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DI 13050.045: Expedited Reinstatement (EXR) Title II Interview

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  • Effective Dates: 03/23/2018 - Present
  • Effective Dates: 05/23/2018 - Present
  • TN 6 (02-18)
  • DI 13050.045 Expedited Reinstatement (EXR) Title II Interview
  • A. Procedure for screening for Title II EXR eligibility
  • 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. Master beneficiary record (MBR)
  • 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.
  • 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.
  • 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 (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 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 for Title II EXR interview
  • 1. Explain EXR provisions
  • 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.
  • 2. Complete EXR package
  • 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
  • Request wage and employment information authorization and record it in the Wage and Employment Information Authorization (WEIA) application per, GN 00204.150C.
  • 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.
  • 3. Establish EXR on DCF
  • 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.
  • 4. Review, develop, and document work activity
  • 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 13050.045A.2., 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.
  • 5. Request prior file
  • 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.
  • * If you cannot find the CPD folder, follow the procedures in DI 13015.080 and DI 13015.090.
  • 6. Representative payee
  • 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.
  • 7. Provisional benefits
  • Start provisional benefits when appropriate. For more information about provisional benefits, see DI 13050.025A.
  • 8. Prepare and send the case to the DDS
  • 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.
  • If possible, retroactivity exists indicate in the remarks, ‘possible retroactivity exists prior to the month of filing’
  • 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
  • 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.
  • * 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.”
  • * 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
  • 9. Update the DCF
  • 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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