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DI 12026.025: Field Office (FO) Processing of the Request for Reconsideration of a Medical Continuing Disability Review (CDR) Determination

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  • Effective Dates: 10/20/2016 - Present
  • Effective Dates: 11/22/2017 - Present
  • TN 2 (08-16)
  • DI 12026.025 Field Office (FO) Processing of the Request for Reconsideration of a Medical Continuing Disability Review (CDR) Determination
  • A. Review the forms
  • Ensure that the appeal forms are appropriate, complete, and filed timely (or establish “good cause” for extending the time limit to file an appeal). Associate all forms with the electronic or paper folder as applicable.
  • 1. SSA-789 (Request for Reconsideration – Disability Cessation Right to Appear)
  • When processing the Form SSA-789:
  • * Check that the form is complete, that the individual indicated whether he or she wishes to appear at the disability hearing, and has completed the block for interpreter and language needs. The individual or his or her representative payee does not need to sign the form.
  • IMPORTANT: The SSA-789 must be dated at the top of the form upon receipt in the FO.
  • NOTE: A completed Modernized Supplemental Security Income Claims System (MSSICS) appeals output can act in place of the SSA-789 in Title XVI and concurrent cases if the individual also provides clear written indication of dissatisfaction with the initial CDR determination.
  • * If the SSA-789 is incomplete, call the individual for the necessary information. If the individual has no phone or the attempt is not successful, send a call in/come in letter and set a diary for 15 days. Document attempts to contact the individual on an SSA-5002 (Report of Contact). If the individual does not respond within the 15 days regarding whether he or she wants a hearing or needs an interpreter, forward the case to the disability determination services (DDS) for resolution.
  • * Provide the individual with a copy of the SSA-789 if applicable.
  • * Provide the individual with the English or Spanish version of the information sheet, SSA-888 (Reconsideration/Disability Hearing Procedures). Versions of these documents are located in DI 33095.025 or DI 33095.030.
  • * Provide the individual with the telephone numbers for his or her service area field office (FO) and disability hearing unit (DHU). Explain to the individual that we prefer him or her to call the DHU with substantive questions or if he or she needs to report a change relating to the disability hearing.
  • NOTE: The Social Security Administration (SSA) does not expect the individuals to make long distance phone calls and the individuals may call either the FO or DHU.
  • 2. SSA-795 (Statement of Claimant or Other Person)
  • Provide the individual with a copy of his or her statutory benefit continuation (SBC) election statement. For information about the SBC election statement, see DI 12027.010B.4.
  • 3. SSA-827 (Authorization to Disclose Information to the Social Security Administration (SSA))
  • Ensure that the SSA-827 forms have the appropriate signature and date, in accordance with DI 11005.056.
  • 4. SSA-3441-BK (Disability Report – Appeal)
  • Verify the completeness of the form. Obtain as much information as available. If the form is incomplete:
  • * Re-contact the individual if the SSA-3441-BK received was not fully completed or any information seems to be incorrect.
  • * Note auditory observations made during any telephone conversation with the individual.
  • * Document additional information that you received from the individual on the EDCS 3367, or on an electronic or paper SSA-5002.
  • * For Title II cases, see MS MCS 008.007 (Report of Contact (RPOC))
  • * For Title XVI cases, when documenting the report of contact in:
  • * Modernized Supplemental Security Income Claim System (MSSICS) see MS MSSICS 022.010 (Report of Contact (DROC)).
  • * Non-MSSICS prepare a paper SSA-5002 to document the additional information, and add this form to the electronic or paper folder.
  • 5. SSA-3881-BK (Questionnaire for Children Claiming SSI Benefits)
  • Review the SSA-3881-BK for completeness in Title XVI childhood disability cases using instructions in DI 12026.025.A.4. in this section.
  • B. Complete system inputs to document appeal information
  • Record essential control information in the system to document the appeal and any SBC information. For more information about SBC system inputs, see DI 12027.010C.
