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DI 13050.045: Expedited Reinstatement (EXR) Title II Interview

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  • Effective Dates: 01/14/2016 - Present
  • Effective Dates: 02/02/2018 - Present
  • TN 3 (01-07)
  • TN 6 (02-18)
  • DI 13050.045 Expedited Reinstatement Interview - Title II
  • DI 13050.045 Expedited Reinstatement (EXR) Title II Interview
  • A. Procedure - screening for eligibility
  • A. Procedure for screening for Title II EXR eligibility
  • Follow these screening steps to determine if an individual is eligible for expedited reinstatement (EXR).
  • To be eligible for EXR the claimant must meet the eligibility requirements listed in DI 13050.001B.1. Review the following sources of information to determine if disability terminated due to the performance of substantial gainful activity (SGA).
  • 1. Review the MBR
  • 1. Master beneficiary record (MBR)
  • Query the MBR to determine if the individual was previously entitled to a disability benefit under title II (i.e., disabled number holder, disabled widow/er, or disabled child), if the entitlement has terminated and the reason for termination. A combination of three of the following MBR entries, with a LAF code of T6, T8, U, or X7, indicates entitlement was terminated due to engaging in SGA:
  • * BENEFIT Line - A DIBCES entry in the reason for suspension/termination (RFST) field.
  • * DIB Line - An “E” entry in the cessation disability reason (CDR) field. NOTE: A medical cessation input after the SGA cessation will overlay the CDR field. The absence of an E in the CDR field is not conclusive evidence that benefits did not terminate due to SGA. See DI 13050.085E.
  • * DIB Line - A difference of 3 or more years between the date in the extended period of eligibility begin date (EBD) field and the date in the disability payment cessation (DBC) field.
  • * DIB Line - A date entry in the extended period of eligibility Medicare begin date (EMD) field that is at least 78 months earlier than the Medicare Part A termination date (or 24 months earlier if the Part A termination date is prior to 10/1/00).
  • * HI-DIB Line - A Medicare Part A termination date more than 78 months (or 24 months if termination date is prior to 10/1/00) after the Applicant's Disability date (ADC).
  • * HISTORY Line - An RFST code entry in the SUSP/TERM field of EPESGA followed by DIBCES in subsequent lines.
  • * SP MSG - Special message text related to SGA cessation and termination information.
  • Query the MBR to determine if the claimant was previously entitled to a disability benefit under Title II (i.e., disabled number holder, disabled surviving spouse, or disabled child). If entitlement has terminated, determine the reason for termination. A combination of three of the following MBR entries, along with a Ledger Account File (LAF) code of T6, T8, U, or X7, indicates entitlement terminated due to the performance of SGA:
  • * BENEFIT Line - reason for suspension/termination (RFST) coding of DIBCES.
  • * DIB Line - Cessation Disability Reason-code of E.
  • 2. Review other corroborating information
  • NOTE: A medical cessation input after the SGA cessation may overlay the CDR entry with an entry of M. A CDR field coding of M is not conclusive evidence that benefits did not terminate due to SGA.
  • * DIB Line - A difference between the extended period of eligibility begin date (EBD) and the disability benefit cessation (DBC) dates of three or more years.
  • * DIB Line - An entry in the extended period of eligibility Medicare begin date (EMD) field that is at least 78 months earlier than the Medicare Part A termination date (or 24 months earlier if the Part A termination date is prior to 10/1/00).
  • * HI-DIB Line - A Medicare Part A termination date more than 78 months (or 24 months if termination date is prior to 10/1/00) after the applicant's disability cessation date (ADC).
  • * HISTORY Line - an RFST of EPESGA in the SUSP/TERM field, followed by DIBCES in subsequent lines.
  • * SP MSG – A special message with information relating to SGA cessation and termination.
  • Review the following additional sources of information to verify the termination was due to SGA and not a medical cessation or other termination:
  • * The NDDSS may contain a record of a medical determination. An intervening medical termination that occurred after the SGA termination will NOT prevent the individual from filing for EXR.
  • * The individual may have a termination notice or the notice may be available on an online system (ORS).
  • * There may be a record in the MRTW, eWork systems or other locally maintained files that may be helpful.
  • * The DCF or eWork may contain information regarding earnings or a previous SGA cessation.
