DI 26510: Completion of Form SSA-831-C3/U3 -- Title II, Title XVI and Concurrent Claims
TN 10 (04-09)
A. Title II
Enter the appropriate “Regulation-Basis” code under which the claimant is allowed or denied.
NOTE: The Reg-Basis Code should reflect the nature of the allowance or denial at the time of adjudication. However, in denials, when a technical requirement is no longer met, the Reg-Basis Code should reflect the nature of the denial at the time the technical requirement was last met.
Select the appropriate code from the reference charts in DI 26510.045C, in this section.
In closed period cases, enter the appropriate Reg-Basis Code applicable to that portion of the determination which reflects that the claimant was found to be disabled. Whenever the Central Office or Disability Quality Branch returns a determination for further consideration, enter the Regulation-Basis Code that is applicable to any new determination that is prepared. For a description of the various bases for determination refer to DI 26510.045C in this section.
When the regulation basis code of the original determination is unavailable, enter “CE” in Item 22. See “Collateral Estoppel – New Regulation Basis Codes” in DI 27515.060. See “Collateral Estoppel – New Regulation Basis Codes” in DI 27515.060. However, if known, the original regulation basis code should be entered here.
A claim denied on the basis of res judicata requires the entry “S1” in Item 22. (See DDS Action on Subsequent Title II Claim -- Claimant Previously Denied Through Date Last Insured/Prescribed Period/Age 22, DI 27516.005B.3.)
NOTE: It is no longer necessary to code a regulation number along with the Regulation Basis code because the National Disability Determination Services System only captures the Regulation Basis code for management information purposes.
NOTE: When adjudicating CDB re-entitlement claims, refer to notes in Childhood Disability Beneficiary (CDB) Re-entitlement, DI 23505.010A and Requirements for Re-entitlement, DI 10115.035A for a change in the re-entitlement period.
|
Basis for Decision |
Enter in Item 22 Reg-Basis Code |
|
|---|---|---|
|
ER1 or PP1 Last met on or after date of current decision |
ER1 or PP1 last met prior to date of current decision |
|
|
Impairment Not Severe—Medical Consideration Alone |
F12 |
F2 |
|
Capacity for SGA—Any Relevant Past Work |
H1 |
H2 |
|
Capacity for SGA—Other Than Relevant Past Work |
J1 |
J2 |
|
Engaging in SGA—(DIB claims only) |
N13 |
N23 |
|
Impairment Prevented SGA for a Period of Less Than 12 Months |
E1 |
E2 |
|
Impairment Prevents SGA at Time of Adjudication but is not Expected to Prevent SGA for a Period of 12 Months |
E3 |
E4 |
|
Insufficient Evidence Furnished |
M54 |
M65 |
|
DAA Is Material to the Determination of Disability |
Z1 |
Z2 |
|
Failure or Refusal to Submit to Consultative Examination and Insufficient Evidence |
L1 |
L2 |
|
NH Does Not Want to Continue Development of Claim—Wants Decision Made on Evidence in File |
M3 |
M4 |
|
NH Does Not Want to Continue Development of Claim—Does Not Indicate Decision to be Made on Evidence in File |
M7 |
M8 |
|
NH Willfully Fails to Follow Prescribed Treatment |
K1 |
K2 |
|
DWB Medicare Only Case—EOD at or after Age 62 Years and 7 Months—No Prior Disability Benefit Entitlement or Not Disabled, Whereabouts Unknown |
X3 |
X3 |
1 ER (earnings requirement); PP (prescribed period).
2 Also use this Reg-Basis Code in situations where the claimant only meets the fully insured requirement at AOD or later, has alleged a visual impairment, and the claimant does not meet the definition of statutory blindness.
3 Use this code if the FO has determined that the claimant is engaging in SGA, the claimant alleges a visual impairment and the DDS determines that the claimant is not statutorily blind.(See Item 22 (Regulation Basis Code – Procedure – Title II – DIB-SGA Alleged, DI 26010.040C. )
4 Do not use M5 when the claimant cooperated but there is insufficient evidence of disability. In these situations, use F1.
