DI 13050.025: Provisional Benefits for Title II Claimant

changes
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~~Effective Dates: 02/19/2016 - Present~~
Effective Dates: 02/02/2018 - Present
~~TN 5 (02-16)~~
TN 6 (02-18)
DI 13050.025 Provisional Benefits for Title II Beneficiary
DI 13050.025 Provisional Benefits for Title II Claimant
A. Provisional benefit eligibility
~~1. When a beneficiary is eligible for provisional benefits~~
1. When a claimant is eligible for provisional benefits
A beneficiary who meets the requirements and completes a request for Expedited Reinstatement (EXR) may receive up to 6 months of provisional cash benefits and Medicare while we make a decision on his or her request. Medicare coverage based on the provisional benefit period is the same Medicare coverage the individual had prior to his or her termination.
A claimant who meets the non-medical requirements and completes a request for Expedited Reinstatement (EXR) may receive up to 6 months of provisional cash benefits and Medicare while we make a decision on his or her request. Medicare coverage during the provisional benefit period is the same Medicare coverage the claimant had prior to his or her termination.
~~2. When a beneficiary is not eligible for provisional benefits~~
2. When a claimant is not eligible for provisional benefits
~~A beneficiary is not eligible for provisional payments when one of the following applies:~~
~~* he or she was not previously entitled to disability insurance benefits (DIB), childhood disability benefits (CDB), or disabled widow(er) benefits (DWB);~~
~~* his or her entitlement did not terminate due to Substantial Gainful Activity (SGA);~~
~~* he or she did not file the request for reinstatement within the required 60-month time limit and we did not find good cause for late filing;~~
* he or she engaged in SGA in the month the request is filed;
* an event has occurred that would preclude entitlement (CDB has married); or
* DDS determines the beneficiary does not meet the disability requirements for EXR.
A claimant is not eligible for provisional benefits when any of the following applies:
* he or she does not meet one of the eligibility requirements for EXR listed in DI 13050.001B.1;
* an event has occurred that would preclude entitlement (a childhood disability benefits (CDB) recipient has married); or
* the disability determination services (DDS) determines the claimant does not meet the disability requirements for EXR.
~~A beneficiary can decline provisional cash benefits, but still elect to receive Medicare coverage during the provisional benefit period.~~
A claimant can decline provisional cash benefits, but still elect to receive Medicare coverage during the provisional benefit period.
~~NOTE: Provisional benefits are not payable to auxiliary claimants, other than a previously entitled DWB or CDB who is eligible and requests EXR. Provisional benefits are not payable to:~~
* a beneficiary requesting EXR of CDB benefits on the record of a living number holder, if the number holder is not currently entitled; or
* a DWB or CDB who does not meet other non-disability requirements (a CDB has married).
NOTE: Provisional benefits are not payable to auxiliary claimants, other than a previously entitled disabled widow(er) benefit (DWB) or CDB who is eligible and requests EXR. Provisional benefits are not payable to a claimant requesting EXR of CDB benefits on the record of a living number holder who is not currently entitled.
3. Paying provisional benefits on a subsequent EXR request
SSA does not pay provisional benefits on an EXR request if the beneficiary previously requested EXR for the same period of eligibility and received provisional benefits based on that request, regardless of how many months he or she received provisional payments on the previous request. However, we can pay provisional payments on a subsequent EXR request if the beneficiary:
The Social Security Administration (SSA) does not pay provisional benefits on an EXR request if the claimant previously requested EXR for the same period of eligibility and received provisional benefits based on that request, regardless of how many months he or she received provisional payments on the previous request. However, we can pay provisional payments on a subsequent EXR request if the claimant:
* was approved for EXR on a previous request;
* completed the initial reinstatement period (IRP);
* completed a trial work period (TWP);
* completed his or her extended period of eligibility (EPE);
* had his or her benefits later terminated due to SGA, and
* files a new request for EXR within 60 months of that termination, or we can find good cause for late-filing.