  • * There may be information on a modernized development worksheet (MDW) record.
  • * There might be earnings posted for the appropriate years on the SEQY.
  • 2. Other queries and systems
  • Review other sources of information to verify that termination was due to SGA, rather than medical or other reasons:
  • * eWork – compare the most recent decision in eWork with the DIB line and History data on the MBR.
  • * Disability Control File (DCF) – query the most recent T2 WORK event (#6 on the ECDR screen) to see if the decision was a cessation.
  • * eView or Claims File Records Management System (CFRMS) – search eView or CFRMS for a form SSA-833 – Cessation or Continuance of Disability or Blindness Determination - or notice indicating termination due to work.
  • NOTE: If you determine that benefits terminated due to work, review the most recent Work CDR determination. Be alert to the possibility of reopening an erroneous decision, and to situations in which the claimant stopped performing SGA within the extended period of eligibility (EPE). In these cases, do not pursue EXR, but instead pursue reopening of the prior decision to reinstate benefits.
  • 3. EXR filing period
  • Determine if the EXR request is within 60 months of the previous benefit termination month. Add 59 months to the disability benefit cessation (DBC) month to determine the ending month of the 60-month period. See DI 13050.010 for further information about the EXR request period and consideration of good cause for late filing. Also, consider the protective filing guidelines in DI 13050.015.
  • Determine if the EXR request is within 60 months (five years) of the previous benefit termination. Add 59 months to the DBC month reflected on the DIB line to determine the end of the 60-month period. For further information about the EXR request period and consideration of good cause for late filing, refer to DI 13050.010. Also, consider the protective filing guidelines in DI 13050.015.
  • 4. Establish protective writing
  • If an interview cannot be taken immediately, establish a protective writing through the 800 Number System and schedule an appointment in the post-entitlement (PE) appointment calendar of the individual's servicing field office (FO). Type “EXPEDITED REINSTATEMENT” in the remarks section of the PE appointment lead. Advise the individual that provisional payments/Medicare cannot begin until the completed EXR request is submitted.
  • If it is not possible to complete an EXR interview immediately, establish a protective writing through the 800 Number System, and schedule an appointment on the claims leads or protective filing appointment calendar of the claimant’s servicing field office (FO). Enter “EXPEDITED REINSTATEMENT” in the remarks section of the DIB appointment lead. Advise the claimant that provisional benefits and Medicare, if applicable, cannot begin until the claimant submits the completed EXR request package.
  • B. Procedure - expedited reinstatement interview – Title II
  • B. Procedure for Title II EXR interview
  • 1. Explain EXR provisions
  • When the screening procedures outlined in DI 13050.045A have been completed, explain the EXR eligibility requirements to the individual and determine if he or she is eligible for EXR (see DI 13050.001B.1.). If eligible, explain the basic provisions of EXR as compared to those of filing a new application. The individual must decide whether he or she wishes to pursue EXR or an initial claim. See DI 13050.020 for a more in depth discussion of some issues to consider. If, after discussing with the individual the requirements of EXR, the individual decides not to file a request for reinstatement, discuss filing a new application for disability benefits. If a protective writing exists for EXR, it must be closed-out per DI 13050.015 and GN 00204.012. If the individual elects to file a new claim instead of EXR, state the reason for not filing EXR in the Remarks section of the initial application form.
  • If you are unable to determine eligibility for EXR based on available evidence, proceed as if the individual is eligible and request the claims folder to confirm eligibility.
  • 2. Obtain EXR request package
  • Obtain a completed and signed EXR package from the individual. The EXR package will include at least the following forms:
  • a. SSA-371, Request for Reinstatement for Title II; (see DI 13050.105).
  • Staple this to the front of the appropriate title II supplemental paper application (i.e., SSA-16-F6 for disabled NHs, SSA-10-BK for DWBs, or SSA-4-BK for CDBs). Write “Supplement to the Request for Expedited Reinstatement” at the top of the SSA-4, SSA-10 or SSA-16 application form.
  • NOTE: The supplemental paper application form will be completed in the same manner as it would for a new initial claim; however the date of onset to use on the EXR supplement is the previously established onset date.