5 Do not use M6 when the claimant cooperated but there is insufficient evidence of disability relating to the period before the insured status requirement was last met. In these situations, use F2.
|
Basis for Decision |
Enter in Item 22 |
|---|---|
|
Impairment Meets Level of Severity of Listings |
A11 |
|
Impairment Equals Level of Severity of Listings |
B1 |
|
Medical and Vocational Considerations |
C1 |
|
Medical and Vocational considerations (35-40 Years of Arduous Unskilled Work, Marginal Education, and Significant Impairment) |
D1 |
1 When the date of onset (in item 15A) is based on statutory blindness, but the claimant is found not disabled for cash benefit purposes (item 18A), enter Regulation-Basis code "A1."
|
Basis for Decision |
Enter in Item 22 Reg-Basis Code |
|
|---|---|---|
|
CDB Claim, or reentitlement CDB claim and re-entitlement period (RP) last met on or after date of current decision |
Reentitlement CDB claim and RP last met prior to date of current decision |
|
|
Impairment Not Severe—Medical Consideration Alone or Condition Disabling but did not Exist Before Age 22 |
F1 |
F2 |
|
Capacity for SGA—Vocational Considerations |
G1 |
G2 |
|
Impairment Prevented SGA for a Period of Less Than 12 Months |
E1 |
E2 |
|
Impairment Prevents SGA at Time of Adjudication but is Not Expected to Prevent SGA for a Period of 12 Months |
E3 |
E4 |
|
Insufficient Evidence Provided |
M51 |
M62 |
|
Failure or Refusal to Submit to Consultative Examination and Insufficient Evidence |
L1 |
L2 |
|
Claimant Does not Want to Continue Development of Claim |
M3 |
M4 |
|
Claimant Willfully Fails to Follow Prescribed Treatment |
K1 |
K2 |
|
Drug Addiction and/or Alcoholism is Material to the Determination of Disability |
Z1 |
Z2 |
1 M5 is not used when the claimant has cooperated but there is insufficient evidence before age 22 to establish disability - use F1 instead.
2 M6 is not used when the claimant has cooperated but there is insufficient evidence before the end of the reentitlement period to establish disability - use F2 instead.
|
Basis for Decision |
Enter in Item 22 Reg-Basis Code |
|---|---|
|
Impairment Meets Level of Severity of Listings |
A1 |
|
Impairment Equals Level of Severity of Listings |
B1 |
|
Medical and Vocational Considerations |
C1 |
|
Basis for Decision |
Enter in Item 22 Reg-Basis Code |
|---|---|
|
Impairment Not Severe—Medical Considerations Alone |
F1 |
|
Capacity for SGA—Any Relevant Past Work |
H1 |
|
Capacity for SGA—Other Than Relevant Past Work |
J1 |
|
Impairment Prevented SGA for a Period of Less Than 12 Months |
E1 |
|
Impairment Prevents SGA at Time of Adjudication but Is Not Expected to Prevent SGA for a Period of 12 Months |
E3 |
|
Insufficient Evidence Furnished |
M5 |
|
Failure or Refusal to Submit to Consultative Examination and Insufficient Evidence |
L1 |
|
NH Does Not Want to Continue Development of Claim |
M3 |
|
NH Willfully Fails to Follow Prescribed Treatment |
K1 |
Parent Determination—Allowance
|
Basis for Decision |
Enter in Item 22 Reg-Basis Code |
|---|---|
|
Impairment Meets Level of Severity of Listings |
A1 |
|
Impairment Equals Level of Severity of Listings |
B1 |
|
Medical and Vocational Considerations |
C1 |
|
Medical and Vocational Considerations (35-40 Years of Arduous Unskilled Work, Marginal Education, and Significant Impairment) |
D1 |
B. Title XVI
Enter the appropriate Regulation-Basis Code. The code should reflect the nature of the allowance or denial at the time of adjudication.
Use a regulation basis code that reflects disability rather than blindness if the claimant was disabled in the month of filing and became statutorily blind in a later month.
In closed period cases, enter the appropriate regulation basis code applicable to the portion of the determination that reflects that the claimant was found to be disabled.
When the regulation basis code of the original determination is unavailable, enter “ACE” in Item 22. See “Collateral Estoppel – New Regulation Basis Codes” in DI 27515.060”. However, if known, the original regulation basis code should be entered here
Enter the regulation basis code that is applicable to any new determination prepared whenever a determination is returned by CO or DQB for further consideration.
NOTE: It is no longer necessary to code a regulation number along with the Regulation Basis code because the National Disability Determination Services System only captures the Regulation Basis code for management information purposes..