* had his or her benefits later terminated due to substantial gainful activity (SGA), and
* filed a new request for EXR within 60 months of that termination, or we can find good cause for late filing.
~~Subsequent request example:~~
Subsequent request example #1:
Ms. Jones requests EXR on 03/04/08 and we approve the request on 05/04/08. She receives 3 months of provisional payments before she is reentitled to disability benefits. She completes her IRP, TWP and EPE. After completing the EPE, Ms. Jones benefits terminate due to SGA in 01/15. On 04/12/15, Ms. Jones again files for EXR because she is no longer performing SGA. As Ms. Jones completed the IRP, TWP, and EPE on the new entitlement period, had her benefits terminated for SGA, and then filed a new EXR requests within 60 months of that termination, she is eligible to again request EXR and receive provisional benefits.
Ms. Jones requests EXR on 03/04/08 and we approve the request on 05/04/08. She receives 3 months of provisional benefits before she is re-entitled to disability benefits. She completes her IRP, TWP and EPE. After completing the EPE, Ms. Jones’s benefits terminate due to SGA in 01/15. On 04/12/15, Ms. Jones again files for EXR because she is no longer performing SGA. As Ms. Jones completed the IRP, TWP, and EPE on the new entitlement period, had her benefits terminated for SGA, and then filed a new EXR request within 60 months of that termination, she is eligible to request a subsequent EXR and receive provisional benefits.
Subsequent request example #2:
Mr. Smith requests EXR on 03/04/08 and we medically deny the request on 05/04/08. He received 3 months of provisional benefits. Mr. Smith refiles for EXR on 05/2010. Because we paid at least one month of provisional benefits on the prior request, we cannot pay provisional benefits on the subsequent request.
B. Provisional benefit amount
1. Benefit computations
Base the provisional benefit payment amount upon the payable benefit amount at the time the previous entitlement terminated, increased by intervening COLAs and recomputations. This is regardless of any other changes (such as overpayments, offsets, etc.). If the prior payable benefit was reduced due to offset or other reductions, base the provisional payment amount upon the prior reduced benefit payable. Apply current tax levies or garnishments to provisional payments in accordance with GN 02410.110 and, GN 02410.210. Apply any Medicare premium arrearages to provisional benefits. If an overpayment exists on the record, do not recover this against provisional benefits without the claimant’s written consent. If we award the EXR request, make adjustments for offsets (Workers Compensation/Public Disability Benefits [WC/PDB] and Government Pension Offset [GPO]), Windfall Elimination Provision (WEP), overpayments, and other payment issues with the first month of reinstated benefits.
Compute the provisional benefit following these steps:
* Base the provisional benefit payment amount upon the payable benefit amount at the time the previous entitlement terminated, increased by intervening cost of living adjustments (COLA) and re-computations. This is regardless of any other changes (such as overpayments, offsets, etc.).
* Base the provisional payment amount upon the prior reduced benefit payable, if the prior payable benefit was reduced due to offset or other reductions.
* Apply current tax levies or garnishments to provisional payments in accordance with GN 02410.110 and GN 02410.210.
* Apply any Medicare premium arrearages to provisional benefits.
* If an overpayment exists on the record, do not recover this against provisional benefits without the claimant’s written consent.
* If we award the EXR request, make adjustments for offsets, such as Workers Compensation/Public Disability Benefits, Government Pension Offset, Windfall Elimination Provision, overpayments, and other payment issues with the first month of reinstated benefits.
2. Dual entitlement benefits
When a beneficiary requests reinstatement on one record and is currently receiving a title II benefit on another record, the provisional benefit is payable only if the provisional benefit amount is greater than the current benefit payable on the other record. If the current benefit amount is higher than the provisional benefit amount, no provisional benefits are payable. If a beneficiary requests EXR for more than one benefit, pay provisional benefits on the record that yields the highest benefit payable amount. (Compute the provisional benefits on different records independently based upon the prior benefit rate on that record with intervening cost of living adjustments [COLAs] and recomputations.)