  • b. SSA-454-BK, Report of Continuing Disability Interview
  • * Enter the month and year of the EXR request in the “Remarks” section (if protective filing exists, use the protective filing date);
  • * Place the remark, “Possible retroactivity exists prior to the month of filing - see SSA-823” in the “Remarks” section of the SSA-454 to alert the DDS to the need to consider retroactive reinstatement.
  • c. SSA-827, Authorization for Source to Release Information to the Social Security Administration
  • Obtain one from claimant. See DI 11005.056A and DI 11005.057A.
  • d. SSA-820/821, Work Activity Report (Self-Employed Person)/Work Activity Report (Employee) and SSA-823, Report of SGA Determination
  • Document SGA/nonSGA during the 12-month EXR retroactive period on th eSSA 820 or 821, and record the SGA determination on the SSA-823.
  • e. SSA-795, Statement of Claimant, indicating the individual's election choice (if applicable) regarding Medicare Part B.
  • See HI 00801.164 for information about Medicare.
  • NOTE: If the interview is by telephone, explain to the individual that you are sending the EXR forms to him or her for signature along with the 60-day EXR close-out notice (see DI 13050.015E). Tell the individual that he or she must return the signed forms before provisional benefits/Medicare can be paid.
  • 3. Request the prior file
  • Request the prior claim folder to confirm eligibility for EXR and to provide the comparison point medical records the DDS will need to make the medical determination. Follow the instructions in GN 03105.000, GN 03103.080F.5., and DI 11005.085B for retrieving a folder. If the prior folder was a certified electronic folder (CEF), convert the file to paper. For more information on how to convert a CEF to paper, see DI 81010.030C.
  • 4. Representative payee
  • If during the interview you determine that the individual is incapable of managing his or her own provisional benefits, develop for a representative payee. If the individual had a representative payee in the previous entitlement period, determine if a representative payee is still needed. See DI 13050.075 for more instructions about payee development.
  • 5. Provisional benefits
  • Start provisional benefits when appropriate (see DI 13050.025A) and send the EXR package to the servicing DDS for a medical determination per DI 13050.055. See DI 13050.075C for rep payee instructions.
  • C. Procedure - workflow outline
  • The following is an outline of the application and award processing procedures for title II EXR cases.
  • The FO technicians must screen cases for EXR eligibility per DI 13050.001 and DI 13050.045A, and discuss filing a new claim versus an EXR with the claimant per DI 13050.020.
  • * If the claimant does not meet the technical requirements for EXR and insists on filing for EXR, the FO must deny the request per procedures in DI 13050.065D.
  • * If the claimant chooses to file a new initial claim for disability benefits, you may use the request for reinstatement as a protective filing. Close out the protective writing per DI 13050.015E and GN 00204.012. Document the reason the claimant chose to file a new claim instead of an EXR in the remarks section of the new initial application.
  • * If the claimant is eligible for EXR and decides to file an EXR request, follow the instructions below to complete the EXR package and process the request.
  • 1. Title II initial development
  • * FO screens for eligibility and takes EXR request for eligible individuals. Ensure that potentially eligible auxiliaries are identified on the “supplemental” SSA-16-F6 (a new application is required for auxiliaries, per DI 13010.610). Establish the EXR request on the DCF (per MSOM CDR 001.002, MSOM CDR 001.003, and MSOM CDR 001.016). Develop for payee as appropriate.
  • * FO identifies all months of SGA and non-SGA in the 12-month period prior to EXR request on the SSA 820 or 821, and records the SGA determination on the SSA-823, per DI 13050.045B.2.d. The DDS will take this date into consideration when establishing the first month of EXR eligibility based on the medical evidence. SGA months should also be documented on the DCF.
  • * FO initiates provisional benefits, beginning the month the signed EXR request was filed. See DI 13050.020 for provisional benefit information.
  • * FO requests the prior claim folder to confirm eligibility for EXR and provide the comparison point decision medical records.
  • * FO sends the EXR case-file to the DDS for medical determination with an EXR folder flag (see DI 13050.105, Exhibit 4). Transfer jurisdiction of the EXR event to the DDS on the DCF and create an EXR issue on the DCF development worksheet (the CDRW screen) to control for return of the case (see DI 13010.605).
  • * DDS receipts case per DI 28057.010B, make the MIRS medical determination and complete the SSA-833. See DI 28057.020F for instructions on completing the SSA-833.