  • When recording appeal information for:
  • * Title II
  • Input appeal information in the Post-entitlement Online System (POS). See MS T2PE 002.003 (POS Selection List (PESL)) and MS T2PE 003.024 (Disability Cessation (PEC1)).
  • * Title XVI
  • * Input appeal information in MSSICS. For more information, see MS MSSICS 020.001 (Appeals - Overview).
  • * Non-MSSICS Cases - Use MSSICS Direct SSR Update (DUSSR). For more information, see MS BUSSR 002.007 (Appeals Process).
  • C. Folder preparation
  • 1. Electronic continuing disability review (eCDR) appeals
  • eCDR includes electronic folder (EF) case processing for initial continuing disability reviews (CDRs) and Age-18 redeterminations. If the individual is appealing a CDR we processed in the Electronic Disability Claims System (EDCS), process the reconsideration electronically. For processing appeals using eCDR in electronic folder cases:
  • * FOs - refer to DI 81010.255 (Electronic Continuing Disability Review (eCDR) Cessation Reconsiderations).
  • * DDSs - refer to DI 81020.255 (Processing a Reconsideration Appeal of an Electronic Continuing Disability (eCDR) Cessation).
  • 2. Paper folders (Modular disability folder (MDF) and brown (non-MDF) folder)
  • Process the paper folder as follows.
  • a. Disability folder(s) available in the FO
  • Place the request for reconsideration, any supporting forms, and any evidence provided by the individual in his or her official disability folder. For document filing instructions see DI 70005.005B.
  • b. Disability folder unavailable in the FO
  • Request the folder and annotate on the request that there is a disability hearing pending. The following references provide information about requesting an MDF:
  • * Title II - DI 40525.100 (Processing Center Action Control System (PCACS) Coordination).
  • * Title XVI (except foreign cases) - SM 01601.415 (Case Control Data – CCTL), and SM 01201.035 (Alert Response (AR) Codes on the SSA-8028).
  • * Foreign Case - DI 12026.020B.5. (Field Office (FO) Responsibilities when an Individual Wants to Request a Continuing Disability Review (CDR) Reconsideration).
  • * Obtain any prior folder needed - DI 13015.080 (Unable to Locate Medical Folder after Initial FO Search - Detective Work).
  • * Unable to locate the prior folder - GN 03105.010 (Reconstruction of Destroyed or Missing Paper Claims Folders), DI 20502.030 (Folder Reconstruction), and DI 28035.000 (Processing of Lost Folders/Medical Evidence).
  • D. Route the folder
  • To establish where to route the folder, determine the type of case first.
  • 1. Cases other than career railroad or foreign cases
  • Route the folder to the FO’s service area DHU.
  • 2. Career railroad case
  • Route the official disability folder to the Great Lakes Program Service Center (GLPSC):
  • * Follow the procedures for processing railroad cases in DI 29005.020 (GLPSC - Career Railroad and Railroad Annuitant Cases).
  • * Include the DHU copy of the SSA-789 in the disability folder and route the folder to: GLPSC, Disability Processing Branch P.O. Box 87755 Chicago, IL 60680-0955
  • 3. Foreign case
  • Do not forward documents or information to the DDS associated with the servicing FO.
  • * Include all documents and information in the disability folder and route the folder to the Office of Earnings and International Operations (OEIO). Do not forward a copy of the SSA-789 to the DHU.
  • * Forward all materials to: Social Security Administration Office of Earnings and International Operations P.O. Box 17775 Baltimore, Maryland 21235-7775
  • E. Process other issues when a reconsideration disability hearing is pending
  • 1. Request for change in time or place of the disability hearing
  • If the individual contacts the FO, rather than the DHU or the disability hearing officer (DHO) take the actions according how the individual makes contact.
  • a. Individual visits the FO
  • Ensure the individual completes and signs an SSA-769-U4 (Request for Change in Time/Place of Disability Hearing). For an exhibit of the form and instructions for its completion, see DI 12095.055.
