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DI 13050.060: Field Office (FO) Procedures for TII Expedited Reinstatement (EXR) Awards

changes
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  • Effective Dates: 04/18/2016 - Present
  • Effective Dates: 02/02/2018 - Present
  • TN 3 (01-07)
  • TN 6 (02-18)
  • DI 13050.060 Expedited Reinstatement Awards - Title II
  • DI 13050.060 Field Office (FO) Procedures for TII Expedited Reinstatement (EXR) Awards
  • A. Policy - favorable medical decision
  • A. Policy for EXR favorable medical decision
  • The DDS makes a determination regarding entitlement and prepares an SSA-833 to document the determination on a Title II request for EXR. The DDS faxes (or uses another locally agreed upon procedure to expedite the decision) the SSA-833 allowance to the FO (see DI 11010.340).
  • The disability determination services (DDS) makes a determination regarding entitlement, prepares an 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 field office (FO).
  • 1. Month of entitlement and retroactivity
  • NOTE: In dual entitlement situations, if the prior record terminated for SGA on both records, each entitlement needs a separate DDS medical decision and a separate SSA-833.
  • If it is found the individual is under a disability and entitled to EXR, benefits can be reinstated retroactively for up to 12 months before the EXR request date (but not earlier than January 1, 2001) provided all factors of entitlement are met. The month of entitlement is the earliest month that the individual did not perform SGA and met all of the EXR eligibility requirements. The month of entitlement can not be before the benefit termination month (BTM) of the previous entitlement.
  • 1. Month of entitlement (MOE) and retroactivity
  • No retroactive payment is due for any month in which the individual engaged in SGA. The month of entitlement must be a non-SGA month. Normal suspension and terminating events apply to all reinstated benefits. Reinstated benefits due are reduced by the amount of provisional payments made.
  • 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 substantial gainful activity (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.
  • EXAMPLE: Mr. Smith was previously entitled to SSDI for back problem and his earlier entitlement terminated due to work on 11/03. In 6/04, Mr. Smith has an accident that re-injures his back and he is unable to work. In 9/04, he decides to request EXR. When the FO develops the case to send to DDS, they provide a request date of 9/04 and note that the following SGA and non-SGA months in the 12-month retroactive period:
  • MOE example: Mr. Smith was previously entitled to Social Security disability insurance (SSDI) for back problems and his entitlement terminated due to work in 1/15. In 06/17, Mr. Smith has an accident that re-injures his back and he is unable to work. In 09/17, he requests EXR. When the FO develops the case to send to the DDS, they document the request date of 09/17 and note the following SGA and non-SGA months in the 12-month retroactive period:
  • SGA Months: 9/03, 10/3, 11/03, 12/03, 1/04, 2/04, 3/04, 5/04
  • SGA Months: 9/16, 10/16, 11/16, 12/16, 1/17, 2/17, 3/17, 5/17
  • Non-SGA Months: 4/04, 6/04, 7/04, 8/04
  • Non-SGA Months: 4/17, 6/17, 7/17, 8/17, 09/17
  • The DDS decides that Mr. Smith meets the medical requirements of EXR in the month of filing (9/04). They then look at the first non-SGA month in the retroactive period, which is 4/04. They determine that though Mr. Smith did not perform SGA, he did not meet the MIRS criteria in 4/04. They then look at the next non-SGA month (6/04) and determine that Mr. Smith did meet the MIRS criteria in that month. Therefore, the month of entitlement for EXR is 6/04, which is the first month of the initial reinstatement period (IRP).
  • The DDS decides that Mr. Smith meets the medical requirements of EXR in the month of filing (9/17). They then look at the first non-SGA month in the retroactive period, which is 4/17. They determine that although Mr. Smith did not perform SGA, he did not meet the MIRS criteria in 4/17. They then look at the next non-SGA month (6/17) and determine that Mr. Smith did meet the MIRS criteria in that month. Therefore, the MOE for EXR is 6/17, which is the first month of the initial reinstatement period (IRP).
  • 2. Auxiliary benefits
  • Auxiliaries previously entitled to benefits on a reinstated number holder's record, who continue to meet initial entitlement requirements, will be reinstated to benefits with the first month of reinstatement for the disabled number holder. A new paper application must be filed following the EF-101 procedures for both previously entitled and new auxiliaries. If auxiliary entitlement was based on the auxiliary's disability, the auxiliary must continue to meet the disability requirements before he or she can be reinstated (DDS must conduct a medical review before we can reinstate the auxiliary). For more information on the technical requirements for childhood disability benefits (CDB), see DI 11020.015.