| Basic for Decision is | Enter in Item 22 Reg-Basis Code | |
|---|---|---|
|
No Visual Impairment1 |
Visual Impairments2 |
|
|
Impairment Not Severe-Medical Consideration Alone |
N30 |
N414 |
|
Capacity for SGA—Any Relevant Past Work |
N31 |
N42 |
|
Capacity for SGA—Other than Relevant Past Work |
N323 |
N433 |
|
Engaging in SGA |
N33 |
N335 |
|
Impairment Prevented SGA for a Period of Less Than 12 Months |
N34 |
N45 |
|
Impairment Prevented SGA at Time of Adjudication But is Not Expected to Prevent SGA for a Period of 12 Months |
N35 |
N46 |
|
Insufficient Evidence Furnished |
N36 |
N36 |
|
Failure or Refusal to Submit to Consultative Examination and Insufficient Evidence |
N37 |
N37 |
|
Applicant Does Not Want to Continue Development of Claim |
N38 |
N38 |
|
Applicant Willfully Fails to Follow Prescribed Treatment |
N396 |
N396 |
1 Enter the applicable Reg-Basis Code from this column when the applicant does not allege a visual impairment.
2 Enter the applicable Reg-Basis Code from this column when the applicant alleges a visual impairment.
3 Also use this code when the applicant has the capacity for SGA but does not have a work history.
4 Also use this code in a multi-category case when a disability recipient is determined not to be statutorily blind.
5 Use this code if the FO has determined that the claimant is engaging in SGA, the claimant alleges a visual impairment and the DDS determines that the claimant is not statutorily blind. Use code N33 for both Engaging in SGA Without or With a Visual Impairment denials. Complicated systems changes prevent a new Regulation Basis Code from being created at this time. Code N44, formerly used in Engaging in SGA with a Visual Impairment denials, was redefined for use in DC Under Age 18 Impairment Not Severe denials.
6 Also use this code along with the appropriate DAA indicator code, when DAA is material to the determination of disability.
|
Basis for Decision |
Enter in Item 22 Reg-Basis Code |
|---|---|
|
Impairment Meets Level of Severity of Listings |
A61 |
|
Impairment Equals Level of Severity of Listings |
A62 |
|
Medical and Vocational Considerations |
A63 |
|
Medical and Vocational Considerations (35-40 Years of Arduous Unskilled Work, Marginal Education, and Significant Impairment) |
A64 |
BI or BS Claim - Allowance
|
Basis for Decision |
Enter in Item 22 |
|---|---|
|
Statutory Blindness |
A61 |
|
Basis for Decision |
Enter in Item 22 Reg-Basis Code |
|
|---|---|---|
|
No Visual Impairment1 |
Visual Impairment2 |
|
|
Engaging in SGA |
N33 |
N33 |
|
Impairment(s) Disabling for a Period of Less Than 12 Months |
N34 |
N45 |
|
Impairment(s) Disabling at Time of Adjudication But is Not Expected to be Disabling for a Period of 12 Months |
N35 |
N46 |
|
Insufficient Evidence Furnished |
N36 |
N36 |
|
Failure or Refusal to Submit to Consultative Examination and Insufficient Evidence |
N37 |
N37 |
|
Applicant Does Not Want to Continue Development of Claim |
N38 |
N38 |
|
Applicant Willfully Fails to Follow Prescribed Treatment |
N393 |
N393 |
|
Impairment(s) Severe But Does Not Cause Marked and Severe Functional limitations; i.e., does not meet or medically or functionally equal the severity of a listing |
