DI 23022.055: Actions on Compassionate Allowances and Disability Determinations Fast-Track Cases

changes
←	*	→

~~Effective Dates: 09/11/2017 - Present~~
Effective Dates: 04/06/2018 - Present
TN 9 (06-13)
DI 23022.055 Actions on Compassionate Allowances and Disability Determinations Fast-Track Cases
A. Actions on Compassionate Allowances (CAL) cases
You must have proper security access and jurisdiction of at least one pending claim to manually add, remove, modify, or reinstate a case to the CAL fast-track process. Regional office (RO) users only need the proper security access. Field office (FO) users do not have this capability.
Process add, remove, modify, and reinstate actions on the Compassionate Allowances page in eView. The Office of Disability Programs (ODP) CAL website provides more information on CAL, houses the impairment summaries, and provides CAL updates. Users must process CAL updates in eView to avoid changing an existing Quick Disability Determinations (QDD) indicator on the case.
In the applicant’s electronic folder (EF), select the yellow/Edit case link at the top of the page. Access the CAL webpage by selecting the hypertext link labeled “CAL” in the top right-hand frame of the EF in eView. The “CAL” link displays “CAL: Y” or “CAL: N”.
The “CAL Home Page” hypertext link connects users to ODP’s CAL website that lists the CAL conditions and contains the CAL information.
The “CAL:” field displays the current status “Yes” or “No.” Take one of the following actions:
* If the CAL value is “Yes”, each applicable condition detected appears as a separate hypertext link leading to the applicable page within the CAL ODP website.
* If the CAL value is “No”, the “CAL Conditions” field will be blank.
The “CAL History” summary table displays the most recent CAL action first and includes the following fields:
* Date: Date CAL was added, reinstated, modified or removed;
* Action: Possible CAL actions are added (manually or through the selection software), reinstated, modified, or removed;
* Office Code: Office responsible for the “Action”;
* Level: Adjudicative level of claim;
* Conditions: If added, modified, or reinstated, the selected conditions will appear. If removed, the field will be blank;
* Reason: Documented rationale for the “Action” (which you selected from a drop down list), or “Other” will display with typed text.
The Reasons column will display the following:
* “Auto Selected” if the selection software detected CAL conditions.
* “Auto-Removed due to EDCS reactivation” when we reactivate a case through Electronic Disability Collect System (EDCS) and the last action taken was “Auto-Selected”.
* Any user-selected reason from a predefined drop down list.
* “Other” (from the drop down list) followed by user entered text.
The applicable action will automatically enable and display the following buttons:
* Add
* Reinstate
* Modify, or
* Remove
Based on the last CAL history action performed, the system will display one or more of the buttons on the lower portion of the CAL page.
The two buttons always enabled are:
* Cancel
* Help
B. Adding cases to CAL processing
If there is no previous CAL history, the disability determination services (DDS), the Office of Quality Review (OQR), and the Office of Disability Adjudication and Review (ODAR) can manually add cases to CAL processing at any adjudication level.
If there is no previous CAL history, the disability determination services (DDS), the Office of Quality Review (OQR), and the Office of Hearings Operations (OHO) can manually add cases to CAL processing at any adjudication level.
The following chart includes a few examples for adding cases to CAL (but not limited to):
When to Add CAL Cases
Examples
New allegation of CAL condition
DDS receives a report from claimant or FO of a CAL condition that was not included in the initial claims allegations on the SSA-3368-BK (Disability Report—Adult) or SSA-3820-BK (Disability Report—Child).
New evidence of CAL condition
DDS discovers a new CAL condition in the medical evidence of record (MER).
System did not identify CAL condition
CAL condition was alleged before the initial transfer, but the system did not recognize it due to misspelling, incorrect acronym, etc.
When the DDS or OQR manually adds a claim as CAL, the system sends the following message to both eView and the DDS legacy system: “Case has been identified as a Compassionate Allowance because of the following conditions: <insert conditions>.
C. Modifying a CAL case
~~DDS, OQR, and ODAR can modify a case in CAL processing.~~
DDS, OQR, and OHO can modify a case in CAL processing.
The following chart includes examples for modifying CAL cases (but not limited to):
When to Modify CAL Cases
Examples
Revise or correct conditions
Claimant alleges Large Intestine Cancer. MER shows diagnosis as Small Cell Cancer of the Large Intestine
Allegation of another CAL condition
DDS receives a report from claimant or FO of a CAL condition that was not included in the initial claims allegations on the SSA-3368-BK (Disability Report—Adult) or SSA-3820-BK (Disability Report—Child).
Evidence of another CAL condition
DDS discovers another CAL condition in the MER.
The DDS can modify CAL conditions by removing the incorrect CAL condition and adding additional CAL conditions. Upon successfully modifying the CAL conditions, EDCS sends the following message to both eView and the DDS legacy system: “Case has been updated with the following Compassionate Allowance conditions: <insert reason>.”
D. Removing cases from CAL and QDD fast-track processing
IMPORTANT: A component must have jurisdiction to remove a case from fast-track processing.
1. CAL cases