  • * DDS faxes EXR approval to the FO so that the FO can initiate necessary non-medical development (see DI 11010.340) (or use other locally arranged alternative to expedite processing).
  • * DDS returns EXR case file to FO. The DDS should NOT send any cases directly to OCO/PC.
  • 2. Complete EXR package
  • 2. Title II - after medical allowance
  • * The FO transfers jurisdiction of the EXR event in the DCF back to FO. Prepare an EF-101 under District Office Final Authorization (DOFA) procedure (GN 01010.008).
  • * The FO confirms a finding of disability (shown as a medical continuation) on the SSA-833. A code of 31 should be coded in item #20 on the SSA-833. Item #24 must show EXR MOE (MMYY). Do not terminate provisional benefits if there is current entitlement to EXR.
  • * The onset date for EXR computation purposes remains the same as the onset date for the previously terminated period of entitlement. The PIA is computed as if the EPE termination and any provisional payments never occurred.
  • * The MOE may be retroactive for up to 12 months, but no earlier than 01/2001. If it is determined that there was SGA in the month of filing, the determination must be reopened to a technical denial as the individual does not meet the EXR requirements (see DI 13050.001B). If there was no SGA in the month of filing but it is determined that the MOE established by the DDS cannot be used for another reason (e.g., SGA in MOE or a prior non-SGA month in the 12 month retroactive period of which the DDS was not aware), a new MOE must be established.
  • The EXR package includes:
  • * SSA-371 - Request for Reinstatement - Title II;
  • * SSA-16-BK-Application for Disability Insurance Benefits, SSA-10-BK Application for Widow(er)’s Insurance Benefits, or SSA-4-BK Application for Child’s Insurance Benefits;
  • * SSA-454-BK - Continuing Disability Review Report;
  • * SSA-3367- Disability Report-Field Office;
  • * SSA-827 - Authorization to Disclose Information to the Social Security Administration;
  • * SSA-820-BK or SSA-821-BK - Work Activity Report (Self-Employment) or Work Activity Report (Employee); and
  • * SSA-795 - Statement of Claimant, indicating the claimant’s choice (if applicable) regarding Medicare Part B.
  • * SSA-823 - Report of SGA Determination
  • The FO must use the MOE established by the DDS; the FO cannot change the MOE. (NOTE: The EXR filing date can be used as protective filing for a new initial claim). If the MOE established by the DDS cannot be used, the FO must send the case back to the DDS to determine a new MOE.
  • Request wage and employment information authorization and record it in the Wage and Employment Information Authorization (WEIA) application per, GN 00204.150C.
  • The PSC DPB can determine a new MOE without sending the case back to the DDS when the change is based on work and earnings or incorrect retroactivity.
  • * The FO codes any deduction, suspension, and termination months due to SGA, Workers Compensation (WC), PDB, Windfall, etc., on the EF-101. Code EXR DIB information on the EF-101 (see DI 13050.060B for detailed processing instructions). The DAC of F must be coded on the EFBNDIB screen.
  • * The FO enters a remark that states “Expedited Reinstatement Case – Priority Handling” in remarks section of EF-101. Add remarks to alert PC/OCO to Medicare and other special issues involved. The MOE on the EF-101 and the MOE on the SSA-833 must be the same.
  • * The FO adjudicates and transfers the EF-101 per MSOM T2PE 009.001. The FO stores an electronic copy of the SSA-833 in eView or NDRED. The FO transfers the EXR event in the DCF to OCO/PC per DI 13010.620 and sends a copy of the EF-101 to ORS.
  • * OCO/PC will route the EF-101 to the module (or other component/location according to local procedures) for handling. (PC employs local Paperless processes as appropriate.) Adjudicating and moving EXR EF101 to OCO/PC creates an EF101 Stub Record in the PC’s Paperless Processing Center (PPC). Do not fax the EF101 to the PC as it could result in a duplicate Action Control Record being established in PPC.
  • * OCO/PC will perform cursory review of EF-101 under DOFA procedures and call the FO if necessary to resolve any issues.
  • * OCO/PC will stop Provisional Benefits and process the EXR award according to DI 13050.060, adjusting for Provisional Benefits paid. OCO/PC will check to be sure the DAC of “F” (never a DAC of “X”) is coded (see SM 00856.300B.1.).
