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DI 12010.040: Action Following A Favorable Title XVI Administrative Law Judge (ALJ) Hearing Decision

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  • Effective Dates: 07/12/2012 - Present
  • Effective Dates: 04/11/2018 - Present
  • TN 3 (07-10)
  • DI 12010.040 Action Following A Favorable Title XVI Administrative Law Judge (ALJ) Hearing Decision
  • A. Policy following return of a favorable Title XVI hearing decision
  • The field office (FO) is responsible for effectuating favorable Title XVI ALJ and Attorney Advisor hearing decisions. See SI 04030.070 for additional development and effectuation procedures.
  • B. Procedure when claimant inquiries about a favorable Title XVI hearing decision
  • 1. Claimant inquiries
  • a. Query
  • If the claimant inquires about the favorable decision and the case is electronic, go to eView or the Case Processing Management System (CPMS) to check on the status of the case. If the case is paper, and the claim folder(s) has not yet been received, obtain an Office of Disability Adjudication and Review (ODAR) query to determine the folder location and the status of the hearing decision.
  • If the claimant inquires about the favorable decision and the case is electronic, go to eView or the Case Processing Management System (CPMS) to check on the status of the case. If the case is paper, and the claim folder(s) has not yet been received, obtain an Office of Hearings Operations (OHO) query to determine the folder location and the status of the hearing decision.
  • b. Folder in transit
  • Contact the regional office about locating or reconstructing the file if the ODAR query shows that a favorable decision was issued and the claim folder(s) has been in transit for more than 10 days,
  • Contact the regional office about locating or reconstructing the file if the OHO query shows that a favorable decision was issued and the claim folder(s) has been in transit for more than 10 days,
  • 2. Development
  • Take no action until the decision and folder are received in the FO or the case is transferred electronically to the FO.
  • 3. Action upon receipt of folder
  • a. Folder review
  • Take the following steps before payment effectuation:
  • * Review the file to determine what additional evidence or development is needed, especially in the area of capability.
  • * If the claimant is determined incapable, see GN 00504.105 regarding payment of current benefits while withholding retroactive benefits.
  • b. Pre-effectuation review contact (PERC)
  • Take the following steps to conduct a PERC:
  • * Initiate a PERC with the claimant.
  • * Refer to SI 00603.003 for processing deferred development claims.
  • * Refer to SI 00603.004 for processing simultaneous development claims.
  • c. Exception to completing development
  • Do not delay payment pending a determination of capability.
  • d. Effectuation
  • Effectuate payment after receiving the ALJ decision and all development is complete as follows:
  • * Locate the diagnosis code(s) and the regulation basis code for the decision on the ODAR CPMS.
  • * Locate the diagnosis code(s) and the regulation basis code for the decision on the OHO CPMS.
  • * Determine the appropriate medical diary. A remark is generated on the CPMS transmittal sheet only for those cases where medical improvement is expected (MIE) or medical improvement is not expected (MINE) is applicable. The diaries that are coded would be less than 3 years for MIE cases and a 7-year diary for MINE cases. If no remark is shown, assume that a 3-year medical improvement possible (MIP) diary is applicable. If the FO has any questions relating to the information on the CPMS transmittal sheet, contact the hearing office manager annotated in the claim folder(s).
  • * To input the diagnosis code(s) and medical diary, follow the processing instructions in SI 00603.040D.
  • * Input the coding to the Supplemental Security Record (SSR) when the claim is effectuated. See SM 01305.900.
  • * View the Query Modify Medical Data (QMMD) screen of the Disability Control File (DCF) to ensure that the diagnosis and diary information has propagated from the SSR. The SSR should update the DCF within 72 hours of your input. If the diagnosis and diary information do not appear on the MMDS, follow the instructions in DI 13010.640 to input the information manually.
  • * Follow current procedures for release of the notice.
  • 4. Hearing decision is in conflict with laws and regulations
  • Follow the protest procedures in GN 03103.260 for Title II and SI 04030.060 for Title XVI if the FO believes that the hearing decision is clearly contrary to or conflicts with the law and regulations.
  • C. References
  • MSOM OHA 001.011 – Hearing/Appeal Query Response.
  • DI 12010.035 - Action Following a Favorable Hearing Decision,
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