  • b. Individual telephones the FO
  • Obtain the information you need to complete the SSA-769-U4 and have the individual (or his or her representative payee) come in to sign this form, or mail the form for signature and return to the FO. Document the information obtained in the telephone conversation electronically (RPOC/DROC), or on a paper SSA-5002 (Report of Contact) and it fax into Non-Disability Repository for Evidentiary Documents (NDRED).
  • * For Title II, see MS MCS 008.007 (Report of Contact (RPOC))
  • * For Title XVI, document the report of contact in:
  • * MSSICS - See MS MSSICS 022.010 (Report of Contact (DROC))
  • * Non-MSSICS - prepare a paper SSA-5002.
  • c. In all requests for a change in time or place of the disability hearing
  • Alert the DHU to all requests to change the time or place of disability hearing. Scan or place the forms and information about the request to change the time or place of disability hearing in the individual’s official folder. Forward the material to the DHU using an SSA-408 (Route Slip) if the folder is paper and is already at the DHU.
  • NOTE: When the individual requests to change the disability hearing and it is less than 10 days before the scheduled hearing date, notify the DHU by telephone or e-mail. Forward the forms and information about the change request based on direction from the DHU (fax, hand-deliver, scan to folder, etc.).
  • 2. Substantial gainful activity (SGA) issues in Title II cases
  • In processing Title II cases with SGA issues, develop and resolve work issues discovered during DDS or DHU review using procedures in DI 10501.025, DI 13010.012, and DI 13010.025.
  • * If the work is SGA:
  • * Prepare an initial SGA determination if conditions meet the requirements for FO processing, and trial work period (TWP), extended period of eligibility (EPE), or Extended Medicaid does not apply.
  • * Advise the individual in the SGA cessation determination notice that we will not conduct a disability hearing on the medical cessation issue because we found him or her “not disabled” due to work. For information on processing SBC, see DI 12027.040 and DI 12027.050.
  • * Send a copy of the SSA-833 (Cessation or Continuance of Disability or Blindness Determination and Transmittal) to the DHU to cancel the hearing process.
  • * If the work is not SGA, or is SGA but EPE or Extended Medicare applies:
  • * Complete FO actions using existing SGA and EPE procedures.
  • * Return case to DDS or DHU for action on medical issue(s).
  • NOTE: The FO must upload all work CDR documentation to eView for electronic cases, and forward documentation to the DDS or DHU for paper cases because the DDS and DHU does not have access to other FO programs where this information could be stored.
  • 3. Subsequent material or information received
  • Most material and information received is in writing. However, the FO must document any information obtained verbally on an SSA-5002 (Report of Contact) or other appropriate SSA form. Upload all new material or information received after the case left the FO into the electronic folder if possible. Check the case control system to establish if the folder is located at the DDS or DHU, and follow the instructions for:
  • a. New evidence
  • When the FO receives subsequent evidence, including sources:
  • * If the official folder is paper, use an SSA-408 (Route Slip) to forward the material to the DDS/DHU.
  • * If we issued a reconsideration determination and the case left the DHU, forward the material to the DHU (or alert them to the presence of subsequent material in the EF) to determine the relevance of the material and the action to take.
  • NOTE: An exception to this routing applies if the case is at an administrative law judge (ALJ) or Appeals Council (AC) location. In these instances, forward the material for folder association and review to the ALJ or AC office where the folder is located.
  • b. Change of address or telephone number
  • When an individual reports a change of address or telephone number after the release of the folder, the FO will:
  • * Update the Title II and Title XVI records (e.g. MBR, MSSICS and EDCS) with the new information.
  • * Send an update after transfer (UAT) to the DDS or DHU with the individual’s new address or telephone number.
  • * If the official folder is paper, use an SSA-408 to forward the change of address information to the DDS or DHU (include the office code for the FO servicing the individual's current address).
  • * Notify the DHU by telephone if a disability hearing is scheduled and the change of address involves a change in the DDS or DHU site. Send an e-mail confirmation of the phone call to the DHU.
