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DI 13050.095: Program Service Center (PSC) Procedures for Expedited Reinstatement (EXR)

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  • Effective Dates: 08/21/2008 - Present
  • Effective Dates: 02/02/2018 - Present
  • TN 3 (01-07)
  • TN 6 (02-18)
  • DI 13050.095 Processing Center Expedited Reinstatement (EXR) Procedures
  • DI 13050.095 Program Service Center (PSC) Procedures for Expedited Reinstatement (EXR)
  • A. Background
  • A. Background for PSC EXR processing
  • The FO or TSC will screen an individual who inquires about EXR and take necessary action using the policies and procedures in DI 13050.001 and DI 13050.045 OCO/PC action can be necessary:
  • * When a previous termination decision has been made but not yet input into the system. Provisional payments can not begin until the prior termination has been effectuated (see DI 13050.025C.2.).
  • * When the FO cannot initiate provisional benefits due to a systems limitation (see DI 13050.025I.3.);
  • * When the EXR decision is made (see DI 13050.045C.2.);
  • * In processing award actions (EF-101) related to EXR (see DI 13050.060C.);
  • * In processing suspension payment actions related to the IRP in direct input exclusion cases (see DI 13050.066); and
  • * In overpayment processing (See DI 13050.080).
  • The field office (FO) processes the EXR request and takes necessary action using the policies and procedures in DI 13050.001 and DI 13050.045. The disability determination services (DDS) makes the medical decision on EXR cases per DI 28057.015 and DI 28057.020. PSC action may be necessary in the following situations:
  • * When we have made a previous work termination decision but it has not been input into the system. Provisional benefits cannot begin until we have effectuated the prior termination, per DI 13050.025C.2;
  • * When the FO cannot initiate or terminate provisional benefits due to a systems limitation. For exclusions and exceptions, see DI 13050.025I-J;
  • * In processing EF-101 award actions related to EXR. For processing instructions, see DI 13050.095B;
  • * In processing suspension payment actions related to the initial reinstatement period (IRP) in direct input exclusion cases. For more information about the IRP, see DI 13050.066; and
  • * In overpayment processing. For overpayment processing information, see DI 13050.080).
  • EXR award and denial processing are high priority actions. It is important that OCO/PC work closely with the field to quickly resolve any issues that may delay the processing of EXR requests or decisions. This is especially important when an individual is requesting EXR but the prior termination has not yet been effectuated on the system, as provisional payments can not begin until the previous benefits have been terminated.
  • EXR award and denial processing are high priority actions. It is important that the PSCs work closely with the FO to resolve any issues that may delay the processing of EXR requests or decisions. This is especially important when we have made a determination to terminate the previous benefit but it has not updated to the master beneficiary record (MBR), as provisional benefits cannot begin until the previous benefits terminate.
  • Requests relating to provisional benefits and to denial of EXR will normally be received by OCO/PC through the MDW system with a code of “2560HP” (or through OCO telephone procedure). Award actions will normally be received through a special FAX number.
  • B. Procedure for EXR and provisional benefits
  • B. Procedure
  • 1. Provisional benefit actions
  • OCO takes priority action on provisional benefits when an alert is received based upon FO input, or on an FO phone call, or an award decision is made or received in OCO. Other PCs take priority actions on provisional benefits when an alert is received based upon FO input, the FO requests action via an MDW, or an award decision is made or received in the PC.
  • The FO initiates provisional benefits through the Post Entitlement Online System (POS). In the event that POS cannot process the Provisional Payment action, a Termination, Attainment, Transfer and Termination (TATTER) exception generates in the Paperless System. The TATTER exception generates in paperless under Type of Event Level (TOEL) DIPROV PAYMENT. For POS exclusion cases, the FO will contact the PSC as indicated in DI 13050.025I.3. The PSC reviews the TATTER exception or the request to process an exclusion and performs a cursory review of the record. This review consists of verifying:
  • * Provisional benefit eligibility
  • * Provisional benefit start date
  • * Primary Insurance Amounts (PIAs) and Family Maximums
  • Process award actions as follows:
  • * Perform cursory review of the EF-101.
  • * Call the FO if necessary to resolve any folder-based issues.
  • * Terminate provisional benefits, if necessary, and process disability reinstatement per instructions in SM 00856.300 through SM 00856.400.
  • * The EXR entitlement is indicated with a new DIB line on the MBR. This new line should include a DOED showing the first month the person is due benefits under EXR. The DDO is the last day of the month prior to the DOED. Ensure DAC of “F” is coded, which indicates an EXR case (see SM 00856.300B.1.).
  • * Adjust for provisional benefits paid and Medicare issues.
  • If the PSC determines that the information is correct per DI 13050.025, the PSC will update the record for any changes to the PIAs and family maximums and initiate provisional benefits via MACADE per SM 00856.200. If the PSC determines that the information is not correct, the PSC will contact the FO using Detailed Office/Organization Resource System (DOORS) to obtain the servicing FO’s email address and request the information from the FO. The PSC will use the high priority procedures in GN 01070.400 through GN 01070.440 to follow up on requests to resolve any discrepancies.