When a claimant requests reinstatement on one record and is currently receiving a Title II benefit on another record, the provisional benefit is payable only if the provisional benefit amount is greater than the current benefit payable on the other record. If the current benefit amount is higher than the provisional benefit amount, no provisional benefits are payable. If a claimant requests EXR for more than one benefit, pay provisional benefits on the record that yields the highest benefit payable amount. If provisional benefits end for a dually entitled beneficiary, payment will resume on the other record as long as they are still eligible for benefits on that record.
NOTE: A claimant must file separate EXR requests for multiple entitlement situations. Evaluate each request against the EXR requirements and process accordingly.
3. Family maximum involved with DWB or CDB request
For DWB and CDB claimants, the payment of provisional benefits may cause the total benefits payable on the record to exceed the family maximum (FMAX). In such cases, pay the provisional benefit amount outside the FMAX and do not adjust the benefit amount for any auxiliary already entitled on the same record during the provisional benefit period.
C. Provisional benefit start month
1. When provisional benefits start
Provisional benefits are payable beginning with the month the beneficiary completes and submits the signed EXR request per DI 13050.045B.2, assuming benefits have not already been paid for that month. Do not use the protective filing date (if one exists) for provisional payment. We can only pay provisional benefits during the consecutive 6-month period that begins with the month the individual completes the EXR request.
Provisional benefits are payable beginning with the month the claimant completes and submits the signed EXR request per DI 13050.045B.2, assuming benefits have not already been paid for that month. If the claimant performed SGA in the month of filing, provisional benefits are payable with the month after the month of filing. We can only pay provisional benefits during the consecutive 6-month period beginning with the month of the EXR request, or the following month if there is SGA in the month of filing.
Start month example: A beneficiary contacts SSA about filing for EXR on 04/24/15 but does not return the signed request forms until 06/03/15. Provisional benefits will begin 06/15, the month the individual completed his/her EXR request. We use the protective filing date of 04/24/15 as the month of filing documented in the Remarks section of the SSA-454 (see DI 13050.045B.2.b). The DDS uses the protective filing date to make the medical determination and establish the month of EXR entitlement, which may be up to 12 months prior to that date.
NOTE: Do not use the protective filing date for determining when provisional payments should begin. We use the protective filing date to determine the retroactive scope of the EXR.
~~2. Previous benefits must be terminated~~
Start month example 1: A claimant contacts SSA about filing for EXR on 04/24/15 but does not return the signed request forms until 06/03/15. He did not perform SGA in June. Provisional benefits will begin 06/15, the month he completed his EXR request.
Provisional benefits cannot start until the previous benefits terminate and the Master Beneficiary Record (MBR) LAF Code is T6, T8, U or X7. If we made a determination to terminate the previous benefit but it has not input to the MBR, the FO should contact the Payment Center (PC) to expedite the termination in order to begin provisional benefits. Use the exclusion case procedures described in DI 13050.025I.3 to expedite the previous benefit termination. We cannot pay provisional benefits for any month in which the beneficiary has already received the same type of benefit payment on the same entitlement.
Start month example 2: A claimant completes and returns a signed request for EXR on 06/25/17. He performed SGA in the month of June, but stopped performing SGA by the date of his request. Provisional benefits will begin 07/17, the month after he stopped engaging in SGA.
EXAMPLE: On 4/18/14, SSA contacts Mr. Jones to tell him that they will terminate his disability benefits due to performing SGA. The benefit termination month (BTM) is 09/13. Mr. Jones contacts SSA on 04/29/14 to say that he has not worked for the last 3 months due to his disability and submits his request for EXR. Though we determined to terminate Mr. Jones benefits, an MBR review shows that the benefit termination has not yet been effectuated. The FO contacts the PC to expedite the termination. Benefits terminate ten days later (05/09/14). Mr. Jones will receive his first month of provisional benefits for 05/14, since he received a benefit payment for 04/14. DDS will use protective filing date of 04/29/14 from the Remarks section of the SSA-454 to make the medical determination.