  • 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 SSA-4 (Application for Child’s Insurance Benefits) for both previously entitled and new auxiliaries and fax it into eView or the Claims File Records Management System (CFRMS). 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 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.
  • B. Procedure - field office actions- Title II
  • 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
  • * Determine an EXR approval by reviewing the SSA-833:
  • * Item 9 will have block A indicated;
  • * Item 10 will show “other”;
  • * Item 20 will show WRM code 31 (for EXR); and
  • * 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”.
  • * Prepare an EF-101 under District Office Final Authorization (DOFA) procedure (GN 01010.027).
  • * Complete the EF-101 following normal amended award procedures (see MSOM T2PE 009.001) except:
  • * The application date is the request date for EXR (use the earlier protective filing date, if one exists).
  • * Although EXR establishes a new period of disability, for PIA computation purposes use the onset date of the previously terminated period of entitlement. The PIA is computed as if the EPE termination and any provisional payments never happened. Never use the EXR date of onset for PIA computation purposes. Ensure all years of earnings not previously included in the MBR PIA history are used to compute the EXR payment PIA. Enter the PIAs, starting with the reinstatement date, on the EFPIAD screen of the EF-101 (for more information on EPE PIA computations, see RS 00605.238).
  • * The monthly benefit payable equals the amount payable at the time the previous period of entitlement terminated, increased by any intervening COLAs, and recomputations due. Dual entitlement benefits payable are also the previous rates increased by any intervening COLAs and recomputations due. For more information on computations, see RS 00615.000.
  • * On the EFBNDIB screen, the DDO field must show an onset date of the last day of the month prior to the month of entitlement (DOED) for EXR. For example, if the EXR DOED is 04/06, the DDO would be 03/31/2006. The DAC of “F” must be coded on the EFBNDIB screen.
  • * The month of entitlement (MOE) may be retroactive from the request date for up to 12 months, but no earlier than 01/2001 and no earlier than the previous benefit termination month (BTM). The FO must use the MOE established by the DDS and shown on the SSA-833; the FO cannot change the MOE. If it is determined that MOE established by the DDS cannot be used (e.g. due to SGA in that month) the case must be sent back to the DDS to determine a new MOE.
  • If the incorrect MOE is discovered in the PSC/OCO, the DPB in PSC 1-6, the DE in ODO or the DPU in PC 8 can determine a new MOE.
  • * Code deduction/suspension/termination months due to SGA, Workers Compensation, PDB, Windfall, etc. on the appropriate screens of the EF-101.
  • * Answer “Y” to WC/PDB Involved on the EFACCT screen to bring the WC/PDB screens into the path
  • * The involvement of Garnishment and Tax Levy are indicated by responses on the EFBENE screen
  • * SSI Windfall Offset is indicated on the EFBEN2 screen
  • * Common screens which affect entitlement are selected from the EFCOMM screen
  • * If SGA or EPE are involved, the question should be answered, “Y” on the EFBNDIB screen. This brings the EFDIBWK screen into the path where the suspension/termination information can be coded.
  • * The EFBNCM lists a selection of three separate menu screens. These screens provide access to Common Screens used for suspension, termination and reinstatement events for miscellaneous situations, disability events and foreign events.
  • * Alert OCO/PC that the case is an EXR case and requires priority handling. Also alert OCO/PC about Medicare and other special issues involved, using the Remarks section of the EFBCRN screen.
  • * Insert remark, “Expedited Reinstatement Case – Priority Handling.”
  • * Include remark to alert OCO/PC to any provisional benefits paid.
  • * If prior period of HI/SMI was not terminated due to extended Medicare, no action is necessary. Medicare eligibility continues.
  • * If HI/SMI terminated prior to the EXR award date, add remark: “Award Medicare based on EXR – See HI 00801.166 – new IEP applicable”.
  • * If appropriate, include remarks about WC, PDB or other special issues.
  • * Adjudicate and transfer EF-101 per MSOM T2PE 009.035 and MSOM T2PE 009.036.
  • * Send a copy of the EF-101 to ORS.
