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DI 32548.015: Disability Determination Services (DDS) Actions Prior to Adjudication

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  • Effective Dates: 02/20/2013 - Present
  • Effective Dates: 05/20/2018 - Present
  • TN 1 (11-00)
  • DI 32548.015 Disability Determination Services (DDS) Actions Prior to Adjudication
  • A. Process
  • The files of potential class members will be retrieved.
  • 1. General - OCO
  • Prior to adjudication OCO will:
  • * Locate and retrieve all claims folders allowed or denied during the Hyatt III timeframe (on or after July 7, 1981, and before November 14, 1991);
  • * Forward the class member claim to the DDS, ODAR or the servicing FO. (Folders sent to the FOs will be those involving work activity; folders sent to ODAR will require ODAR adjudication of the Hyatt III claim).
  • * Forward the class member claim to the DDS, the HO or the servicing FO. (Folders sent to the FOs will be those involving work activity; folders sent to the HO will require the HO adjudication of the Hyatt III claim).
  • * Flag OCO Hyatt III folders with the case flag/alert (DI 32548.095, Exhibit 2).
  • 2. General - DDS
  • Prior to Adjudication the DDS will:
  • * Determine subclass membership, see DI 32548.001B.
  • * If it is obvious claimant is not eligible for Hyatt III review, document the reason claimant is not eligible and forward the folder to:
  • Office of General Counsel
  • Correspondence Control Staff
  • Altmeyer Room 617
  • 6401 Security Blvd.
  • Baltimore, MD 21235
  • Attn: Class Action Coordinator
  • * If a fully favorable medial determination was issued either because of a subsequent application or a previous Hyatt III reopening (see DI 32548.020C.1.b.).
  • B. Policy - consolidation of readjudication claims
  • 1. Jurisdiction and consolidation - subsequent non-class claim pending
  • When a subsequent non-class claim is pending and at least one readjudication claim qualifies for Hyatt III review, it will be consolidated as follows. See DI 32548.012 for the definition of a readjudication claim and special priority instructions, which apply when the class claim is a pending claim.
  • * If the pending claim is before the Appeals Council or is one for which an ALJ hearing has been held or an ALJ decision rendered, the Class Claim and the pending claim will not be consolidated for adjudication.
  • * If the pending claim is one for which an ALJ hearing has been scheduled but has not yet been held, the Class Claim and the pending claim must be consolidated for disability adjudication by an ALJ.
  • * If the pending claim is one for which an ALJ hearing has been requested by the claimant but has not yet been scheduled, the Class Claim and the pending claim shall be consolidated for adjudication by the North Carolina DDS. If the DDS renders an adverse determination, the DDS forwards the class member's consolidated claims to ODAR to schedule a hearing by an ALJ.
  • * If the pending claim is one for which an ALJ hearing has been requested by the claimant but has not yet been scheduled, the Class Claim and the pending claim shall be consolidated for adjudication by the North Carolina DDS. If the DDS renders an adverse determination, the DDS forwards the class member's consolidated claims to the HO to schedule a hearing by an ALJ.
  • * If the pending claim is at the initial or reconsideration level, the Class Claim and the pending claim must be consolidated for adjudication at the reconsideration level by the North Carolina DDS.
  • NOTE: Do not consolidate unless all potential Hyatt III claim files are in the DDS. Additionally, even claims subject to consolidation should be consolidated only to the extent practicable. Thus, if consolidation would unreasonably delay a determination on the current claim, consolidation is not required.
  • 2. Jurisdiction - non-pending claims
  • Readjudication class claims for which a current claim is not pending will be adjudicated by the following components.
  • * Class claims last decided by the North Carolina DDS will be adjudicated by the North Carolina DDS.
  • * Class claims last decided by an ALJ, the AC, or a Federal court will be adjudicated by an ALJ.
  • NOTE: For class members with more than one class claim, class claims will be adjudicated by an ALJ if at least one of the claims was finally decided by an ALJ, the AC, or a Federal court.
  • 3. Appeal rights for ODAR claims consolidated at the DDS
  • * In readjudication cases returned from ODAR for consolidation, class members are entitled automatically to a hearing before an ALJ if the DDS determination is unfavorable.