2. Termination of previous benefits
Provisional benefits cannot start until the previous benefits terminate and the master beneficiary record (MBR) Ledger Account File (LAF) Code is T6, T8, U or X7. If we made a determination to terminate the previous benefit but the MBR does not reflect it, the field office (FO) should contact the program service center (PSC) to expedite the termination in order to begin provisional benefits. Use the exclusion case procedures described under DI 13050.025I.3 in this section to expedite the previous benefit termination. We cannot pay provisional benefits for any month in which the claimant has already received the same type of benefit payment on the same entitlement.
EXAMPLE: On 4/18/14, SSA contacts Mr. Jones to tell him that they will terminate his disability benefits due to performing SGA. The benefit termination month (BTM) is 09/13. Mr. Jones contacts SSA on 04/29/14 to say that he has not worked for the last 3 months due to his disability and submits his request for EXR. Though we made a final determination to terminate Mr. Jones benefits, the record has not terminated. The FO contacts the PSC to expedite the termination. Benefits terminate ten days later (05/09/14). Mr. Jones will receive his first month of provisional benefits for 05/14, since he received a benefit payment for 04/14.
D. Provisional benefit end month
~~Payment of provisional benefits ends with the earliest of:~~
* the month SSA makes a determination and issues the notice regarding the individual's EXR request;
* the month the beneficiary works and performs SGA;
* the month before the beneficiary attains full retirement age;
* the month before the beneficiary dies; or
* the 5th month following the month the beneficiary completed the EXR request.
The claimant may not receive more than 6 months of provisional benefits. Payment of provisional benefits ends with the earliest of:
* the month SSA makes a determination and issues the notice regarding the claimant’s EXR request;
* the month the claimant works and performs SGA;
* the month before the claimant attains full retirement age, see DI 13050.025B.2 in this section; or
* the month before the claimant’s death.
~~NOTE: These months are the last month the provisional payment is payable. Therefore, if a beneficiary begins SGA in 04/2015, 04/2015 is the last possible month of provisional benefits.~~
NOTE: These months are the last month the provisional payment is payable. Therefore, if a claimant begins SGA in 04/2015, 04/2015 is the last possible month of provisional benefits. Provisional benefits do not resume if the claimant stops performing SGA.
E. Suspension and terminating events
Suspend or terminate provisional benefits following normal benefit policies. Such suspension or termination events include:
* prisoner suspension,
* alien suspension, and
* marriage of a CDB
For a discussion of suspension and termination events, see GN 02602.005, RS 00203.030, RS 00203.035, and RS 00207.002. Provisional benefits will not resume when a suspension event continues beyond the provisional benefit period ending month.
F. Medicare entitlement
A beneficiary previously entitled to disability benefits who requests benefit reinstatement also receives Medicare coverage during the provisional benefit period. It is important to understand the type of Medicare coverage that exists when the beneficiary enters the provisional benefit period (Disabled Working Individual [DWI], Extended Medicare, End Stage Renal Disease [ESRD]) as the DDS medical determination affects the types of coverage differently. For instructions regarding Medicare coverage and termination as they relate to EXR, see HI 00801.164 to HI 00801.167 and DI 13050.070.
A claimant previously entitled to disability benefits who requests benefit reinstatement also receives Medicare coverage during the provisional benefit period. It is important to understand the type of Medicare coverage that exists when the claimant enters the provisional benefit period (e.g. Disabled Working Individual [DWI], Extended Medicare, End Stage Renal Disease [ESRD]), as the DDS, medical determination affects the types of coverage differently. For instructions regarding Medicare coverage and termination as they relate to EXR, see HI 00801.164 to HI 00801.167 and DI 13050.070.