  • * Store an electronic copy of the SSA-833, the SSA-371, SSA 16, SSA 10 and SSA 4 (if applicable), SSA 820/821, SSA 823 and the EXR flag sheet found in DI 13050.105 (Exhibit 4) and fax them into eView using the “MDF E” barcode and annotate the “Note” field with “EXR Documentation” or into NDRED using the “other” document type and annotate the “Remarks” field with “EXR Documentation.”
  • * Transfer the EXR event on the DCF to OCO/PC per DI 13010.620. Follow-up using critical case procedures, if needed.
  • * Tickle case for two weeks to verify via MBR review that OCO/PC has processed the reinstatement. If the reinstatement has not been processed, make a critical case telephone contact with the module assigned to the case.
  • * Query PCACS to verify location/jurisdiction of the EF-101 action.
  • * Access Detailed Office/Organization Resource System (DOORS) to obtain correct telephone number for the ODO Telephone Process or PSC module, per MSOM DOORS 002.002, MSOM DOORS 002.003.
  • * Set a one week tickle to requery the reinstatement.
  • * Follow RS 02803.145B.2.c if the reinstatement has not been processed after an additional week.
  • * Once the reinstatement has been processed, send the folder to the National Record Center (NRC), 6002 East GeoSpace Dr., 601 South 291 HWY, Independence, MO 64056 for storage. Include the paper SSA-833 in the folder. Attached the correct coversheet for non-actionable Title II folders and mark the folder “All FO/PC Actions complete.”
  • * OCO/PC will issue the reinstatement notice.
  • C. Procedure - processing center (PC) actions
  • * OCO/PC receives EF-101 from FO and performs a cursory review of the EF0101 under DOFA procedures. OCO/PC will also receipt the SSA-833 to document the electronic file. Normally review of the SSA-833 is not needed.
  • * Perform a cursory review of the EF-101 under DOFA procedures. Call the FO if necessary to resolve any issues.
  • * Stop provisional benefits, if necessary, and process the disability reinstatement, adjusting for Provisional Benefits paid and Medicare issues (see SM 00856.300 and SM 00856.400). The Medicare reinstatement action is considered a new initial enrollment period (IEP) and equitable relief provisions are applied as appropriate. (See HI 00801.166)
  • * Ensure the DAC of F (never a DAC of X) is coded per (SM 00856.300B.1.).
  • * Send the reinstatement notice to the beneficiary using AURORA notice E3956. See NL 00703.956.
  • * Clear the EXR event in the DCF as a continuance per DI 13010.625.
  • * Transfer the EXR event on the Disability Control File (DCF) from the DDS to the FO.
  • * 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.
  • * Adjudicate and transfer the EF-101 per MS T2PE 009.035 and MS T2PE 009.036.
  • * 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.
  • * Store the SSA-833 in eView or CFRMS. 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.
  • * Transfer the EXR event on the DCF to the PSC per DI 13010.620.
  • * The 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, query PCACS to verify location/jurisdiction of the EF-101 action.
  • * For PSC 1-6 cases, access the Detailed Office/Organization Resource System (DOORS) and contact the module via telephone.
  • * For PSC 7, send an email to ||OCO ODO PITAG.
  • 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. Contact PSC7 by selecting PROGRAM INTEGRITY TAG with the subject line Manager to Manager. After the PSC processes the EXR award, send the paper folder to:
  • National Records Center
  • 6002 E GeoSpace Dr.
  • 601 S 291 Hwy.
  • Independence, MO 64056
  • D. Policy – payment of representative’s fees
  • Attach the correct coversheet for non-actionable Title II folders and mark the folder “All FO/PC Actions complete.”
  • GN 03910.010 asserts a beneficiary’s right to representation, which includes expedited reinstatement. Individuals have the right to representation while applying for EXR and any related appeals. A representative who wants to charge or collect a fee for services provided in these administrative proceedings must first obtain SSA’s authorization, except when the conditions described in GN 03920.010 are present.
  • D. Policy for Payment of Representative’s fees
  • If SSA makes a favorable medical determination on the EXR request, and the claimant’s Title II benefits are reinstated, and the claimant’s representative requests a fee for the administrative services he/she provided the claimant, SSA does not include these provisional payments in authorizing a fee under the fee agreement process. In addition, SSA does not use these provisional payments to calculate the amount of the Title II 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. Refer to GN 03920.017, Payment of Representative’s Fee, and GN 03920.030, Representative’s Fee – Title II Past-Due Benefits.
  • 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 GN 03913.000.
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