  • * OCO/PC will send the EXR reinstatement notice to beneficiary. The EXR award notice is available in Aurora as E3956 (see NL 00703.956 for the sample notice).
  • * OCO/PC will clear the EXR event in the DCF as a continuance per DI 13010.625.
  • * The FO will verify that title II benefits have been reinstated (via the MBR). Review the MBR to see that there is a new DIB line with a DAC of F on the MBR. eWork cannot be used until the MBR is set up correctly (for more information on eWork processing, see eWork Help Screen Index “Correcting the MBR in EXR Cases”). The DDO should be the last day of the month prior to the EXR month of entitlement (DOED). The DOED should show the benefit reinstatement month. The DAC of “F” should be shown, which indicates the period of entitlement is due to EXR.
  • * The FO will send the EXR folder to the National Record Center (NRC) 6000 East GeoSpace Dr., 601 South 291 HWY, Independence, MO. Include the paper SSA-833 in the folder and attach the correct cover sheet. Mark the folder “All FO/PC Actions Complete.”
  • NOTE: If the interview is by telephone, send the EXR forms for signature, along with the 60-day EXR close-out notice per DI 13050.015E. Explain that the claimant must sign and return the forms before we can pay provisional benefits and reinstate Medicare.
  • D. Policy - technical denial - FO responsibilities
  • 3. Establish EXR on DCF
  • If, after going through the screening process in DI 13050.045A, or at a later date, the FO determines that the individual is or was not entitled to expedited reinstatement (EXR) because he or she does not meet the non-medical requirements for EXR (see DI 13050.001B and DI 13050.005A.2.), issue a technical denial notice to the individual and appropriate third party, stop provisional benefits (if being paid) as per DI 13050.025J and contact the individual to:
  • * Explain the basis for non-entitlement, and
  • * Inform the individual that he or she has the option of filing a new initial application for disability benefits, requesting a reconsideration of the EXR determination, or filing a new EXR request. Discuss the merits of each option to help the individual determine which option would be most advantageous.
  • Establish an EXR event on the DCF following these steps:
  • * On the MCDR screen, select 8=Establish Disability Review.
  • * On the ECDR screen, select 2=EXR.
  • * Complete the DRES screen to establish the EXR event.
  • The request for reinstatement can be used as a protective filing for a new initial application if that is what the individual chooses to file. Process the EXR denial and take action based upon the individual's decision per DI 13050.020.
  • 4. Review, develop, and document work activity
  • A denial of expedited reinstatement is an initial determination that carries appeal rights as discussed in DI 13050.085C. However, the action taken to terminate provisional payments due to a determination being reached on the EXR request cannot be appealed.
  • Ensure accurate processing by verifying the prior record terminated properly and by verifying any earnings during the retroactive period. Take the following steps:
  • * Review any recent eWork decision (refer to the NOTE in DI 13050.045A2, in this section)
  • * Develop all work activity in the retroactive period up to 12 months prior to the date of filing, or from the Benefit Termination Month (BTM), whichever is later. Use the initial claim policy rules to evaluate earned wages per DI 10505.005D
  • * Document employment using forms SSA-820-BK or SSA-821-BK.
  • * Tell the claimant about his or her responsibility to report any change in work activity.
  • E. Procedure - technical denial – Title II
  • 5. Request prior file
  • 1. Individual files initial claim
  • Take the following steps to retrieve the prior folder:
  • * Request the comparison point decision (CPD) folder the disability determination service (DDS) will need to make the medical determination.
  • * Follow the instructions for retrieving a folder in the medical CDR instructions found in DI 13015.030 through DI 13015.250, and DI 40525.020 through DI 40525.150.
  • * If you cannot find the CPD folder, follow the procedures in DI 13015.080 and DI 13050.090.
  • Document the basis for EXR non-entitlement on the RPOC screen if the application is taken on MCS or an SSA-5002 if a paper application is taken. Close out the existing EXR protective writing through normal close-out procedures (include a close-out statement in the remarks on the initial claim application, etc.).
  • 6. Representative payee
  • 2. Individual requests EXR
  • * Obtain a form SSA-371, Request for Reinstatement for Title II.
  • * Establish the EXR event in the DCF, per DI 13010.610.