G. Appeals process
Actions to pay, adjust or terminate provisional benefits are not initial determinations and are not subject to the administrative and judicial review (appeals) process. However, overpayment decisions relating to provisional benefits are subject to review. For a discussion about appeals, see DI 13050.085.
H. Special situations
~~1. Beneficiary is already entitled to, or eligible for, another title II retirement, auxiliary or survivor benefit~~
Pay the higher amount of either the title II benefit the beneficiary already receives or the provisional benefit payable. Regardless of the benefit actually paid during the provisional period, afford Medicare entitlement to the beneficiary.
1. Claimant is eligible for supplemental security income (SSI) provisional benefits
If the beneficiary receives reduced benefits based on an application with a date of entitlement before attainment of full retirement age, do not count months in which he or she receives provisional disability benefits towards reducing the reduction factor.
Regular payment provisions apply. Consider windfall offset. Title II provisional benefits are income for SSI computation purposes. The claimant must file a separate request for reinstatement under Title XVI.
If provisional benefits terminate, resume the other benefit, if still payable.
2. Claimant attains full retirement age (FRA) during the provisional benefit period
2. Beneficiary is eligible for SSI provisional benefits
Provisional benefits terminate when a claimant attains FRA. Provisional benefits do not automatically revert to an aged benefit at FRA. If the claimant wishes to receive aged benefits, he or she must file an application, or already be entitled to a benefit that will automatically convert to an aged benefit at full retirement age (regular widow's benefit or retirement).
Regular payment provisions apply. Consider windfall offset. Title II provisional benefits are income for SSI computation purposes. The beneficiary must file a separate request for reinstatement under title XVI.
3. Claimant has appeal pending on prior claim denial, or on termination of prior entitlement
~~3. Beneficiary attains full retirement age (FRA) during the provisional benefit period~~
Provisional disability benefits terminate when a beneficiary attains FRA. Provisional benefits do not automatically revert to an aged benefit at FRA. If the beneficiary wishes to receive aged benefits, he or she must file an application, or already be entitled to a benefit that will automatically convert to an aged benefit at full retirement age (regular widow's benefit or retirement).
~~4. Beneficiary is entitled to provisional benefits for multiple title II benefits~~
A beneficiary must file separate EXR requests for multiple entitlement situations. Evaluate each request against the EXR requirements and process accordingly. Pay provisional benefits on the record that yields the highest benefit payable.
~~5. Beneficiary has appeal pending on prior claim denial, or on termination of prior entitlement~~
The appeal of a prior claim denial, or termination appeal, has no effect on the beneficiary’s eligibility for EXR. The beneficiary can receive provisional benefits and reinstate through EXR, if the beneficiary meets EXR eligibility requirements in the month of the EXR request.
The appeal of a prior claim denial, or termination, has no effect on the claimant’s eligibility for EXR. The claimant can receive provisional benefits and reinstatement through EXR, if the claimant meets EXR eligibility requirements in the month of the EXR request.
I. Initiating provisional benefits
If the beneficiary is eligible for EXR based on non-medical eligibility requirements, begin provisional benefits via POS (do not use the Critical Payment System [CPS] to initiate provisional payments; for non-receipt of EXR provisional payments, see DI 13050.100). If subsequent development determines that EXR does not meet non-medical requirements, see instructions in MSOM T2PE 003.024.
If the claimant is eligible for EXR based on non-medical eligibility requirements, begin provisional benefits via the Post Entitlement Online System (POS). Do not use the Critical Payment System (CPS) to initiate provisional payments. For non-receipt of EXR provisional payments, see DI 13050.100. If subsequent development determines that the claimant’s EXR request does not meet the non-medical requirements, see instructions in MS T2PE 003.024.
