TN 7 (07-18)

A. Policy for EXR favorable medical decision

The disability determination services (DDS) makes a determination regarding entitlement, prepares a Form SSA-833 (Cessation or Continuance of Disability or Blindness Determination and Transmittal – Title II) to document the determination on a Title II request for EXR and sends the folder and SSA-833 allowance to the FO.

NOTE: In dual entitlement situations, if the prior record terminated for substantial gainful activity (SGA) on both records, each entitlement needs a separate DDS medical decision and a separate SSA-833.

1. Month of entitlement (MOE) and retroactivity

If the claimant is disabled and entitled to EXR, we may reinstate benefits retroactively for up to 12 months before the EXR request date, but no earlier than January 1, 2001 provided the claimant meets all factors of entitlement. The MOE is the earliest month that the claimant did not perform SGA and met all of the EXR eligibility requirements. If there is SGA in all months of the 12-month retro period and in the month of filing, the first possible MOE is the month following the month of filing. The month of entitlement cannot be before the benefit termination month (BTM) of the previous entitlement. The MOE must be a non-SGA month. If the claimant performed SGA in the month of filing and the following month, the FO must issue a technical denial. Normal suspension and terminating events apply to all reinstated benefits.

MOE example: Mr. Smith was previously entitled to Social Security disability insurance (SSDI) for back problems and his entitlement terminated due to work in January 2015. In June 2017, Mr. Smith has an accident that re-injures his back and he is unable to work. In September 17, he requests EXR. When the FO develops the case to send to the DDS, they document the request date of September 2017 and note the following SGA and non-SGA months in the 12-month retroactive period:

SGA Months: September 2016, October 2016, November 2016, December 2016, January 2017, February 2017, March 2017, and May 2017

Non-SGA Months: April 2017, June 2017, July 2017, August 2017, and September 2017

The DDS decides that Mr. Smith meets the medical requirements of EXR in the month of filing (September 2017). They then look at the first non-SGA month in the retroactive period, which is April 20017. They determine that although Mr. Smith did not perform SGA, he did not meet the Medical Improvement Review Standard (MIRS) criteria in April 2017. They then look at the next non-SGA month (June 2017) and determine that Mr. Smith did meet the MIRS criteria in that month. Therefore, the MOE for EXR is June 2017, which is the first month of the initial reinstatement period (IRP).

2. Auxiliary benefits

Reinstate benefits to auxiliaries previously entitled on the number holder's record, who continue to meet the initial entitlement requirements with the first month of reinstatement for the disabled number holder. Obtain a signed Form SSA-4-BK (Application for Child’s Insurance Benefits) for both previously entitled and new auxiliaries and fax it into eView or the Claims File User Interface (CFUI). Process the claim following the EF-101 procedures. If an auxiliary received a benefit based on the auxiliary’s disability, the auxiliary must meet the initial entitlement requirements and continue to meet the disability requirements before reinstatement. You must send the case to the DDS for a continuing disability review (CDR) to confirm he or she meets disability requirements before we can reinstate the auxiliary. For more information on the technical requirements for childhood disability benefits (CDB), see DI 11020.015.

NOTE: While we are required to develop auxiliary applications, do not allow pursuit of auxiliary claims to delay processing of the number holder’s award.

B. Title II FO procedures

Follow these procedures:

1. Determine an EXR approval by reviewing the SSA-833:

   • Item 9A will be selected

   • Item 10 will show “other;”

   • Item 20 will show WRM code 31; and

   • Remarks will show “Expedited Reinstatement MOE MM/YY”.

2. Transfer the EXR event on the Disability Control File (DCF) from the DDS to the FO.

3. Complete the Electronic Form 101 (EF-101) following normal amended award procedures, see KC Net EXR EF101 guide. The following screens require entries unique to EXR awards:

   • EFACCT: Code the Critical Case indicator with “Y.” If Workers’ Compensation (WC) or Public Disability Benefits (PDB) is involved, code the WC/PDB Involved indicator with “Y.”

   • EFPIAD: enter Primary Insurance Amounts (PIA) beginning with the EXR MOE. Although EXR re-establishes entitlement to payment, for PIA computation purposes, we proceed as though the original period of disability has not terminated. Therefore, use the disability onset date for the previously terminated period of entitlement, and compute the PIA as if the Extended Period of Eligibility (EPE) termination never occurred. Use all years of earnings not previously included in the Master Beneficiary Record (MBR) PIA history to compute the EXR PIA. For detailed information on the EPE PIA computations, refer to RS 00605.238.

   • EFBENE: review all fields to ensure necessary screens are in the EF101 path (for example, garnishment or tax levy involvement).