  • 3. Appeal rights for the HO claims consolidated at the DDS
  • * In readjudication cases returned from the HO for consolidation, class members are entitled automatically to a hearing before an ALJ if the DDS determination is unfavorable.
  • * In readjudication cases where there is consolidation of a non-Hyatt III claim with multiple claims (i.e., an individual filed several applications within the Hyatt III timeframe) the class member is automatically entitled to an ALJ hearing if the claim remanded for consolidation purposes had reached the ALJ hearing level and the DDS Hyatt III determination is unfavorable.
  • C. Policy - consolidation of redetermination claims
  • Redetermination claims are not consolidated with pending claims.
  • D. Procedure
  • Take the following actions prior to determining whether a class member is disabled.
  • 1. Review
  • Examine the folder for Form SSA 1696-U4 (Appointment of Representative) or any other indication of current or prior representation.
  • 2. Responders
  • All responders are class members unless, in the process of retrieving and readjudicating the claim, it is discovered that the claimant does not have a qualifying Hyatt III claim. That is, there is no evidence the claimant filed a disability application, or the claimant did not receive a final medical denial/cessation by a NC adjudicator on or after 07/07/81 through 11/14/91. [That is, the final determination/decision is based on fraud, lack of insured status, SGA, etc. See DI 32548.001B.3.b.].
  • * If claimant does not have a qualifying claim:
  • * Prepare an SSA-559 explaining why claimant is ineligible.
  • * Staple the SSA-559 to the front of the folder/holder and; forward to OPB, Litigation Staff. See DI 32548.015A.2.b. for the address.
  • * If claimant does have a qualifying claim, conduct substantive class review. See DI 32548.020 - DI 32548.025.
  • 3. DDS update of class member"s condition - primary subclass claims
  • The claims of Primary Subclass members are reopened which requires updating the information in the file. See DI 32548.010D.3. Take the following action to update the file:
  • * If Hyatt III folder is received from OCO:
  • * Contact class member by mail or telephone. If contact is by telephone explain that you are taking another look at his/her claim under Hyatt III even if the claimant had received a notice saying he/she did not qualify for this review.
  • * Obtain updated information about the claimant"s condition, medical treating sources, etc., on Form SSA-3441-F6 (Reconsideration Disability Report).
  • * Use an SSA-3368-BK (instead of the SSA-3441-F6) if processing a Hyatt III reconstructed folder.
  • NOTE: In non-pay cases this information must cover the period from the earliest Hyatt III alleged onset date to the present. In current pay cases, the information must cover the period from the earliest Hyatt III application to the subsequent onset date. REMEMBER THAT THE HYATT III DETERMINATION/DECISION CANNOT RESULT IN A LESS FAVORABLE DISABILITY ONSET DATE THAN THE SUBSEQUENT CLAIM.
  • * If Hyatt III folder is received from FO:
  • * Obtain any additional information needed to process the case that was not secured at the FO interview. See DI 22505.001 for general medical evidence development procedures.
  • * Follow DDS procedures for contacting the claimant, his/her representative, or the FO.
  • * When contacting class members, advise them that the information being requested relates to their Hyatt III review.
  • 4. Attorney or other representative involved
  • Take the following steps if an attorney or other representative is involved.
  • * If an attorney or other representative is involved, conduct development through the claimant"s attorney or representative, unless the attorney or representative gives written permission to contact the claimant directly.
  • * Send an SSA-1696-U4 (Appointment of Representative) to the class member to complete and return if one is not in file.
  • * If the SSA-1696-U4 is old, i.e., dated at the time of the prior determination/decision(s), or if more than one SSA-1696-U4 is in file, contact the class member to determine the correct status of his/her representative and obtain a current SSA-1696-U4.
  • 5. Folder routing
  • Route folders as follows:
  • * Route favorable and partially favorable determinations to the FO for development and payment action.
  • * Route unfavorable determinations to the FO to be held during the appeal period.
  • * If the claimant is entitled automatically to an ALJ hearing (see DI 32548.015B.3.), request the FO to forward the files to ODAR after any effectuation action.
  • * If the claimant is entitled automatically to an ALJ hearing (see DI 32548.015B.3.), request the FO to forward the files to the HO after any effectuation action.
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