1. Using POS to start provisional benefits
Input the request for provisional benefits on the Provisional Payment (PEPP) screen of the title II Post-entitlement Online System (POS). Instructions are in MSOM T2PE 003.040. Follow these steps to access the PEPP screen:
* Select option 2, title II/PE, on the SSA MAIN menu and press Enter.
Input the request for provisional benefits on the Provisional Payment (PEPP) screen of the Title II POS. Instructions are in MS T2PE 003.040. Follow these steps to access the PEPP screen:
* Select option 2, Title II/PE, on the SSA MAIN menu and press Enter.
* On the POS Menu (PEMU) screen, select 1 to establish and complete the required fields, press Enter.
* On the Postentitlement Selection List (PESL) screen select item 7 (Provisional Payments) and item 1 (Addr/Dir Dep/Tel) for the appropriate BIC, press Enter.
* On the Post Entitlement Address (PEAD) screen, enter any needed changes to the beneficiary’s address, bank data, or telephone number propagated to the PEAD screen from the MBR. If no changes are necessary and all information is correct, press enter to advance to the PEPP screen.
* On the PEPP screen, enter the date of the EXR request in MMYY format, any remarks that may be needed, and press Enter.
* On the Post Entitlement Selection List (PESL) screen select item 1 (Addr/Dir Dep/Tel) and item 7 (Provisional Payments) for the appropriate BIC and, press Enter.
* On the Post Entitlement Address (PEAD) screen, enter any needed changes to the claimant’s address, bank data, or telephone number propagated to the PEAD screen from the MBR. If no changes are necessary and all information is correct, press enter to advance to the PEPP screen.
* On the PEPP screen, enter the provisional payment start month in MMYY format. Add any necessary remarks, and press Enter. The provisional benefit start month is the month we receive the EXR request package. However, if the claimant engaged in SGA in the month of the request, the provisional payment start month is the following month. If the provisional benefit start month is later than the current operating month (COM), make the POS input after the COM changes.
NOTE: If the claimant engaged in SGA in both the month of the EXR request and the following month, deny the request for EXR. For denials, see DI 13050.065
2. Processing exception cases for provisional benefits
~~Some cases require processing in the PC to start provisional benefits. The following situations will generate an exception alert in the PC that requires manual processing:~~
* concurrent title II/title XVI cases and a PMA check is payable;
Some cases require manual processing in the PSC to start provisional benefits. The following situations will generate an exception alert in the PSC:
* concurrent Title II/Title XVI cases and a PMA check is payable;
* DWB and CDB cases in which there are other entitled auxiliaries on the same record; and
* cases where the individual requesting EXR already is entitled to another title II benefit
* cases where the individual requesting EXR is already entitled to another title II benefit
If the direct input does not process, do not attempt to re-input through POS. Check PCACS for an Action Control Record (ACR) with TOELs DIPROV PAYMENT. It may take up to three business days for the ACR to appear in PCACS. If the ACR does not appear in PCACS after three business days, contact the PC of jurisdiction.
If the direct input does not process, do not attempt to re-input through POS. Check PCACS for an Action Control Record (ACR) with TOELs DIPROV PAYMENT. It may take up to three business days for the ACR to appear in PCACS. If the ACR does not appear in PCACS after three business days, contact the PSC of jurisdiction.
If the ACR is present in PCACS, tickle the case for 15 business days to allow for PC processing. If the MBR does not update after 15 business days, contact the PC of jurisdiction and tickle the case for 15 days for follow up.
If the ACR is present in PCACS, tickle the case for 15 business days to allow for PSC processing. If the MBR does not update after 15 business days, contact the PSC of jurisdiction and tickle the case for 15 days for follow up.
