TN 11 (01-17)

A. Introduction to completing the form SSA-454-BK in adult cases

The SSA-454-BK (Continuing Disability Review Report) collects information necessary for a CDR and expedited reinstatement (EXR) case. The report records the most current information about the disabled individual’s condition since the most recent favorable medical decision or the comparison point decision (CPD). This report collects pertinent information about the disabled individual’s medical and non-medical sources and treatments, work status, educational and vocational training, and current daily activities.

NOTE: The field office (FO) should not complete the SSA-454-BK in mine improvement not expected (MINE) and MINE-equivalent cases. For more information on MINE cases, see DI 13005.022.

The FO is responsible for informing the disabled individual, representative payee, or appointed representative that we will collect information to evaluate continuing eligibility for disability payments and that we will determine whether medical improvement has occurred.

NOTE: For Age-18 medical redeterminations, use the SSA-3368-BK (Disability Report - Adult). For additional information on cases, involving Age-18 medical redeterminations see:

• DI 11070.000, Title XVI Childhood and Age 18 Disability Redetermination Cases (Public Law 104-193 as Modified by P.L. 105-33) FO

• DI 13050.000, Expedited Reinstatements

• DI 13005.005, Basis for Deciding Continuance of Disability.

B. Making a determination for a work CDR

The FO determines whether the disabled individual qualifies, or is already participating in, a trial work period (TWP), an extended period of eligibility (EPE), Section 1619, or other work incentive programs (for example, the Ticket to Work program). The FO makes any work related determination prior to sending a case to the disability determination services (DDS) for a medical review. If the FO determines the need for a full medical CDR, the FO will initiate the CDR process by establishing the review on the Disability Control File (DCF), if it is not already established. For cases involving a work related determination, see:

• DI 13010.000, Work Activity

• DI 55025.000, Ticket Use Status; and

• DI 13010.610, The Disability Review Establishment (DRES) Screen.

C. Documents to collect for the CDR

For the CDR, the FO must obtain the following documentation:

• A completed SSA-454-BK (Continuing Disability Review Report),

• SSA-827 (Authorization to Disclose Information to the Social Security Administration (SSA)) and,

• SSA-3367 (Disability Report – Field Office) for procedures on completing the SSA-3367 (Disability Report – Field Office), see DI 11005.045. For FO electronic case procedures, see DI 81010.000.

  NOTE: Obtain the paper CPD folder if the CPD folder is not in the Electronic Disability Collect System (EDCS).

The disabled individual, representative payee, or appointed representative, must answer all questions on the SSA-454-BK (Continuing Disability Review Report). Enter “not applicable”, “don’t know”, “none”, or “does not apply” for any question that the person completing the form does not know the answer to. For references to documents to collect for a CDR, see:

• DI 81010.242, Unable-to-Locate (UTL) Paper Comparison Point Decision (CPD) Folder

• DI 13050.045B.2, Obtain EXR Request Package (for Title II)

• DI 13050.050B.2, Obtain EXR Request Package (for Title XVI)

• DI 13005.040E, Completion of Form SSA-454-BK in Title XVI child cases in this section.

NOTE: For procedures on completing the form SSA-3367 (Disability Report – Field Office) in EDCS, see DI 81010.025A.

D. Completing the SSA-454-BK (Continuing Disability Review Report)

1. Page 1 – Top Box for “SSA use only”

The top of page 1 includes spaces for the FO to add the:

• “Date of the last medical disability decision”, for example, the CPD see DI 28010.105,

• Claim number, including the Beneficiary Identification Code (BIC),

• Number Holder’s name, and

• Type(s) of case(s) for review (for example, DIB, Title XVI disabled individual (TXVI DI), etc.).

2. Section 1 – Information About The Disabled Person

This section (Items 1A – 1G) collects basic identifying information about the disabled individual.

3. Section 2 – Contacts

This section (Items 2A – 2J) collects the name, relationship, address, phone number and language preference of someone who can assist the disabled individual with the CDR information, if necessary. This person can be the representative payee, appointed representative, a relative, friend, or any person willing to assist the disabled individual. This section also collects information about the person completing the report for the disabled individual.

