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DI 13050.085: Appeals Process Under Expedited Reinstatement

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  • Effective Dates: 09/06/2012 - Present
  • TN 2 (02-06)
  • DI 13050.085 Appeals Process Under Expedited Reinstatement
  • A. Background
  • There are two types of determinations that can be made in connection with an individual's request for expedited reinstatement (EXR). The types of determinations can be categorized as either provisional benefit determinations or EXR determinations. If an individual disagrees with a determination, then the procedure for handling the disagreement is determined by the type of determination that is involved.
  • B. Policy - Provisional Benefit Determinations
  • 1. Appeal
  • Determinations made in connection with provisional benefits are not subject to the administrative and judicial review (appeals) process (see GN 03101.080 and SI 04010.010). Although these determinations cannot be appealed, accept an individual's informal protest and reexamine the case to determine if corrective action is warranted.
  • 2. Provisional Benefit Determination Protest
  • If an individual protests a determination concerning payment of provisional benefits, explain that the fact and/or amount of provisional benefits, including determinations to stop payment of provisional benefits, cannot be formally appealed. If the individual wishes to protest a provisional benefit determination, accept any statements and/or evidence the individual presents and review the determination to make sure it is correct.
  • * If the facts or evidence show the determination is incorrect, correct the action and issue a new notice.
  • * If the facts or evidence show the determination is correct, advise the individual that the determination is correct.
  • * Document all actions on a SSA-5002, Report of Contact, and retain for the EXR folder.
  • C. Policy - Reinstatement Determination
  • 1. Appeal
  • An EXR determination is an initial determination that is subject to the administrative and judicial review (appeals) process (see GN 03101.070 and SI 04010.010).
  • NOTE: Appeals related to EXR are excluded from Prototype processing. Initial claims associated with EXR cases are also excluded from Prototype processing. Payment continuation does not apply to the EXR appeals process.
  • 2. Time Limit For Filing Appeal
  • The time period for filing an appeal is 60 days from the date the individual received notice of the initial EXR determination. It is assumed that the individual received the notice five days after it was sent, unless proven otherwise. See GN 03101.010 and SI 04005.012 for further discussion of the appeals period and consideration of good cause for late filing of an appeal.
  • 3. Who May File an Appeal
  • A party to any initial determination who can show in writing that his/her benefit rights may be adversely affected by the initial determination may file an appeal (see GN 03101.050).
  • D. Procedure – Processing Appeals
  • EXR cases are excluded from prototype processing. Therefore, denied EXR requests will follow appeals processing as referenced in GN 03102.100 to GN 03102.375 and SI 04020.010 to SI 04020.060. Related systems inputs are described in DI 13050.085E.
  • 1. Reconsideration of Non-Medical Issue(s)
  • If the individual wishes to appeal a non-medical issue, such as a SGA denial, a denial based on excess resources, or a denial because the prior claim was not terminated due to SGA, complete a Request for Reconsideration, SSA-561-U2. Follow established SSA jurisdiction procedures outlined in DI 12005.010. Document the determination on the IRMK screen of the DCF.
  • 2. Reconsideration of Medical Issue(s)
  • If the individual wishes to appeal a medical determination, such as reinstatement denied because the individual is not under a disability based on MIRS, complete a Request for Reconsideration, SSA-561-U2, and the appropriate CDR medical decision reconsideration forms (SSA-3441, etc). Forward the reconsideration request, medical forms, supporting documents and EXR folder to the DDS following procedures described in DI 12005.001.
  • NOTE: While the medical development forms and systems inputs used for reconsideration in the CDR process are used for EXR, the CDR reconsideration procedure is not. The CDR Disability Hearing Unit (DHU) procedure is not applicable to EXR decisions. There is no right to continued payments or Medicare in the EXR appeals process. Goldberg-Kelly also does not apply to title XVI provisional payments.
  • When the DDS makes the reconsideration decision, it will return the folder to the FO for processing. The FO will process the folder according to the award and denial instructions contained in:
  • * DI 13050.090 - Simultaneously filed EXR and initial claim on the same benefit,
  • * DI 13050.060 - Title II award procedures,
  • * DI 13050.060 – Title XVI award procedures and
  • * DI 13050.065 - Title II and title XVI denial procedures.
  • 3. Individual Appeals the Reconsideration Determination
  • If the individual disagrees with the reconsideration determination, the individual can request a hearing with an administrative law judge (ALJ) by completing the standard forms (HA-501-U5, etc). Send the hearing request, EXR folder and supporting documents to the hearing office in accordance with the procedures in GN 03103.001 and SI 04030.010.
  • If the individual disagrees with the reconsideration determination, the individual can request a hearing with an administrative law judge (ALJ) by completing the standard forms (HA-501-U5, etc). Send the hearing request, EXR folder and supporting documents to the hearing office in accordance with the procedures in GN 03103.001 and SI 04030.010.
