DI 30005.125:
Group II Period of Disability Decisional Deficiencies
Effective Dates: 01/12/2017 - Present- Effective Dates: 02/16/2018 - Present
- TN 8 (04-04)
- DI 30005.125 Group II Period of Disability Decisional Deficiencies
- A. Definition - group II decisional deficiency
A group II period of disability decisional deficiency is a substantive deficiency that affects the date when disability started, ended or ceased. The period of disability is significant because it may affect the month of entitlement (MOE), the primary insurance amount (PIA) or the earnings freeze.- A group II period of disability decisional deficiency is a substantive deficiency that effects the date when disability started, ended or ceased. The period of disability is significant because it may effect the month of entitlement (MOE), the primary insurance amount (PIA) or the earnings freeze.
- The defined group II period of disability decisional deficiencies are listed in DI 30005.125C.
- B. Policy
- A group II period of disability decisional deficiency exists when the case contains sufficient documentation to:
* support a different onset, ending or cessation date that is material, i.e., the different date has the potential to affect the MOE, the PIA or the earnings freeze, or- * support a different onset, ending or cessation date that is material, i.e., the different date has the potential to effect the MOE, the PIA or the earnings freeze, or
- * establish an onset date when there is a reopening issue, and the adjudicating component reopened the prior determination when they should not have or failed to reopen the prior determination when they should have, regardless of whether the review component agrees with the adjudicating component's established onset date (EOD).
NOTE: When sufficient documentation exists that supports an onset date different than the EOD (i.e., a different month and/or year), the different onset date is considered to have the potential to affect the PIA, MOE or disability freeze. (In situations involving onset as of the first day of a month, a different day could also be a material discrepancy.) Neither the adjudicating component, nor the review component, is responsible for determining whether the PIA, MOE or disability freeze is actually affected; nor is this a factor in determining whether an onset date decisional deficiency exists. Onset date decisional deficiencies are based only on the potential impact of adjudicating components not following existing policy/procedure applicable to them. Review components will not cite a Group II deficiency if an exact EOD is not required per DI 25501.300A.2, or the EOD meets the onset expedient criteria in DI 25501.300A.5.- NOTE: When sufficient documentation exists that supports an onset date different than the EOD (i.e., a different month and/or year), the different onset date is considered to have the potential to effect the PIA, MOE or disability freeze. (In situations involving onset as of the first day of a month, a different day could also be a material discrepancy.) Neither the adjudicating component, nor the review component, is responsible for determining whether the PIA, MOE or disability freeze is actually effected; nor is this a factor in determining whether an onset date decisional deficiency exists. Onset date decisional deficiencies are based only on the potential impact of adjudicating components not following existing policy/procedure applicable to them. Review components will not cite a Group II deficiency if an exact EOD is not required per DI 25501.300A.2, or the EOD meets the onset expedient criteria in DI 25501.300A.5.
- C. Procedure - defined group II decisional deficiencies
- 1. Group II onset date decisional deficiency - no reopening issue
- Review components will cite a group II onset decisional deficiency when the case contains an incorrect onset date determination; i.e., the case contains sufficient documentation to support a different onset date than the adjudicating component's EOD.
- 2. Group II onset date decisional deficiency - reopening issue involved
- Review components will cite a group II onset date decisional deficiency involving a reopening issue is when:
- * the case contains the prior folder from the last adjudicated unfavorable determination; and
- * there is sufficient evidence in file to establish the onset date; and
- * the adjudicating component failed to reopen the prior determination when they should have; or
- * reopened the prior determination and established the onset date when they should not have.
- Included in this category is when the adjudicating component correctly reopens the prior determination but establishes an incorrect onset date or fails to reopen the prior determination when they should regardless of whether they establish the correct onset date.
- 3. Group II ending date decisional deficiency
- Review components will cite a group II ending date decisional deficiency when the case contains sufficient documentation to support a different ending date, if any. Included in this category are cases in which the adjudicating component prepared:
- * a closed period allowance, and the review component determined that the ending date is incorrect; or
- * a closed period allowance that should have been an open period allowance; or
- * an open period allowance that should have been a closed period allowance.
- 4. Group II cessation date decisional deficiency
- Review components will cite a group II cessation date decisional deficiency when the case contains an incorrect cessation date determination; i.e., the case contains sufficient documentation to support a different cessation date.
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