  • NOTE: Medicare reinstatement action should consider new initial enrollment period (IEP) and equitable relief provisions as appropriate.
  • * Send the reinstatement notice to the beneficiary. The EXR award notice is available in DPS and Aurora. See NL 00703.956 for the sample notice. Use the procedures in DI 13050.060 to prepare needed award forms for EXR cases.
  • * Clear the EXR event in the DCF as a “continuance” per DI 13010.625B.
  • The FO also initiates actions to terminate provisional benefits through POS as indicated in DI 13050.025 J. In the event that POS cannot process the termination action, a TATTER exception will generate in the Paperless System. The TATTER exception generates in paperless under the TOEL DIPROV TERM. The PSC reviews and processes the TATTER exception according to SM 00856.300B.2.
  • C. Process
  • 2. Procedure when the PSC receives the EXR award from the FO
  • OCO/PC processing of actions relating to EXR provisional payments, Medicare, and reinstatement allowance and denial processing are in SM 00856.100 to SM 00856.400. EXR Notices are available in DPS and Aurora.
  • EF-101s transferred from the FO generate into the PSC paperless system under the TOEL CLAIM / EF101, CRIT, or QDD. The PSC performs a review under DOFA procedures. If there are any discrepancies, the PSC will use DOORS to obtain the servicing FO’s email address and request the information from the FO. The PSC will use the high priority procedures in GN 01070.400 through GN 01070.440 to follow up on requests. The PSC will process the award actions as follows:
  • * Stop provisional benefits, if necessary, and process the disability reinstatement, adjusting for provisional benefits paid and Medicare entitlement per, SM 00856.300 and SM 00856.400. Consider the Medicare reinstatement action as a new initial enrollment period (IEP) and apply equitable relief provisions as appropriate per, HI 00801.166.
  • * Ensure the EXR entitlement updated with a new DIB line on the MBR. This new line should include a date of entitlement to disability (DOED) showing the first month the person is due benefits under EXR. The disability date of onset (DDO) is the last day of the month prior to the DOED. Ensure there is a disability award code (DAC) of “F,” which indicates an EXR case per, SM 00856.300B.1.
  • * Send the reinstatement notice to the beneficiary using the Document Processing System (DPS) notice E3956. For notices, see NL 00703.956.
  • * Close the EXR event on the disability control file (DCF) as a continuance per DI 13010.625 immediately after verifying the month of entitlement on the SSA-833 Cessation or Continuance of Disability or Blindness Determination and Transmittal – Title II is the correct date to process to the MBR.
  • D. Policy - TOEL for EXR and Provisional Benefits
  • 3. Procedure when the PSC receives the EXR award from the Office of Hearings Operations (OHO)
  • The following are PCACS TOELs to use in EXR processing:
  • An EXR determination is an initial determination that is subject to the administrative and judicial review (appeals) process as indicated in DI 13050.085. The PSC receives favorable administrative law judge (ALJ), Appeals Council and US District Court decisions involving EXR from OHO for review and processing. The PSC records incoming favorable decisions with TOEL APPEAL/ DHEAR or APPEAL/ COURT. The PSC reviews these decisions and takes the following actions:
  • * Completes the SSA-833 for the EXR entitlement,
  • * Reviews the record to determine if there is any SGA after the EXR Month of Entitlement (MOE),
  • * Prepares an EF-101 for EXR entitlement according to DI 13050.060, and
  • *  Processes the claim to payment as indicated in DI 13050.095B.2.
  • 1. DIPROV Payment
  • If the PSC determines that there are errors in an ALJ decision, the PSC will follow the instructions in DI 42010.075 to contact the hearing office to request an amended decision or protest the decision per DI 42010.080.
  • This combination will be used when a claimant is requesting reinstatement and Provisional Benefits have been initiated.
  • C. PSC allowance and denial process
  • 2. DIPROV TERM
  • This combination will be used when a DDS decision is received showing that the claimant is NOT entitled to reinstatement under EXR, and we must terminate provisional payments. This combination will also be used when the six-month provisional payment period has expired, and for termination of provisional payments due to FRA Attainment or SGA.
  • 3. DIPROV Resume
  • This combination will be used when a DDS decision is received showing that the claimant is disabled and is entitled to reinstatement under the new provisions.
  • E. References
  • SM 00856.001 - Expedited Reinstatement (EXR) - Provisional Benefits
  • SM 00856.100C. - Provisional Benefits and Medicare
  • SM 00856.200 - Handling Provisional Benefit Requests
  • SM 00856.300 - Action During Provisional Benefits
  • SM 00856.400 - Action After Provisional Benefits Ends
  • The PSC processing of actions relating to EXR provisional benefits, Medicare, and reinstatement allowance and denial processing are in SM 00856.100 to SM 00856.400 and HI 00801.164 to HI 00801.167. EXR notices are available in DPS and AURORA.
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