DDS, OQR, and ODAR can remove a case from CAL processing. When the DDS or OQR removes a claim from CAL processing as described in DI 23022.055A, EDCS sends an automatic message to both eView and the DDS legacy system, as follows: “Case has been removed from the Compassionate Allowance process because <insert reason>.”
DDS, OQR, and OHO can remove a case from CAL processing. When the DDS or OQR removes a claim from CAL processing as described in DI 23022.055A, EDCS sends an automatic message to both eView and the DDS legacy system, as follows: “Case has been removed from the Compassionate Allowance process because <insert reason>.”
2. QDD cases
DDS, OQR, or the RO, may remove a case from QDD processing only with supervisory approval. FO staff and supervisors do not have this capability. The DDS may remove a case from QDD processing at the point it meets any one of the criteria listed in this section. Remove a case from QDD using eView or your case processing system. To access the QDD page in eView:
* Select the yellow Edit/Lock case link at the top of the page.
* Select the QDD link at the far right on the header bar to display the QDD page. Click on the “Remove” button to display a box with a drop-down list of the reasons for removal.
* Select the correct reason and then select “OK”. The system will remove the case from QDD, and the indicator on the header bar will change to QDD: N.
NOTE: The DDS can reinstate a case to QDD with DDS supervisory approval.
E. Streamlined fast-track processing removal reasons
You must identify the proper reason for removing cases from the fast-track process. The following is a list and explanation of removal reasons.
1. All claims in the case are denials
If after the adjudicator receives all available medical evidence and all claims in the case are denials, remove the case from fast-track processing. If any claim in a case is fully or partially favorable, do not remove from fast-track processing.
Examples of fully favorable, partially favorable, and fully unfavorable determinations:
* One claim is fully favorable, the other is not – Do not remove;
* One claim is a denial, the other is an adverse onset – Do not remove;
* Both claims are denials – Remove.
2. All claims in the case are DDS “no determinations”
Use this removal reason if the DDS returns all claims in the case to the FO with no determination.
For instructions on processing no determination claims, see DI 81020.127.
3. Non-fast-track action or development is required
Use this removal reason if any of the following applies:
* Class action re-adjudication
* Clearly not a CAL case –remove CAL only,
* Extensive FO development or assistance required,
* Medical deferment, or
* Reactivation or reopening.
The following chart explains when it’s appropriate to remove the case from fast-track processing due to required additional actions or development:
Removal Reason
Explanation
Class action re-adjudication
Remove the case from fast-track processing. For instructions on court-ordered reviews, see DI 42502.001.
Clearly not a CAL case – remove CAL only
Remove the CAL identifier if:
* review of all MER the evidence does not confirm the CAL condition alleged on the SSA-3368 or SSA-3820; or
* the system picked up a particular CAL condition but, upon further review, it is obvious that the condition is not a CAL condition for the claimant.
Example of clearly not a CAL case:
The allegation belongs to another family member as recorded in the remarks section.
Extensive FO development or assistance required
Remove the case from fast-track processing if the case requires extensive FO development or assistance.
Examples of FO development or assistance required:
* Work issues,
* Whereabouts unknown,
* Age verification,
* Marital status, or
* Citizenship status.
Medical deferment
Remove the case from fast-track processing if development of medical evidence has been deferred in accordance with DI 22505.010.
Reactivation or Reopening
Remove the case from fast-track processing if the case requires:
* Reactivation in accordance with DI 81020.117, or
* Reopening in accordance with DI 27505.001.
F. Reinstating a case to CAL or QDD fast-track processing
1. Reinstating a case to CAL processing
~~If the last action was a removal from CAL processing, DDS, OQR, and ODAR can reinstate certain cases. The following chart includes examples for reinstatement (but are not limited to):~~
If the last action was a removal from CAL processing, DDS, OQR, and OHO can reinstate certain cases. The following chart includes examples for reinstatement (but are not limited to):
When to Reinstate CAL Cases
Examples
CAL condition mistakenly removed
Action taken to remove CAL on the incorrect claim.
Medical evidence supporting the CAL condition is received after removal.
Previous MER did not substantiate the CAL condition but subsequent MER received after removal confirms the CAL condition.
When the DDS reinstates a claim as CAL, EDCS will send the following message to both eView and the DDS legacy system: “Case has been identified as a Compassionate Allowance because of the following conditions: <insert conditions>.”
2. Reinstating a case to QDD processing
If necessary, with supervisory approval, you may reinstate a case previously removed from QDD.
G. References
* DI 23022.030 Identifying and Receipting Compassionate Allowances and Quick Disability Determinations Cases
* DI 23022.040 Compassionate Allowances and Quick Disability Determinations Fast-Track Case Development
* DI 23022.050 Making the Determination in a Compassionate Allowances or Quick Disability Determinations Fast-Track Case
* DI 27505.001 Conditions for Reopening a Final Determination or Decision
* DI 81010.085 Transferring Cases in the Electronic Disability Collect System (EDCS)
* DI 81020.117 Processing Medical Reactivations

POMS Reference

DI 23022.055: Actions on Compassionate Allowances and Disability Determinations Fast-Track Cases