  • NOTE: The DHU forwards or associates the email confirmation to the folder.
  • 4. Individual fails or refuses to submit additional information for reconsideration
  • The FO must transmit or forward the folder to the DDS if the individual fails or refuses to complete the necessary forms or provide additional evidence needed to support the request. Indicate what information is lacking using an SSA-5002 and associate this form with the folder. If the DDS does not have enough information to make a medical determination, it will follow guidelines as outlined in DI 23005.001, DI 23007.004, or DI 23007.005.
  • 5. Individual wishes to withdraw a request for reconsideration of a disability cessation or adverse medical reopening
  • Never suggest to an individual that he or she withdraw a request for CDR reconsideration.
  • a. Contact the office where the case folder is located
  • E-mail or telephone the appropriate office (DDS or DHU) and request it return the case folder to the FO. Request that the DHU postpone the hearing process, pending disposition of the withdrawal.
  • NOTE: The DDS or DHU forwards requests for withdrawal sent directly to them to the FO.
  • b. Title II
  • Follow the general withdrawal instructions in GN 03102.200B.4.
  • * Career Railroad Cases - GLPSC handles requests for withdrawals.
  • * Foreign Cases - OEIO handles requests for withdrawals.
  • c. Title XVI
  • Follow the general withdrawal instructions in SI 04020.020
  • d. Request for withdrawal approved
  • Ensure that we terminated benefits, and the individual repaid SBC payments, before approving the withdrawal. For more information on conditions for withdrawal, see GN 00206.005.
  • Send a copy of the individual’s notice approving the withdrawal to the DHU to cancel the hearing process.
  • e. Request for withdrawal not approved
  • When processing a denied request for withdrawal:
  • * Return the case to the DDS or the DHU.
  • * Include, or upload, a copy of the notice informing the individual that the FO did not approve his or her request.
  • f. Cancellation of the request for withdrawal
  • When an individual wants to cancel his or her request for withdrawal:
  • * If the individual files a cancellation of withdrawal within 60 days from the date the individual received the notice of approval of withdrawal, process the case as though no withdrawal took place.
  • * Reinstate any previously approved SBC benefits retroactive to the month benefits stopped unless the individual indicates otherwise.
  • * Include a copy of the individual's cancellation of the withdrawal in the folder. Ensure the individual's (and any representative’s) name, address, and telephone number, are on the request for cancellation.
  • * Return the folder to the component (DDS or DHU) that had the case on the date we received the request for withdrawal.
  • 6. Individual dies before we make the reconsideration determination
  • Input the death information to the individual’s record(s), and forward or upload the proof of death to the folder. Review the folder to determine leads to anyone who may be entitled or adversely affected by the cessation determination.
  • * Title II cases could include a surviving spouse, auxiliary beneficiaries, or a representative of the estate.
  • * For Title XVI cases, refer to SI 02101.003 (SSI Underpayment Due - individual Deceased - General).
  • NOTE: A death certificate has the cause(s) of the death, which can aid the DHO in making a determination if the cause of death was related to the individual’s disability.
  • a. Substitute party involved
  • If a substitute party involves a change in the DHU location, see instruction in DI 12026.025E.3.b. in this section. When a substitute party is involved:
  • * Secure an SSA-770-U4 (Notice Regarding Substitution of Party Upon Death of Claimant – Reconsideration of Disability Cessation). Use this form when allowing the substitute party to pursue the appeal of a deceased individual. For instructions about this form, see DI 12095.065.
  • * Inform the substitute party that a hearing may not be necessary if we are able to issue a favorable determination based on available evidence.
  • * Telephone the DHU and report the individual's death. If the substitute party informed the FO that he or she wishes to appear at the disability hearing scheduled for the individual, inform the DHU to not postpone the hearing. Also, provide the DHU with the substitute party's name, address, and telephone number. Otherwise, the DHU will postpone any hearing scheduled pending receipt of the SSA-770-U4.