4. Section 3 – Medical Condition(s)

This section (Items 3A – 3D) collects information about the illnesses, physical injuries and mental condition(s) that limit the disabled individual’s ability to work. This section also collects the illnesses, physical injuries and mental condition(s) of a child under age 18 that limit the disabled child’s ability to do the same things as other children of the same age.

5. Section 4 - Medical Treatment

This section (Items 4A – 4G) collects information about the treating sources, types of treatment received, and medical tests performed within the last 12 months. This information is necessary to compare the disabled person’s current condition to the condition at the time of the CPD. The complete names, addresses (including zip code), and telephone numbers of the treating sources are necessary. If the individual answers “No” to items 4.A. and 4.B., skip to Section 5.

The SSA-454-BK (Continuing Disability Review Report) contains space for up to five treating sources. If the disabled person has more than five treating sources, add the additional information to Section – 11 Remarks.

6. Section 5 – Medicines

This section collects the names of prescription and non-prescription medicines within the last 12 months, prescribing physicians (if any), and reasons for the medicines the disabled person is taking. If a prescribing physician is listed in this section, the physician’s information should be placed in Section 4 – Medical Treatment.

7. Section 6 – Other Medical Information

This section collects information about any additional sources that have medical information about any of the disabled person’s physical or mental conditions. Examples of other sources include, but are not limited to, worker’s compensation board, vocational rehabilitation agencies, insurance companies, prisons, attorneys, and social service agencies.

8. Section 7 – Education and Training

This section (Items 7A and 7B) collects information about any additional education or training the disabled person has received since the CPD. If the disabled individual is participating in a vocational rehabilitation program, see DI 14510.003. The DDS needs this information to evaluate medical improvement and to determine whether an exception to medical improvement applies. Do not answer these questions in Title XVI childhood cases.

9. Section 8 – Vocational Rehabilitation, Employment or Other Support Services

This section (Items 8A – 8D) collects information regarding the disabled person’s participation in any vocational rehabilitation, employment or participation in any type of work support services. If the disabled person is participating in the Ticket to Work program, see DI 55025.010 and DI 14510.003. If the answer to the question is “Yes”, the FO must complete work development before sending the case to DDS, see DI 13010.000. The DDS needs this information to evaluate medical improvement and to determine whether an exception to medical improvement applies.

10. Section 9 – Daily Activities

This section (Items 9A - 9C) collects detailed information about the disabled person’s daily activities. The DDS uses this section to determine how the disabled person’s condition(s) affects the ability to perform substantial gainful activity (SGA).

11. Section 10 – Work

This section collects information about any employment or work a person has performed since the last medical disability decision, the comparison point decision (CPD). If the individual answers “Yes”, the FO must complete work development before sending the case to the DDS, see DI 13010.000.

12. Section 11 – Remarks

This section provides space for any additional information the person completing the form wishes to provide. It also requests the completion date of the form.

E. Collecting information for Title XVI child cases

Be flexible in applying the procedural guideines in DI 13005.040D in this section. The purpose of the SSA-454–BK (Continuing Disability Review Report) is to obtain all of the information the DDS need, but also to avoid duplicative work by the FO, the disabled individual, or representative payee. To avoid unnecessary work, follow the guidelines in DI 13005.040D in this section.

Some questions on the SSA-454-BK (Continuing Disability Review Report) do not apply to most Title XVI child cases. Other questions duplicate items on the SSA-3881-BK (Questionnaire for Children Claiming SSI Benefits). Complete the required forms for Title XVI child cases following the procedures in DI 13005.040D in this section.

F. Procedure for collecting information for Title XVI child cases

Complete the appropriate questions for the Title XVI childhood case on the form SSA-454-BK (Continuing Disability Review Report). The form SSA-454-BK (Continuing Disability Review Report) identifies the appropriate questions to answer based on the child’s age. Complete the entire SSA-3881-BK (Questionnaire For Children Claiming SSI Benefits) and provide the necessary information for the disabled child CDR on the appropriate age-related function report (SSA-3375-BK through SSA-3379-BK). For electronic FO case procedures, see DI 81010.000.