   • EFBEN2: Code the “Disability Involved” indicator with “Y.” Even if work is involved, code the “Work Involved” indicator with “N.” Capture work information on the EFDIBWK screen. Bring the EFDIBWK screen into the EF101 path by coding the “SGA or EPE Involved” indicator on the EFBNDIB screen with “Y.” Code the “Appointed Representative Involved,” special notice due to Visual Impairment, and “SSI Windfall Offset” indicators as necessary.

   • EFCOMM: select Common screens which affect entitlement (for example, beneficiary marriage or citizenship)

   • EFBNDIB: the DDO is the last day of the month prior to the EXR MOE (the date of entitlement to disability [DOED]). For example, if the DOED is 04/16, the DDO is 03/31/2016. Code the DAC field with “F.”

   • The DOED cannot be earlier than the previous benefit termination month (BTM). The FO must use the MOE established by the DDS, shown on the SSA-833. The FO cannot change the MOE. If the FO cannot use the MOE established by the DDS (for example, because the claimant performed SGA in that month), send the case back to the DDS to determine a different MOE. If the PSC discovers an incorrect MOE, designated PSC technicians have authorization to correct certain DDS MOE determinations. If there is SGA-level work during the EXR Initial Reinstatement period (IRP) or the new EPE is involved, code the “SGA or EPE Involved” indicator with “Y.”

   • EFDIBWK: code SGA months in the EXR IRP and the new EPE, if applicable. Include this information in remarks on the EFBCRN screen.

   • EFBCLM: the application file date is the EXR protective filing date, if any. The application receipt date is the date we receive the completed EXR package.

   • EFBCRN: use remarks to alert the PSC that this is an EXR case and requires priority handling. Use remarks to alert PSC to any special issues such as SGA months since the EXR MOE, payment of provisional benefits, WC/PDB, etc. If Medicare terminated prior to the EXR award date, add, “Award Medicare based on EXR – See HI 00801.166 – new IEP applicable” to remarks. However, if the claimant’s HI/SMI eligibility has not terminated, no additional remarks are necessary, as HI/SMI will continue based on EXR.

   • EFBNCM: this screen lists a selection of three separate menus. These screens provide access to Common Screens used for suspension, termination and reinstatement events for miscellaneous situations, disability events and foreign events.

   • EFMBEN: Compute the monthly amount payable as if the prior period never terminated due to SGA, increased by intervening COLAs and recomputations. Adjust benefits for any changes in offsets such as, Workers Compensation/Public Disability Benefits and Government Pension Offset, Windfall Elimination Provision, overpayments, and other payment issues with the first month of reinstated benefits.

4. Adjudicate and transfer the EF-101 per MS T2PE 009.035 and MS T2PE 009.036.

5. Use the Print function, #8 on the EFMENU screen, to send a copy of the EF-101 to ORS. There is no need to print a paper copy of the EF101.

6. Store the SSA-833 in eView or CFUI. Check the electronic folder to confirm the forms listed in DI 13050.045B.2 are in file. If they are not in the electronic folder, fax them in.

7. Transfer the EXR event on the DCF to the PSC per DI 13010.620.

8. The program service center (PSC) will issue the reinstatement notice.

C. Follow-up procedures – EXR awards (or EXR EF-101s)

If the beneficiary is not receiving provisional benefits, tickle the case for 20 days to verify via the MBR that the PSC has processed the reinstatement. If the beneficiary is receiving provisional benefits, tickle the case for 30 days. If the reinstatement is not processed, follow these steps:

1. Query PCACS to verify location/jurisdiction of the EF-101 action.

2. Access the Detailed Office/Organization Resource System (DOORS) using the search SSN function and send an email to the appropriate module with the subject line “EXR Award Effectuation Request.” Add a “Special Message” to the MBR indicating the date the effectuation request was sent.

3. Tickle the case for 10 days. If the MBR does not correctly reflect the reinstatement after the follow-up tickle expires and the beneficiary is not receiving provisional benefits, consider critical case processing according to DI 13050.100. If a dire need or an adverse public relation situation exists, FOs should use the Manager-to-Manager process to contact the PSCs per GN 01070.228.

4. After the PSC processes the EXR award, send the paper folder to the following address:

   National Records Center
   6002 E GeoSpace Dr.
   601 S 291 Hwy.
   Independence, MO 64056

   Attach the correct coversheet for non-actionable Title II folders and mark the folder “All FO/PC Actions complete.”

D. Policy for payment of representative’s fees

Claimants have the right to representation while applying for EXR and any related appeals. We do not include provisional benefits in authorizing a fee under the fee agreement process. Do not use provisional benefits to calculate the amount of past due benefits to withhold for direct payment of a representative’s fee under the fee agreement or fee petition process, or to pay a fee authorized by a court. For more information on representatives fees, see subchapter GN 03913.000.