  • * If the folder is electronic, upload the completed SSA-770-U4 and any additional medical information (e.g., recent hospitalizations, physician's report) into the electronic folder (EF).
  • NOTE: If the DHU is different from the one that previously had the folder, create a message to the DHU stating: “Substitute party requested disability hearing in your area.”
  • * If the folder is paper, prepare an SSA-408 (Route Slip) and route the completed copies of the SSA-770-U4 to the component with the folder and to the appropriate DHU. Include any additional medical information.
  • NOTE: If the DHU is different from the one that previously had the folder, annotate the SSA-408 to show: “Substitute party requested disability hearing in your area - Attached forwarded for folder association.”
  • b. Substitute party wishes to withdraw a request for reconsideration
  • When a substitute party wishes to withdraw the request for reconsideration:
  • * Route the completed SSA-770-U4 according to instructions in DI 12026.025E.6.a. in this section.
  • * If the office with the case returns the case to the FO for action on the withdrawal, the FO will ensure that the conditions meet the requirement for withdrawal, see GN 00206.005. Follow the general withdrawal instructions in GN 03102.200B.
  • c. Substitute party not located
  • Document that you were unable to locate a substitute party electronically (RPOC/DROC), or on a paper SSA-5002 (Report of Contact) and fax the documentation into the Non-Disability Repository for Evidentiary Documents (NDRED). Include the name and address of any known next of kin of the individual in the documentation.
  • * For Title II, see MS MCS 008.007 (Report of Contact (RPOC)).
  • * For Title XVI, document the report of contact in:
  • * MSSICS - See MS MSSICS 022.010 (Report of Contact (DROC))
  • * Non-MSSICS - prepare a paper SSA-5002 to document the information obtained. Forward the SSA-5002 for folder association.
  • d. References for electronic cases
  • For electronic cases:
  • * FOs processing appeals using eCDR should refer to DI 81010.255.
  • * DDS processing appeals using eCDR should refer to DI 81020.255.
  • e. Remand, common issue, and escalated cases
  • For information about:
  • * Remand cases
  • See GN 04440.247C.1. (Reviewing Informal Remand Cases).
  • * Common issue cases
  • See DI 12045.005 (Claims Under Different Titles - Common Issue – General).
  • * Escalated cases
  • Send escalated cases, or material for folder association, to the DHU rather than the DDS when the case is currently at the DHU or when the DHU made the reconsidered determination.
  • F. References
  • * DI 10501.025 Clearly Not SGA
  • * DI 12027.010 Processing Statutory Benefit Continuation (SBC)
  • * DI 13010.012 Protection from Medical Review Based on Work Activity
  • * DI 13015.005 Failure To Cooperate (FTC)/Whereabouts Unknown (WU) Procedures
  • * DI 20502.030 Folder Reconstruction
  • * DI 23040.001 DDS: Interpreters for Individuals with Limited English Proficiency (LEP) or Individuals Requiring Language Assistance
  • * DI 29005.020 GLPSC - Career Railroad and Railroad Annuitant Cases
  • * DI 70005.005 Overview of the Paper Modular Disability Folder (MDF)
  • * DI 81001.005 Certified Electronic Folder (CEF) Overview
  • * DI 81010.150 Processing Claims Appeals of Medical Decisions in Electronic Disability Collect System (EDCS)
  • * DI 81010.200 Electronic Continuing Disability Review (eCDR) Short Term Process Overview
  • * DI 81010.255 Electronic Continuing Disability Review (eCDR) Cessation Reconsiderations
  • * DI 81020.025 Processing Electronic Reconsideration Cases
  • * DI 81020.255 Processing a Reconsideration Appeal of an Electronic Continuing Disability (eCDR) Cessation
  • * GN 00304.000 Proof of Death – Table of Contents
  • * GN 03101.020 Good Cause for Extending the Time Limit to File an Appeal
  • * GN 03102.200 Claimant Requests Reconsideration
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