TN 6 (02-18)

A. Policy for EXR medical denials

1. Background Information for medical denials

When the disability determination services (DDS) makes an unfavorable medical determination on an EXR request, it documents the reason for the denial and returns the folder to the field office (FO). The DDS can deny an EXR request because the disability is not the same as or related to the prior disability, or because the claimant is not disabled when evaluated under the medical improvement review standard (MIRS).

An EXR denial is an initial determination that carries appeal rights as discussed in DI 13050.085C. However, the claimant cannot appeal the action taken to terminate provisional payments due to the determination reached on the EXR request.

NOTE: You may use the request for reinstatement as a protective filing for a new application if the claimant chooses to file a new application. Process the EXR action based upon the claimant's decision per DI 13050.020.

B. Procedure for EXR medical denial

1. How to determine an EXR medical denial

The FO will receive the folder from the DDS with a completed SSA-832 Title XVI Cessation or Continuance of Disability Determination and Transmittal, or SSA-833 Title II Cessation or Continuance of Disability Determination and Transmittal, and a personalized explanation. Determine the basis for the medical determination by reviewing the following items on SSA-832 or SSA-833:

• Item 9 will have blocks B and C indicated, the date entered in box B and C should be the EXR date of filing;

• Item 10 will have block D indicated, which shows “other”;

• Item 11 will show code 28 for Title II not same as related denial, 61 for Title XVI not same as or related denial, or normal CDR codes for MIRS denials-see DI 28084.015;

• Item 20 will show WRM code 31 (for EXR); and

• Remarks will show “Expedited Reinstatement”.

2. Denial notice

The FO sends a denial notice found in the Document Processing System (DPS) to the claimant and any appropriate third party. The notice will:

• Explain the basis for the denial, and

• Inform the claimant that he or she may file a new application for disability benefits, request a reconsideration of the EXR decision, or file a new EXR application.

For information about inserting appropriate Medicare language in denial notices, see to DI 13050.070E.

3. Provisional benefits

Terminate provisional benefits. The last month provisional benefits are payable is the month the field office mails the EXR denial notice, provided the benefit is not subject to earlier termination for another reason. For termination reasons, see DI 13050.025A.2 and DI 13050.030A.2.

a. Provisional benefits for Title II

If the denial is for medical improvement, (item 11 of the SSA-833 indicates a MIRS denial):

• Input a medical cessation through POS to stop provisional payments. For termination instructions, see MS T2PE 003.024 and DI 13050.025J,

• Use option 10=CESSATION to clear the EXR event from the Disability Control File (DCF),

If the denial is coded “not the same as or related impairment” (item 11 of 833

indicates code of 28),

• Do not use POS, as the POS input terminates any Medicare coverage in effect; instead, send a request to the program service centers (PSC) to stop the provisional payments. When DDS denies EXR because the current impairment is not “the same as or related” to the original disabling impairment, we do not terminate Medicare coverage,

To contact the PSC of jurisdiction:

For PSC 1-6 cases, follow locally established procedures for resolution of high priority cases, or send a 2560HP. Enter the remark “Do not place in backlog”, and

For PSC 7 cases, send an email to ||OCO ODO PITAG.

• Use option 5, SSR/MBR/STOP CDR to clear the EXR event from the DCF, per DI 13010.620.

b. Provisional benefits for Title XVI

To terminate provisional benefits for Title XVI do the following:

• Post payment status code N07 to the SSR. For termination instructions, see SM 01701.080 and SM 01305.001O.6 and

• Clear the EXR event within the DCF as a cessation, per DI 13010.620.

4. Medicare and Medicaid

Refer to HI 00801.165C and DI 13050.070 for the effect an unfavorable medical decision has on Medicare entitlement and SI 01730.010 for the effect on Medicaid.

NOTE: If the DDS medically denies an EXR request on a concurrent claimant under the MIRS, initiate a medical CDR for the other title, per DI 13001.005A.8

C. Policy for EXR technical denials

FO technicians must screen cases for EXR eligibility per DI 13050.001, DI 13050.045A and DI 13050.050A, and discuss filing a new claim versus an EXR with the claimant per DI 13050.020. If the claimant is not eligible for EXR for not meeting the technical requirements for EXR, and the claimant insists on filing, the FO must deny the request per procedures in DI 13050.065D in this section. If the claimant chooses to file a new initial claim for disability benefits, you may use the request for EXR as a protective filing. If you determine that the claimant is not eligible for EXR after the claimant files the request (for example, if the claimant engaged in SGA in both the month of the EXR request and the following month), technically deny the request per procedures in DI 13050.065D and DI 13050.065E in this section.

