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DI 12521.025: FO Actions Prior to Final DDS Readjudication

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  • Effective Dates: 06/12/2015 - Present
  • Effective Dates: 05/24/2018 - Present
  • TN 57 (02-97)
  • DI 12521.025 FO Actions Prior to Final DDS Readjudication
  • A. Policy
  • 1. General
  • The FO will contact the class member (or representative, if applicable) to update the medical sources and work activity information.
  • See DI 12586.070 for determining the applicability of tolerances, the applicable tolerance period, and the applicability of tolerances for the development of title XVI non-medical factors of eligibility and/or continuing eligibility.
  • NOTE: A systems record will not be established until after an allowance is made.
  • 2. Obtaining Folders
  • During the folder retrieval process, ODIO and/or NEPSC will ask the FO to obtain the folder(s) if case control information indicates that a folder for the potential class member is located in the FO.
  • 3. Lost Folders
  • A folder containing the Dixon class claim(s) is considered lost if it cannot be located within 120 days of the initial search (i.e., the date on which the alert is generated). ODIO and/or NEPSC will initiate reconstruction if the presumptions in DI 12521.015B.5. and DI 12521.015B.6. do not apply. (See DI 12521.025B.4.)
  • B. Procedure
  • 1. Updating Class Member's File
  • Take the following action to update a class member's claim.
  • * Review the Dixon alert package which contains the Dixon Court Case Flag/CATS Alert, and related queries (e.g., FACT, Supplemental Security Record/Stored Terminated and Lacking Eligibility File (SSR/STALE), AR-25, OHAQ (when needed), Summary Earnings Query (SEQY), and ODIO overnight) and any material associated with the reply form (e.g., medical evidence, Form SSA-1696-U4).
  • * Review the SEQY to determine if earnings are different from those of original certified earnings record. If the date first insured or date last insured has changed since the original Dixon determination, annotate the route slip to that effect when transmitting development to DDS.
  • * In cases where the DDS has requested assistance, process the Form SSA-883-U3 (Request for Evidence or Assistance (Disability Case)).
  • * Contact the class member or the current representative, if applicable, for an update of the claimant's medical condition and medical sources. Ask the claimant if he/she has any evidence relevant to the period to be readjudicated to submit.
  • NOTE: The Dixon order requires that SSA provide reasonable efforts to assist the class member in obtaining evidence. It DOES NOT require SSA to reconstruct the names of doctors, medical centers, etc., that a claimant may have visited when the claimant is now unable to recall that information.
  • * Refer to the Dixon alert for the period to be developed that the Dixon screener has annotated on the alert.
  • Use Form SSA-3441-F6 (Reconsideration Disability Report) to obtain updated medical source and condition information. In termination cases, use Form SSA-454-BK (Report of Continuing Disability) to update the folder.
  • NOTE: The relevant period extends from the earliest date based on the application(s) which results in class membership up to the AOD (including AOD in later onset date allowance cases or DOF in title XVI cases), covered by any subsequent claim(s) that is denied for any reason after July 19, 1983, or for a reason other than not severe on or before July 19, 1983, or EOD in a subsequent allowance (regardless of whether the subsequent allowance is continuing, ceased or was a closed period), or the present if no subsequent applications have been filed.
  • * Use Form SSA-3368-BK (Disability Report) to obtain information in lost folder cases (see e. above for the period the form should cover).
  • * Obtain Form SSA-827s (Authorization to Release Medical Information to SS) for all medical sources, as necessary.
  • * Record work activity on Form SSA-820-F4 (Work Activity Report-Self-Employed) or SSA-821-F4 (Work Activity Report-Employee). If it appears that the work activity may result in either a denial for SGA or a later onset, develop the work per DI 10105.001 ff.
  • * Forward the updated folder(s) to the N.Y. ODD (or the appropriate DDS) for Dixon review.
  • 2. SGA - Determination was a Denial
  • Take the following action if the class member is working at the SGA level and the original determination was a denial (see DI 12586.070 for determining the applicability of tolerances and the applicable tolerance period).