  • * Document the basis for EXR ineligibility on an SSA-553, Special Determination, or an SSA-5002, Report of Contact and annotate the Remarks screen of the DCF.
  • * Retain supporting documentation with the above forms in a brown folder.
  • * Annotate the MBR with a special message that reflects the following data: date the request for EXR was filed, date of denial determination, basis for denial, SSA employee identifier (such as unit code or last name) and field office code.
  • If during the interview you determine that the claimant is incapable of managing his or her own provisional benefits, develop for a representative payee. If the claimant had a representative payee in the previous entitlement period, determine if the claimant still needs a representative payee. For more instructions about payee development, refer to DI 13050.075.
  • EXAMPLE:
  • 7. Provisional benefits
  • SP MSG1 TRANS DT-07/01
  • Start provisional benefits when appropriate. For more information about provisional benefits, see DI 13050.025A.
  • EXR-FILED 06/10/01–DENIED 07/02/01-PREVIOUS ENTITLEMENT TERMINATED DUE TO MEDICAL CESSATION-UNIT DQQ FO 815
  • 8. Prepare and send the case to the DDS
  • 3. Notice
  • Include all forms in the EXR request package listed in DI 13050.045B.2 in this section, in the paper file. In addition, take the following actions:
  • * SSA-16-BK, SSA-10-BK, or SSA-4-BK –Complete the paper application as usual, using the date of onset from the prior period of disability for the current onset date.
  • * SSA-820-BK and SSA-821-BK – Use these forms to develop and document all work activity in the 12-month retroactive period, or from the Benefit Termination Month (BTM), whichever is later.
  • * SSA-823- In Item 2C under Continuing Disability Review/Post-Entitlement (CDR/PE), document the following:
  • * the month of EXR filing, prior termination month and protective filing date if applicable, and
  • * the SGA determination for each month in the retroactive period.
  • Send an EXR denial notice to the claimant and any appropriate third parties. Refer to DI 13050.105, Exhibit 8. Retain a copy of the notice for the file. Title II EXR denial notices are contained in DPS. Include Medicare information as appropriate. Refer to DI 13050.070 for instructions on inserting the appropriate Medicare language.
  • If possible, retroactivity exists indicate in the remarks, ‘possible retroactivity exists prior to the month of filing’
  • 4. Provisional benefits paid
  • If there is SGA in all months of the 12-month retroactive period and in the month of filing, the first possible MOE is the month following the month of filing. In this situation, annotate the remarks of the SSA-823 with “SGA in the month of filing. First possible MOE is MM/YY”.
  • * The retroactive period does not include months prior to the BTM. Therefore, if the BTM is fewer than 12 months before the request for EXR, do not provide SGA and non-SGA determinations for months prior to the BTM
  • Terminate provisional benefits, if started. See MSOM T2PE 003.024.
  • Example: EXR filing date is 09/2016. Benefits previously terminated in 01/2016. The retroactive period is 01/2016-08/2016. The claimant engaged in SGA in 01/2016 through 03/2016. The claimant did not engage in SGA 04/2016 through 09/2016. The earliest MOE the DDS could establish is 04/2016, the first non-SGA month in the retroactive period.
  • 5. Medicare
  • Before sending the case to the DDS, fax the documents in the EXR request package to:
  • * eView – use the MDF E barcode and annotate the “Note” field with “EXR Documentation,” or
  • * CFRMS – use the document type of “Other,” and annotate the “Remarks” field with “EXR Documentation.”
  • If Medicare entitlement exists, refer to DI 13050.070.
  • Send the case to the DDS:
  • * Pair the completed EXR packet with the prior decision folder. If the prior decision was an electronic file it must be converted to paper, see DI 81010.030C and;
  • * Attach the EXR Case Flag to the paper medical folder and;
  • * Mail the paper folder to the appropriate DDS
  • 6. DCF clearance
  • 9. Update the DCF
  • Clear the EXR from the DCF via the IFOA screen using the SSR/MBR/OTHER CONDITIONS – STOP CDR option (see DI 13010.620D.3.).   
  • Update the DCF taking the following steps:
  • * Transfer the event to the servicing DDS per DI 13010.620.
  • * Establish an issue (for example, EXRDDS) on the DCF development worksheet (CDRW) to control for the DDS decision. For more information about the CDRW, see DI 13010.605
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