D. Procedure for Title II technical denials

1. Claimant chooses to file a new initial claim

Document the reason the claimant decided to file a new initial claim instead of an EXR request on the RPOC screen in MCS. For paper applications, use an SSA-5002 Report of Contact to document the choice. Close out the existing EXR protective writing through normal close-out procedures (include a closeout statement in the remarks on the initial claim application, etc.).

2. Claimant chooses to file for EXR

If the claimant is not eligible for EXR, but chooses to file for EXR, take the following steps:

1. Obtain a form SSA-371- Request for Reinstatement for Title II;

2. Establish the EXR event in the DCF, per DI 13010.610;

3. Document the reason the claimant is ineligible for EXR on an SSA-553-Special Determination, or an SSA-5002 - Report of Contact. Also, annotate the Remarks screen (IRMK) of the DCF with the reason for EXR ineligibility;

4. Retain supporting documentation with the above forms in a paper medical folder, and fax a copy into eView or CFRMS;

5. Add a Special Message to the MBR with the following information:

   • EXR request date,

   • denial determination date,

   • basis for denial,

   • SSA employee identifier (such as unit code or last name) and field office code.

   Special Message Example:

   • SP MSG1 TRANS DT-07/16

   • EXRFILED 06/10/17–DENIED 07/02/17-PREVIOUS ENTITLEMENT TERMINATED DUE TO MEDICAL CESSATION-UNIT XYZ FO 815

6. Send an EXR denial notice to the claimant and any appropriate third party. Title II EXR denial notices are available in DPS. Include Medicare information as appropriate. For instructions on inserting the appropriate Medicare language, see DI 13050.070.

7. Terminate provisional benefits, if started. For termination instructions, see MSOM T2PE 003.024 and DI 13050.025J.

8. If there is Medicare entitlement, refer to DI 13050.070.

9. If there is an established EXR event on the DCF, close it. On the IFOA screen, select 5=SSR/MBR/STOP CDR for the clearance reason (see DI 13010.620D3).

E. Procedure for Title XVI technical denial

1. Claimant chooses to file a new initial claim

Document the reason the claimant decided to file a new initial claim instead of an EXR request on the DROC screen in MSSICS. For paper applications, use an SSA-5002 – Report of Contact to document the choice. Close out the existing EXR protective writing through normal close-out procedures (include a closeout statement in the remarks on the initial claim application, etc.).

2. Claimant chooses to file for EXR

If the claimant is not eligible for, but chooses to file for EXR, take the following steps:

1. Obtain a form SSA-372, Request for Reinstatement for Title XVI;

2. Establish the EXR event in the DCF, per DI 13010.610;

3. Document the reason the claimant is ineligible for EXR on an SSA-553 - Special Determination, or an SSA-5002 - Report of Contact. Also, annotate the Remarks screen (IRMK) of the DCF with the reason for EXR ineligibility;

4. Retain supporting documentation with the above forms in a paper medical folder and fax them into eView or CFRMS;

5. Process the denial. Post payment status code N07 to the SSR, per SM 01701.080 and SM 01305.001O.6); and

6. Add a Remark with the following information to the SSR:

   • EXR request date,

   • denial determination date,

   • basis for denial, and

   • SSA employee identifier (such as unit code or last name) and field office code.

     Remark Example:

     RMKS 1: EXRFILED 06/10/17–DENIED 07/02/17-PREVIOUS ENTITLEMENT TERMINATED DUE TO MEDICAL CESSATION-UNIT XYZ FO 815

7. Send a manual EXR denial notice to the claimant and any appropriate third party. Retain a copy of the notice in the file and fax into eView or CFRMS.

8. Terminate provisional benefits, if started. For termination instructions, see SM 01701.080.

9. If there is an established EXR event on the DCF, close it. On the IFOA screen, select 5=SSR/MBR/STOP CDR for the clearance reason. For information on IFOA inputs, see DI 13010.620D3.