N43 |
N43 |
|
Impairment Not Severe |
N44 |
N44 |
1 Enter the applicable Reg-Basis Code from this column when the applicant does not allege a visual impairment.
2 Enter the applicable Reg-Basis Code from this column when the applicant alleges a visual impairment.
3 Also, use this code along with the appropriate DAA indicator, when DAA is material to the determination of disability.
DC Claim and Claimant under Age 18—Allowance
|
Basis for Decision |
Enter In Item 22 |
|---|---|
|
Impairment Meets Level of Severity of Listings |
A61 |
|
Impairment(s) Medically Equals Level of Severity of Listings |
A65 |
|
Impairment(s) Functionally Equals Levels of Severity of Listings |
A66 |
BC Claim-Allowance
|
Basis for Decision |
Enter in Item 22 Reg-Basis Code |
|---|---|
|
Statutory Blindness |
A61 |
C. Description of Basis for Decision
1. Allowance
a. Impairment meets listings
|
Description of Basis for Decision |
Type of Claim |
Reg. Basis Code1 |
|---|---|---|
|
The individual is disabled on medical considerations alone because the disability is caused by an impairment specifically listed in the "Listing of Impairments" and the medical evidence contains the specific findings listed for the impairment. This entry will also include cases of “statutory blindness.” No allowance should be coded as meeting the listings unless the specific medical criteria of one or more of the listed impairments are met, as shown by the medical evidence in file. |
DIB, DWB, CDB Parent Determination DI, DS, AI, AS DC age 18-21 DC under 18 BI/BS/BC |
A1 A61 A61 A61 |
b. Impairment equals listings
| Description of Basis for Decision | Type of Claim |
Reg. Basis Code1 |
|---|---|---|
|
The individual is disabled on medical considerations alone (or for DCs under 18, functional considerations as well) because of an impairment or a combination of impairments of severity equal to the level of severity contemplated in the "Listing of Impairments," but where all the specific requirements of the Listing are not met on the basis of the medical evidence in file. |
DIB, DWB, CDB Parent Determination DI/DS, AI, AS DC Age 18-21 DC under 18 Medically Equals DC Under 18 functionally equals |
B1 A62 A65 |
c. Severe impairment(s) short of the Listings plus adverse vocational factors
|
Description of Basis for Decision |
Type of Claim |
Reg. Basis Code1 |
|---|---|---|
|
The individual is disabled as defined in Regulation 404.1520(f) or 416.920(f) on the basis of a severe impairment(s) short of the severity in the “Listing of Impairments,” together with adverse vocational factors. |
DIB, DWB, CDB Parent Determination DI/DS, AI, AS DC Age 18-21 |
C1 A63 |
d. 35-40 years of arduous unskilled work
|
Description of Basis for Decision |
Type of Claim |
Reg. Basis Code1 |
|---|---|---|
|
The individual with 35-40 years of arduous unskilled work and a marginal education who cannot work at the customary level of physical exertion because of a significant impairment(s) is disabled. |
DIB, DWB Parent Determination DI/DS, AI, AS |
D1 A64 |
2. Denial
a. Impairment prevents(ed) SGA (GA) for a period of less than 12 months
|
Description of Basis for Decision |
Type of Claim |
Reg. Basis Code1 |
|---|---|---|
|
The impairment is (or was) severe enough to prevent SGA (GA) at or after AOD but is not expected to (or did not) prevent SGA (GA) for a period of 12 months and is not expected to result in death. |
DIB, CDB, DWB Parent Determination DI/DS, AI, AS DC Age 18-21 |
E1, E2, E3 or E42 4 E1 or E32 4 N34 or N45 N35 or N464 |
b. Impairment(s) causes (or caused) marked and severe functional limitations for a period of less than 12 months
| Description of Basis for Decision | Type of Claim |
Reg. Basis Code1 |
|---|---|---|
|
The impairment(s) did (or does) cause marked and severe functional limitations at or after AOD but is not expected to (or did not) cause marked and severe functional limitations for a period of 12 months and is not expected to result in death. |
DC under 18 |
N34, N355 N45 or N465 |
c. Impairment not severe
|
Description of Basis for Decision |
Type of Claim |
Reg. Basis Code1 |
|---|---|---|
|
The individual is found not disabled on medical considerations alone because the impairment is not severe. The criteria of a non-severe impairment are met when the impairment(s) does not significantly limit the individual’s physical or mental capacity to perform basic work-related functions. For DCs under age 18, the criteria of a nonsevere impairment are met when the impairment(s) does not cause more than a minimal limitation in the individual’s ability to function in an age -appropriate manner. |
DIB, DWB, CDB Parent Determination DI/DS, AI, AS DC Age 18-21 DC under 18 |
F1 or F2 F1 N30 or N41 N44 |
d. Child’s impairment(s) is not severe before age 22 or the end of the CDB re-entitlement period
|
Description of Basis for Decision |
Type of Claim |
Reg. Basis Code1 |
|---|---|---|
|
The individual is found to have a disabling impairment, but the condition was not disabling before age 22. |
CDB |
F1 or F2 |
e. Impairment(s) severe but does not cause marked and severe functional limitations; i.e., does not meet or medically or functionally equal the severity of a listing
|
Description of Basis for Decision |
Type of Claim |
Reg. Basis Code1 |
|---|---|---|
|
The impairment is severe but not disabling because it does not cause marked and severe functional limitations (i.e. it does not meet or medically or functionally equal the severity of a listing. |
DC under 18 |
N43 |