~~To contact the PC of jurisdiction:~~
* For PSC 1-6 cases, follow the locally established procedures for resolution of high priority cases, or send a 2560HP. Enter the remark “Do not place in backlog”
* For PC 7 cases, send an email to ||OCO ODO PITAG requesting status
To contact the PSC of jurisdiction:
* For PSC 1-6 cases, follow locally established procedures for resolution of high priority cases, or send a modernized development worksheet (MDW) 2560HP request. Enter the remark “Do not place in backlog”
* For PSC 7 cases, send an email to ||OCO ODO PITAG requesting status
If the MBR does not update after the second 15-day tickle or if a dire need/adverse public relation situation exists, FO’s should use the Manager-to-Manager process to contact the PC per GN 01070.228. Contact PC7 by selecting PROGRAM INTEGRITY TAG with the subject line Manager to Manager.
If the MBR does not update after the second 15-day tickle or if a dire need/adverse public relation situation exists, FOs should use the Manager-to-Manager process to contact the PSC per GN 01070.228. Contact PSC7 by selecting PROGRAM INTEGRITY TAG with the subject line Manager to Manager.
3. Processing exclusion cases for provisional benefits
~~Exclusion cases do not process through a POS input, and requires manual action by the PC. Some examples of exclusion cases are:~~
Exclusion cases do not process through a POS input, and require manual action by the PSC. Some examples of exclusion cases are:
* the provisional benefit is not payable in the first month of the provisional period (payment is suspended) or
* the EXR request date is more than 60 months after the previous termination (good cause found for late filing)
Do not use CPS to start provisional payments, as Supplementary Medical Insurance (SMI) premiums will not be withheld and may result in a termination of SMI due to non-payment of premiums. Requests for initiation of provisional payments are high priority actions.
* Send requests for PC 7 to initiate provisional payments for exclusion cases to ||OCO ODO PITAG.
* For PSC 1-6 cases, follow the locally established procedures for resolution of high priority actions, or send a 2560HP. Enter the remark “Do not place in backlog”:
Do not use CPS to start provisional benefits, as any monies withheld from CPS payments for supplemental medical insurance (SMI) premiums are not credited until the provisional benefit action is processed and may result in an incorrect termination of SMI due to non-payment of premiums. Requests for initiation of provisional benefits are high priority actions.
* Send requests for PSC 7 to initiate provisional benefits for exclusion cases to ||OCO ODO PITAG.
* For PSC 1-6 cases, follow locally established procedures for resolution of high priority actions, or send a 2560HP. Enter the remark “Do not place in backlog”:
Tickle for 15 days to follow up. If the MBR does not update after the 15-day follow up tickle expires or if a dire need/adverse public relation situation exists, FO’s should use the Manager-to-Manager process to contact the PCs per GN 01070.228. Contact PC7 by selecting PROGRAM INTEGRITY TAG with the subject line Manager to Manager.
Tickle for 15 days to follow up. If the MBR does not update after the 15-day follow up tickle expires or if a dire need/adverse public relation situation exists, use the Manager-to-Manager process to contact the PSCs per GN 01070.228. Contact PSC7 by selecting PROGRAM INTEGRITY TAG with the subject line Manager to Manager.
~~J. Procedure for terminating provisional benefits~~
J. Terminating provisional benefits
When the provisional benefit period ends, provisional benefits and Medicare entitlement based solely on the provisional benefit period must terminate, see HI 00801.165. Medicare entitlement based on age, ESRD, or extended Medicare does not terminate at the end of the provisional benefit period. For a detailed discussion about Medicare in relation to EXR determinations, see DI 13050.070.
When the provisional benefit period ends, provisional benefits and Medicare entitlement based solely on the provisional benefit period terminate, see HI 00801.165. Medicare entitlement based on age, ESRD, or extended Medicare does not terminate at the end of the provisional benefit period. For a detailed discussion about Medicare in relation to EXR determinations, see DI 13050.070.
1. Terminating benefits due to substantial gainful activity (SGA)
1. Terminating benefits due to SGA
~~The performance of SGA during the provisional benefit period terminates provisional benefits.~~
The performance of SGA during the provisional benefit period terminates provisional benefits. The FO technician must:
* Develop work activity during the provisional benefit period.
