DI 13050.065:
Title II and Title XVI Expedited Reinstatement (EXR) Medical and Technical Denials
Effective Dates: 11/24/2015 - Present- Effective Dates: 02/02/2018 - Present
TN 2 (02-06)- TN 6 (02-18)
DI 13050.065 Expedited Reinstatement Denials - Title II and XVI- DI 13050.065 Title II and Title XVI Expedited Reinstatement (EXR) Medical and Technical Denials
A. Policy - Medical Denial- A. Policy for EXR medical denials
1. Background- 1. Background Information for medical denials
When the DDS makes an unfavorable medical determination on an expedited reinstatement (EXR) request it completes a SSA-832 and/or SSA-833 to document the reason for the denial and returns the file to the field office. The DDS can deny an EXR request because the disability is not the same as or related to the prior disability or because the individual is not disabled when evaluated under the medical improvement review standards (MIRS).- 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).
The last provisional benefit payable is the month the denial notice is sent, if not stopped earlier for another reason. The disability determination (denial of EXR) may be appealed but the provisional payment determination may not be appealed (see DI 13050.085B).- 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.
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: 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.
NOTE: If the DDS medically denies an EXR request on a concurrent individual under the MIRS, initiate a medical CDR for the other title, per DI 13001.005A.8- B. Procedure for EXR medical denial
2. FO Responsibilities- 1. How to determine an EXR medical denial
The FO sends a denial notice to the individual and any appropriate third party, and stops provisional benefits per DI 13050.025J. and DI 13050.030K. The notice will:* Explain the basis for non-entitlement, and* Inform the individual that he or she has the option of filing a new application for disability benefits, requesting a reconsideration of the EXR decision, or filing a new EXR application.- 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”.
The request for reinstatement can be used as a protective filing for a new application if the individual chooses to file a new application. Process the EXR action based upon the individual's decision per DI 13050.020.- 2. Denial notice
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.- 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.
B. Procedure - Medical Denial- For information about inserting appropriate Medicare language in denial notices, see to DI 13050.070E.
1. How To Determine An EXR Medical Denial- 3. Provisional benefits
The FO will receive the folder from the DDS with a completed SSA-832/833 and a personalized explanation completed. Determine the basis for the medical determination by reviewing the SSA-832/833:* Item 9 will have blocks B and C indicated;* 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”.- 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 01305.001P.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. Denial Notice- 2. Claimant chooses to file for EXR
The FO sends the appropriate EXR denial notice to the individual and any proper third party. Use the personalized denial language provided by the DDS to explain the reason the reinstatement request is denied. Title II Denial notices are contained in DPS. Refer to DI 13050.070E. for information about inserting appropriate Medicare language in denial notices.- If the claimant is not eligible for EXR, but chooses to file for EXR, take the following steps:
- * Obtain a form SSA-371- Request for Reinstatement for Title II;
- * Establish the EXR event in the DCF, per DI 13010.610;
- * 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;
- * Retain supporting documentation with the above forms in a paper medical folder, and fax a copy into eView or CFRMS;
- * 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.
3. Provisional Benefits- 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
- * 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.
- * Terminate provisional benefits, if started. For termination instructions, see MSOM T2PE 003.024 and DI 13050.025J.
- * If there is Medicare entitlement, refer to DI 13050.070.
- * 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).
Terminate provisional benefits. The last provisional benefit payable is for the month in which the denial notice is mailed, provided the benefit is not subject to earlier termination for another reason (See DI 13050.025A.2 and DI 13050.030A.2).- E. Procedure for Title XVI technical denial
a. Title II- 1. Claimant chooses to file a new initial claim
If the denial is based on medical improvement, (item 11 of the 833 indicates a MIRS denial):* input a medical cessation through POS to stop provisional payments (see MSOM T2PE 003.024)* Use option 10 CESSATION to clear the EXR event from the DCF.- 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.).
If the denial is based on “not the same as or related impairment (item 11 of 833 indicates code of 28)* Do not use POS. Send an HP request to payment center to stop the provisional payments.* Use option 5, SSR/MBR/OTHER CONDITIONS – STOP CDR to clear the EXR event from the DCF (see DI 13010.620).- 2. Claimant chooses to file for EXR
b. Title XVI* Post payment status code N07 to the SSR (see SM 01701.080 and SM 01305.001P.6) and/or* Clear the EXR event within the DCF as a cessation (see DI 13010.620).- If the claimant is not eligible for, but chooses to file for EXR, take the following steps:
- * Obtain a form SSA-372, Request for Reinstatement for Title XVI;
- * Establish the EXR event in the DCF, per DI 13010.610;
- * 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;
- * Retain supporting documentation with the above forms in a paper medical folder and fax them into eView or CFRMS;
- * Process the denial. Post payment status code N07 to the SSR, per SM 01701.080 and SM 01305.001P6); and
- * 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.
4. Medicare- Remark Example:
If Medicare entitlement exists, refer to DI 13050.070.- RMKS 1: EXRFILED 06/10/17–DENIED 07/02/17-PREVIOUS ENTITLEMENT TERMINATED DUE TO MEDICAL CESSATION-UNIT XYZ FO 815
- * 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.
- * Terminate provisional benefits, if started. For termination instructions, see SM 01701.080.
- * 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.
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