow-up and status received;
* Diary the case for the number of days the Cadre promised a resolution (but not more 30 days) for follow-up
* Add all documents received from the Cadre to the claim file.
* Staple the SDW Flag provided by the Cadre to the front of the claim folder.
* Follow normal procedure in scheduling and holding the hearing.
b. If hearing has already been scheduled:
* Inform the Cadre of the scheduled hearing date.
* Send the documents requested by the Cadre via fax, FedEx or Priority Mail.
* Diary the case for 10 days if the date will be before the scheduled hearing
* File a copy of the Cadre's request in the claim file
* Inform the claimant or his/her representative of the Cadre's involvement and any ramification surrounding the Cadre's action [i.e., insured date will be developed accurately].
* Do not delay the hearing unless the claimant (or his/her representative) agrees to the delay in writing.
* If the Claimant agrees to delay the hearing, follow the procedures under "If hearing has not yet been scheduled" until the Cadre's action is completed. Reschedule the hearing and advise the claimant and his/her representative of the rescheduled hearing date.
* If the Cadre is unable to complete their action by the scheduled hearing date, and the Claimant does not agree to delay the hearing, hold the hearing and place the case in POST to await completion of the Cadre's action.
* Note in the Record that the claimant was informed that the SDW Cadre is submitting additional non-medical evidence, and the Record will not be complete without it.
* Once the information is received, follow the post-hearing "proffer procedures" in HALLEX I-2-7-30, before placing it in the Record.
* The claimant and his/her representative should be allowed to submit additional evidence in the POST period.
E. Procedure - OAO and the Appeals Council (AC) Actions on SDW Appeals
1. Handling Reviews on SDW Cases That Were Mapped At the Initial Level
In reviewing SDW cases which have been mapped, the map is located in the Jurisdictional Documents/Notices (Red) section in EDCS or the modular claims folder (MDF), or prong filed on the right side of the brown Kraft folder. These cases should also have a SDW flag on the outside cover of the claims folder or an electronic flag in EDCS. The “SDW map” will serve as information and guidance for the AC when reviewing an ALJ’s decision (or dismissal). Routing of SDW AC decisions follows the SDW PSC jurisdictional breakdown in accordance with DI 11010.285.
2. Handling SDW AC Reviews That Were Not Mapped
The Office of Appellate Operations (OAO) may receive requests for review of an ALJ decision on SDW cases that have not been mapped. Process as usual, unless contacted by the SDW Cadre as described in paragraph 2 below. At a later point in time the Cadre will map the case, taking into consideration the prior decision. The Cadre will map the case and update the SDW questionnaire. During the mapping, if a case has a questionable ALJ or AC decision, the Cadre will contact the SSA Regional Office to determine if a request for reopening under the SSA regulations is appropriate. If appropriate, the SSA Regional Office will prepare a memorandum stating the grounds for the request for reopening to the Executive Director, OAO to request reopening. If the AC reopens and revises the decision, the favorable decision will be routed to the PSC of SDW jurisdictional breakdown for effectuation according to regular POMS procedures.
OAO may receive a Memorandum from the SDW Cadre requesting the claim folder or documents from the file if the Cadre discovers that an ALJ issued a decision and the claims file in now located in OAO on an SDW case that has not been mapped. When the OAO staff receives the Cadre’s Memorandum, they should run an Appeals Council Automated Processing System (ACAPS) query to determine the case status.
a. If a request for review of ALJ’s decision has not been filed:
* If the claims file is located in the SSA National Records Center in Independence, MO, the SDW Program Analyst in the Executive Director’s Office will contact the Mega-site and request that they release the claims file (or requested material) to the requesting Cadre member.
* The SSA National Records Center employee will pull the claim file and ship it or a photocopy of the requested material to the Cadre member.
* The SSA National Records Center employee will annotate the appropriate case control systems with the location code (if the file is shipped).
* If a request for review is subsequently filed while the case is still awaiting Cadre mapping, the OAO staff will contact the Cadre member and request the claims file be returned immediately for processing.
* The Cadre will put a SDW flag on the froSSAnt of the claim folder and indicate on the SDW flag whether OAO needs to diary the case to await additional mapping documentation from the Cadre.
* If no further documentation is indicated, OAO will place the claims folder into the request for review queue.
* If additional documentation is indicated, OAO will diary the claim folder to await the Cadre’s mapping documentation.
b. If a request for review of ALJ’s decision has been filed:
* The SDW Program Analyst in the Executive Director’s Office will receive the Memorandum from the requesting Cadre by Fax (703-605-7101).
* He or she will contact the OAO Branch with jurisdiction of the case.
* If necessary, the OAO Branch staff will secure the claims folder from the SSA National Records Center (or other locations).
* Branch staff will photocopy the requested documentation and Fax it (or if too voluminous, mail it via Priority Mail) to the requesting Cadre member.
* The OAO Branch staff will diary the claim for 30 days to await the Cadre’s mapping documentation.
* Upon receipt of the documentation (or at the end of the 30 day diary), the OAO Branch staff will place the case back into the request for review queue.
F. PSC Actions on SDW Appeals
In addition to receiving initial and amended SDW awards for effectuation, the PSC’s will also receive favorable ALJ determinations. In general, these favorable ALJ determinations will be processed in the same manner as ALJ decisions on non-SDW cases. The ALJ decision will be handled in accordance with existing procedures for ALJ decision effectuation, regardless of whether the case has been mapped.
The ALJ decision will be TOELed APPEAL HEARING and will be routed to the Disability Processing Branch (DPB) for preparation of the SSA-831. The case will then be routed to the module Claims Authorizer (CA) for preparation of the award, and, if necessary, to the Benefit Authorizer (BA) for MADCAP input. The Disability Processing Specialist (DPS) and the CA should be aware that SDW cases may involve complex retroactivity, insured status, and protective filing situations, as well as work after onset and multiple periods of disability. Documentation in the file, including the "SDW map", can give important clues to the appropriate periods of entitlement. If a question arises regarding information on an SDW map, PSC personnel may contact the Cadre member or their PSC's SDW coordinator.
If either DPB or the module recognizes the case as a SDW claim, a SDW flag should be stapled on the folder/holder. The BA action will be subject to review by the PETE, in accordance with existing PSC procedures.
PSC may receive hearing decision cases that are SDW cases but have not been mapped. PSC should follow regular POMS procedures to process these hearing decisions. At a later point in time the Cadre will map the case, taking into consideration the prior decision and update the SDW questionnaire.
All program related and technical questions should be directed to your RO support staff or PC OA staff. RO support staff or PC OA staff may refer questions or problems to their Central Office contacts.

POMS Reference

DI 12001.005: Handling Appeals Pending on SDW Cases – Additional Workflow Information