* Document the work on form SSA-820 or SSA-821 and record the determination on form SSA-823 and fax into eView or non-disability repository application (NDRED).
* Notify the Disability Determination Services (DDS) examiner by telephone of the work and SGA finding.
* Document the work on form SSA-820-BK (Work Activity Report Self-Employment) or SSA-821-BK (Work Activity Report - Employee) and record the determination on form SSA-823 (Report of SGA Determination – For SSA Use Only) and fax into eView or the Claims File Records Management System (CFRMS).
* Notify the DDS examiner by telephone of the work and SGA finding.
* Forward the documentation to the DDS.
* If the beneficiary has engaged in SGA, terminate provisional benefits through POS input, see MSOM T2PE 003.024.
* The last month of provisional benefits payable is the first month of SGA. Provisional benefits do not resume after termination due to SGA.
* If the claimant has engaged in SGA, terminate provisional benefits through POS input, see MSOM T2PE 003.024. The last month of provisional benefits payable is the first month of SGA. Provisional benefits do not resume after termination due to SGA.
* For cases in PSC 1-6 jurisdiction, send an MDW to request action on Medicare termination issues, if necessary.
* For cases in PC 7 jurisdiction, send an email to ||OCO ODO PITAG to request termination of Medicare, if necessary.
* For cases in PSC 7 jurisdiction, send an email to ||OCO ODO PITAG to request termination of Medicare, if necessary.
~~If the beneficiary performs SGA in the month of the EXR request, recall the folder from DDS and process a FO jurisdiction technical denial as outlined in DI 13050.045E.~~
If the claimant performs SGA in the month of the EXR request and the following month, recall the folder from the DDS and process an FO jurisdiction technical denial as outlined in DI 13050.065D. For EXR requests filed prior to April 17, 2017, recall the folder and deny the request if the claimant performed SGA in the month of filing.
2. Terminating provisional benefits due to medical denial determination
Terminate provisional benefits (if currently being paid) when DDS makes a medical determination to deny expedited reinstatement. The last month provisional benefits are payable is the month the EXR denial notice is mailed. See DI 13050.070 to determine how a medical determination may affect Medicare coverage. To stop provisional payments input the medical decision via POS, refer to DI 13050.065B.3.
Terminate provisional benefits (if currently being paid) when the DDS makes a medical determination to deny expedited reinstatement. The last month provisional benefits are payable is the month the FO mails the EXR denial notice. To determine how a medical determination may affect Medicare coverage, see DI 13050.070. To stop provisional benefits input the medical decision via POS, refer to DI 13050.065B.3.
3. Terminating benefits due to full retirement age (FRA)
3. Terminating benefits due to FRA
~~When a beneficiary reaches FRA during the provisional benefit period, provisional benefits automatically terminate.~~
When a claimant reaches FRA during the provisional benefit period, provisional benefits automatically terminate.
4. Terminating benefits due to end of the six month provisional benefits period
Provisional benefits and Medicare based solely on the provisional benefit period automatically terminate after six months of payments.
~~5. Terminating benefits when the beneficiary dies during provisional period~~
5. Terminating benefits when the claimant dies during the provisional period
If the beneficiary dies during a month that comes after the EXR request but before a medical decision by the DDS, stop the provisional payments. The month before the month of death is the last month that provisional benefits are payable. The DDS should make a medical decision based on the evidence provided. If we approve the EXR request based on the medical evidence, pay any retroactive benefits as an underpayment per GN 02301.030.
If the claimant dies during a month that comes after the EXR request but before a medical decision by the DDS, stop the provisional benefits. The month before the month of death is the last month that provisional benefits are payable. The DDS should make a medical decision based on the evidence provided. If we approve the EXR request based on the medical evidence, pay any retroactive benefits as an underpayment per GN 02301.030.

POMS Reference

DI 13050.025: Provisional Benefits for Title II Claimant