TN 5 (01-16)

A. Procedure for appeal of medical cessation

1. Reconsideration request

If the Disability Determination Services (DDS) issues a medical cessation determination, the beneficiary may request a reconsideration of the decision.

a. Appeal filed within 10 days with payment continuation

If the beneficiary files an appeal within 10 days, with a payment continuation request:

• Suspend Section 301 development;

• Process the payment continuation;

• Complete the request for reconsideration and route the claim to Disability Determination Services (DDS);

• Annotate the master beneficiary record (MBR) special message field or the supplemental security record (SSR) remarks field with “Potential 301 case pending medical cessation recon mm/dd/yy.”

NOTE: If the DDS subsequently confirms the cessation, resume Section 301 development per DI 14510.003C.

b. Payment continuation not applicable

When a payment continuation request is not applicable:

• Process the reconsideration and route the claim to DDS;

• Complete Section 301 development and fax the SSA-4290-F5 (Development Of Participation In Vocational Rehabilitation or Similar Program) and supporting documents into eView or NDRED;

• Transmit to the Office of Disability Operations (ODO) by faxing the Potential 301 Flag into the Paperless Processing Center system using the paperless fax number 1-877-385-0643;

• Annotate the MBR special message field or SSR remarks field with “potential Section 301 determination sent to ODO mm/dd/yy.”

2. Hearing request before an administrative law judge (ALJ)

If DDS affirms the medical cessation decision, the beneficiary may request a hearing on the decision.

a. Hearing request filed within 10 days with payment continuation

If the FO receives a hearing request filed within 10 days with a payment continuation request:

• Suspend Section 301 development;

• Process the payment continuation;

• Process the hearing request;

• Annotate the MBR special message field or the SSR remarks field with, “Potential 301 case pending medical cessation hearing mm/dd/yy.”

NOTE: If the hearings office confirms the cessation, resume Section 301 development per DI 14510.003.

b. Payment continuation not applicable

When a payment continuation request is not applicable:

• Process the hearing request;

• Complete the Section 301 development and fax the SSA-4290-F5 and supporting documents into eView of NDRED

• Annotate the MBR special message field or SSR remarks field with, “Appeal pending at ODAR, SBC declined, and potential Section 301 determination sent to ODO on mm/dd/yy.”

• Transmit to ODO by faxing the Potential 301 Flag into ODO’s Paperless Processing System using fax number 1-877-385-0643.

B. Procedure for appeal of ODO determination on Section 301 payments

A determination that a beneficiary is not eligible for Section 301 payments is an initial determination that has appeals rights.

1. Supporting documentation

When a beneficiary appeals a determination regarding eligibility for continuing payments, take the statement as to why he or she disagrees with the determination. Obtain his or her documentation that supports his or her allegations about participating in a qualifying program. Document the statements on an SSA-5002 (Report of Contact).

EXAMPLE: If the beneficiary claims that he or she participates in a program of VR services and takes part in the activities and services outlined in his or her employment plan, but received a notice denying Section 301 payments, obtain copies of any materials to support the statement. Use an SSA-4290-F5 to obtain evidence from the provider of services.

NOTE: Statutory benefit continuation rights do not apply to appeals of termination of Section 301 payments.

2. Reconsideration of ODO determination

If the FO receives a request for reconsideration of the ODO determination on continued payment:

• Obtain an SSA-561-U2 (Request for Reconsideration) and supporting documentation.

• Fax the SSA-4290-F5, SSA-561-U2, and related documentation into eView or NDRED.

• Fax the Potential 301 Flag into paperless using fax number 1-877-385–0643.

If the case is at DDS for a medical cessation appeal when you receive the request for reconsideration of the ODO determination, hold the material until we make a determination on the cessation appeal. Annotate the Special Message field of the MBR or Remarks field of the SSR with, “Potential Section 301 case awaiting medical appeal decision.”

If we affirm the cessation, forward the request for reconsideration to ODO.

If we reverse the cessation, you do not need an ODO determination.

3. Hearing before ALJ

If the FO receives a request for a hearing on the issue of Section 301 payments:

• Obtain an HA-501-U5 (Request for Hearing by Administrative Law Judge) and supporting documentation.

• Send the case to the hearings office.

If a medical appeal is pending when you receive the appeal of the ODO determination:

• Fax the material into eView or NDRED and hold until the ALJ makes a decision on the cessation.

• Annotate the Special Message field of the MBR or Remarks field of the SSR with, “Potential Section 301 case waiting medical appeal decision.”

If the ALJ affirms the cessation, forward the hearing request following usual procedures.

If the ALJ reverses the cessation, you do not need a hearing on the issue of Section 301 payments.

4. Appeals Council review

If the beneficiary is dissatisfied with the result of the ALJ hearing on the Section 301 determination, he or she may request Appeals Council review of the ALJ decision. Obtain form HA-520-U5 and any supporting documentation. If a medical cessation appeal is pending when you receive a request for Appeals Council review, hold the material until the Appeals Council makes a decision. Annotate the special message field of the MBR or remarks field of the SSR with “Potential Section 301 case awaiting appeal decision.”

If the Appeals Council affirms the cessation, forward the request for Appeals Council review following usual procedure, as explained in DI 12020.001.

If the Appeals Council reverses the cessation, you do not need an Appeals Council review on the issue of Section 301 payments.

C. Procedure for appeal of termination of Section 301 payments

ODO will terminate Section 301 payments effective with the month after the month in which one of the following first occurs:

• The beneficiary completes his or her program of VR services, employment services, or other support services;

• The beneficiary stops participating in the program for any reason;

• ODO determines that the beneficiary’s continued participation in the program will no longer increase the likelihood that he or she will not return to the disability or blindness benefit rolls.

The appeals process is the same as described in DI 14510.035B.

NOTE: Statutory benefit continuation rights do not apply to appeals of terminations of Section 301 payments.