f. Capacity for SGA (CDB case)
|
Description of Basis for Decision |
Type of claim |
Reg. Basis Code1 |
|---|---|---|
|
The child has a severe impairment(s) but is found not disabled because he or she has a functional and vocational capacity to engage in substantial gainful activity. |
CDB |
G1 or G2 |
g. Capacity for SGA—relevant past work
|
Description of Basis for Decision |
Type of Claim |
Reg. Basis Code1 |
|---|---|---|
|
The individual has a severe impairment(s) but is found not disabled because he or she has the functional and vocational capacity to engage in substantial gainful activity in relevant past work. |
DIB, DWB Parent Determination DI/DS,AI, AS and DC Age 18-21 |
H1 or H2) H1 N31 or 42 |
h. Capacity for SGA—other than relevant past work
|
Description of Basis for Decision |
Type of Claim |
Reg. Basis Code1 |
|---|---|---|
|
The individual has a severe impairment(s) but is found not disabled because he or she has the functional and vocational capacity to engage in substantial gainful activity in other than relevant past work for which he or she is capable by past education, training or work experience. |
DIB, DWB Parent Determination DI/DS,AI,AS and DC Age 18-21 DC Under 18 |
J1 or J2 J1 N32 or N43 |
i. Failure to follow prescribed treatment
|
Description of Basis for Decision |
Type of Claim |
Reg. Basis Code1 |
|---|---|---|
|
The individual willfully, without justifiable cause, fails to follow therapy prescribed by the treatment source for a disabling impairment which is amenable to treatment that could be expected to restore ability to work, or, if a DC under 18, to function in an age - appropriate manner. |
DIB, CDB, DWB Parent Determination DI/DS, AI, AS and DC Age 18-21 DC Under 18 |
K1 or K2 K1 N396 |
j. Refusal or failure to appear for a consultative examination
|
Description of Basis for Decision |
Type of Claim |
Reg. Basis Code1 |
|---|---|---|
|
The individual refuses or fails to present him or herself for a consultative examination which is considered essential to a proper determination and there is insufficient evidence in file to make a determination |
DIB, CDB, DWB Parent Determination DI/DS, AI, AS and DC Age 18-21 DC Under 18 |
L1 or L2 N37 |
k. Failure to cooperate in submitting evidence of disability
|
Description of Basis for Decision |
Type of Claim |
Reg. Basis Code1 |
|---|---|---|
|
The individual is found not disabled because of failure to cooperate in submitting medical, functional, or vocational evidence necessary for a determination. |
DIB, CDB, DWB Parent Determination DI/DS, AI, AS and DC Age 18-21 DC Under 18 |
M5 or M63 M5 N36 |
l. Does not wish to continue development of claim
|
Description of Basis for Decision |
Type of Claim |
Reg. Basis Code1 |
|---|---|---|
|
1) Wants Decision Made on Evidence in File—The individual does not wish to continue development of the claim, wants a decision made on the evidence in file and the evidence does not establish that the individual is disabled. |
DIB, CDB, DWB Parent Determination DI/DS, AI, AS and DC Age 18-21 DC Under 18 |
M3 or M4 M3 N38 |
|
2) Does Not Indicate Decision to be Made on Evidence in File—The individual does not wish to continue development of the claim, does not indicate that he/she wants a decision to be made on the evidence in file and the evidence does not establish that the individual is disabled. |
DIB, DWB CDB Parent Determination DI/DS, AI, AS and DC Age 18-21, DC Under 18 |
M7 or M8 M3 or M4 M3 N38 |
m. SGA
|
Description of Basis for Decision |
Type of Claim |
Reg. Basis Code1 |
|---|---|---|
|
Engaging in SGA—The individual is found not disabled because he /she is engaging in substantial gainful activity. |
DIB, DWB DI/DS, AI, AS and DC Age 18-21 |
N1 or N2 N33 |
n. DAA
|
Description of Basis for Decision |
Type of Claim |
Reg. Basis Code1 |
|---|---|---|
|
Drug addiction and/or Alcoholism is material to the determination of disability |
DIB, DWB, CDB |
Z1 or Z2 |
1 The numerical codes "1," "3," "5" and "7" (e.g., "A1" or "E3") signify that the earnings requirement (in DIB cases) or the prescribed period requirement (in DWB and CDB re-entitlement cases) is not at issue. The numerical codes "2," "4," "6" and "8" indicate that in addition to the basis for the disability determination, the earnings requirement, prescribed period requirement, or re-entitlement period requirement expired before the date of the current decision; e.g., claimant is not disabled through the date the earnings requirement was last met.
2 These codes are used to differentiate between an impairment that prevents SGA at time of adjudication but is not expected to prevent SGA for 12 months as opposed to an impairment that no longer prevented SGA at time of adjudication and did not prevent SGA for 12 months.
3 Do not use M6 when the claimant cooperated but there is insufficient evidence of a disability relating to the period before the insured status or prescribed period requirement was last met. In these situations, use F2.
4 These codes are used to differentiate between an impairment that results in marked and severe functional limitations at time of adjudication but is not expected to do so for 12 months (N35, N46), as opposed to an impairment that no longer causes marked and severe functional limitations at time of adjudication and did not do so for 12 months (N34, N45).
5 Also use this code along with the appropriate DAA indicator when DAA is material to the determination of disability.
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