  • 4. Individual Appeals the Hearing Decision
  • If the individual disagrees with the decision made by an ALJ, the individual can request a review of the hearing decision by completing a HA-520-U5, Request for Review of Hearing Decision/Order. Send the request, EXR folder and supporting documents to the Appeals Council. The Appeals Council will notify the individual of the final action and provide an explanation of the appeal rights in a notice.
  • E. Procedure - System Inputs
  • 1. Title II
  • * Record an appeal of a medical denial made in connection with a request for EXR on the title II Disability Cessation screens on the Postentitlement Selection List (PESL) Menu of the title II postentitlement online system (POS). Refer to MSOM T2PE 003.024 through MSOM T2PE 003.026 for detailed input instructions.
  • * From the POS main menu select 6, Disability Cessation.
  • * On the PEC1 screen, input 1 for medical cessation.
  • * On the PEC2 screen, input the date of the appeal request and number 3, for recon request without payment continuation.
  • NOTE: Benefit continuation is NOT applicable for EXR medical denials.
  • * On the PECN screen, select 1, Decision Notice Released – Additional Systems Notices Possible.
  • * Select Y to record folder movement and indicate destination of folder on the next screen.
  • * Add a special message to the MBR to indicate the status of an appeal of a non-medical issue in an EXR case. Indicate the appeal level, date the appeal was filed, SSA employee identifier (such as unit code or last name) and field office code. Indicate in subsequent special messages the outcome of the appeal and any further appeals activity. Also document the reconsideration determination on the IRMK screen of the DCF.
  • EXAMPLE:
  • SP MSG1 TRANS DT-08/01 EXR-RECON FILED 08/05/01-UNIT DQQ FO 815
  • SP MSG2 TRANS DT-09/01 EXR-RECON DENIED 09/10/01-HEARING FILED 09/15/01-UNIT DQQ FO 815
  • * Forward to DDS and create an issue on the DCF development worksheet to control for return of the file.
  • 2. Title XVI
  • Record EXR appeals in SSI cases through the appeals screens in Direct SSR Update. Refer to MSOM MSSICS 020.002 through MSOM MSSICS 020.026 for input instructions.
  • F. Policy - Special Processing Considerations
  • 1. EXR Denied and New Initial Claim Possible
  • An individual can file for reconsideration of the denied EXR request and a new initial claim, if applicable. The individual also has a right to make a new EXR request. If the individual chooses to request a reconsideration of the EXR decision, process the reconsideration per EXR instructions contained in this section. An initial claim will be processed through normal initial claim processing procedures.
  • There are special considerations in processing joint EXR and initial claim actions, refer to DI 13050.090. When an EXR request and simultaneous initial claim both require medical decisions the initial claim will be escalated to the reconsideration level (see DI 12045.030 and DI 28057.025). Per the statute, the original EXR request will serve as a protective writing for the new initial claim. See DI 13050.090 for processing instructions.
  • Forward the EXR reconsideration and new initial claim to the DDS in the same folder.
  • If the individual elects to file a new EXR request, process the request following the appropriate procedures established in this chapter, but do not initiate a new period of provisional benefits if provisional benefits were paid on the first EXR request - see DI 13050.025A.3.
  • 2. Initial Claim Denied and EXR Possible
  • An individual can file for reconsideration of the initial claim denial under current reconsideration procedures and file an EXR request, including the start of provisional payments and Provisional Medicare. Process the EXR request in the appropriate manner under instructions in this section. If both the initial claim and the EXR request require medical decisions escalate the EXR request to the reconsideration level (see DI 12045.030 and DI 28057.025). The denied initial claim does not serve as a protective writing for EXR. See DI 13050.090 for processing instructions and special consideration in processing joint EXR and initial claim actions.
  • Forward the reconsideration and new request for EXR to the DDS in the same folder.
  • 3. EXR Filed and a Hearing Request is Pending at ALJ
  • An individual may inquire about EXR while a hearing request is pending at the ALJ on a prior termination decision or an initial claim denial. If the requirements for EXR are met, process the EXR request as follows.
  • * Do not escalate the initial EXR request to the hearing level. DDS will make the medical determination.
  • * Follow locally established procedures to contact the hearing office to request the medical records the DDS will need to determine EXR entitlement (the CPD file and subsequent medical information).
  • * Forward the EXR request to the DDS for a medical decision.
  • If DDS denies the EXR request and the beneficiary appeals the decision:
  • * determine if both cases are “common issue” cases (see DI 12045.010, Processing Disability Claims at Different Levels of Appeal, Title II and Title XVI-Common Issue Cases); if yes,
  • * escalate the appeal to the hearing, and coordinate both cases with the appropriate hearing office.
  • NOTE: If the EXR request is approved, the FO will notify ODAR immediately and advise them of any pertinent issues that the approved EXR request raises (e.g., overpayment, prior period of disability ended, etc…). ODAR will then determine if the pending hearing request can be dismissed.
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