  • * If SGA began within 12 months after the alleged onset and continued throughout the Dixon period to be developed, and the original determination was a denial, prepare Form SSA-831-U3/C3 (Disability Determination) to reopen and revise the original determination to denial based on SGA. Because that needs to be recorded onto CATS, send a copy of the Form SSA-831-U3/C3 to: SSA, ODIO Class Action Section Attention: Dixon Coordinator P.O. Box 17369 Baltimore, MD 21298-0050.
  • If readjudication is within ODAR's jurisdiction, do not prepare Form SSA-831-U3/C3. Instead, advise ODAR of the SGA determination.
  • If readjudication is within OHO's jurisdiction, do not prepare Form SSA-831-U3/C3. Instead, advise OHO of the SGA determination.
  • * Forward the folder to the NY ODD (or the appropriate DDS) for readjudication in all other situations involving work.
  • * Please do not forward completed folders to The Class Action Section (CAS) located in Baltimore, Maryland. Upon completion of a case, the folder should be forwarded to the appropriate storage facility (PSC, WBDOC, ODO). CAS does not house completed folders.
  • 3. Obtaining Folders
  • Assist in locating folders upon request from ODIO, NEPSC, or the DDS.
  • 4. Lost Folders
  • Take the following actions when ODIO and/or NEPSC determines that the Dixon class claim(s) cannot be located and the Dixon court-ordered presumptions in DI 12521.015B.5. and DI 12521.015B.6. do not apply.
  • * Initiate reconstruction (GN 03105.010) beginning with the period covered by the earliest Dixon claim that results in class membership.
  • NOTE: The court order requires the class member to submit evidence pertaining to his/her condition during the period to be readjudicated if the class member's claims file cannot be located and the presumptions in DI 12521.015B.5. and DI 12521.015B.6. do not apply.
  • * Contact the class member to obtain the names of doctors, hospitals, medical centers, etc., that the claimant may have visited (see DI 12521.025B.1. above). Ask the class member if he/she has any evidence relevant to the period to be readjudicated to submit.
  • DO NOT RECONSTRUCT the names of doctors, hospitals, medical centers, etc., which a particular claimant visited when the claimant is now unable to recall that information. Provide reasonable efforts to assist the claimant in obtaining evidence relevant to the readjudication of his/her claim(s).
  • NOTE: The court order requires that SSA ONLY contact those sources identified by the claimant. If SSA writes to a source requesting a report and no response is received, SSA will make one follow-up by letter (or phone call). If the evidence received from the treating source(s) or other medical source(s) is insufficient for adjudication, SSA will recontact the source(s) for additional information. SSA will not obtain a consultative exam if the request for information is unsuccessful.
  • * Forward all material to the N.Y. ODD (or the appropriate DDS) after reconstruction is completed for the Dixon review.
  • 5. Class Member Represented
  • If a class member has a current representative of record, conduct development through the current representative unless otherwise indicated. (See GN 03910.040 ff.) Obtain Form SSA-1696-U4 if one is not in file.
  • 6. Systems Input
  • DDS controls via NDDSS.
  • 7. Change in Date Last Insured
  • Notify the DDS of the new date last insured if it changed since the prior denial/cessation.
  • 8. Whereabouts Unknown/Failure to Pursue
  • If the class member's whereabouts become unknown or the class member does not wish to pursue his/her request for Dixon review:
  • * Follow DI 11010.045 and DI 11055.085.
  • * Annotate the alert to show either “Whereabouts Unknown” or “Failure to Pursue” and forward a copy of the alert to: Office of General Counsel Correspondence Control Staff Altmeyer Room 617 6401 Security Blvd. Baltimore, MD 21235 Attn: Class Action Coordinator
  • * Take action for filing of folder(s).
  • 9. Class Member Deceased
  • If a class member is deceased:
  • * Apply existing procedures for determining distribution of any potential underpayment (see GN 02301.055A. and SI 02101.001 ff., as appropriate).
  • * If there is no eligible party to receive any potential underpayment, or there is no Medicaid issue, record this fact on Form SSA-5002 and send to LS at the address in DI 12521.025B.8.b. above. The Dixon coordinator is responsible for clearing the case from CATS.
  • * Take action for filing of folder(s).
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