DI 44001.125: Coordination of Dual Eligibility Cases with Railroad Retirement Board (RRB)

changes
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~~Effective Dates: 02/18/2016 - Present~~
Effective Dates: 11/20/2017 - Present
TN 2 (03-10)
DI 44001.125 Coordination of Dual Eligibility Cases with Railroad Retirement Board (RRB)
Great Lakes Program Service Center-Disability Processing Branch (GLPSC-DPB) has jurisdiction for processing disability claims that require coordination with the RRB. These claims are called dual eligibility cases because the claimants usually also file a disability claim or are entitled to a disability annuity with RRB.
RRB prepares and signs railroad retirement (RR) disability determinations for career RR workers or their dependents, and SSA prepares and signs Social Security determinations for the same claimants.
A. Background on dual eligibility processing
SSA and RRB negotiated and signed a Memorandum of Understanding (MOU). Under the terms of the MOU, SSA and RRB agreed to share medical evidence and coordinate disability determinations in dual eligibility cases to limit or prevent making different disability determinations. Medical Evidence is shared pursuant to section 7(b) 3of the Railroad Retirement Act (RRA). (While we coordinate decisions based on a mutual agreement, furnishing medical evidence and other records is required by statute).
The two agencies exchange medical evidence, medical consultants’ assessments, and coordinate their disability determinations. If the determinations do not agree, and the disagreement represents a conflict per DI 44001.125D in this section, SSA disability processing specialists (DPS) and RRB examine the basis for the disagreement and determine whether both agencies had access to the same medical evidence and all issues were considered.
If the disagreement cannot be resolved following coordination, RRB and SSA each issue its own determination despite the conflict. A RRB disability determination is not binding on SSA, nor is an SSA disability determination binding on RRB.
The GLPSC-DPB DPS documents the coordination with RRB on SSA-415 (Notice of Disability Determination and Transmittal), per DI 44001.125C in this section.
The RRB disability examiner or field service contact representative sends an e-mail to request medical evidence from GLPSC-DPB with an RR-5 (Request for SSA Medical Evidence). The RRB disability examiner uses an RL-34b (Reply to Social Security Administration Request for Evidence and Disability Information) to send copies of the RRB decision and medical evidence to GLPSC-DPB. For more information regarding the use of these forms, faxing documents into the EF, and methods of transmitting data to RRB see DI 44001.125F in this section.
B. Initial coordination with RRB – DPS responsibilities
Upon receipt of a new claim,
* Contact RRB and ask if the claimant also filed a claim for a disability annuity with RRB. The coordination required will depend on whether RRB has a claim, and what stage of development the RRB claim has reached.
* Document all contacts on an SSA-415 (Notice of Disability Determination) or an SSA-5002 (Report of Contact). Cite the name and phone number of the RR examiner; the date, time, and result of the initial contact; and sign and date the form. See Developing Medical Evidence in DI 44001.120.
* Upon completion of the disability determination, see DI 44001.125C in this section for final coordination instructions, including providing copies of SSA determination to RRB.
NOTE: Whenever possible, make an effort to simplify and shorten the GLPSC-DPB/RRB coordination process by discussing the case with the RR examiner by phone and or e-mail.
1. RRB does not have a claim for disability
Record this information on the SSA-415 or SSA-5002 and proceed with the medical development and decision process on the SSA claim.
2. RRB has made a disability determination
GLPSC-DPS should:
* Request copies of the RRB medical evidence, medical consultants’ (MC) assessments, and decision documents. See DI 44001.125F.2.a. in this section regarding faxing new evidence into the CEF.
* Proceed with the disability review, including forwarding the claim for MC assessment and preparing decisional documents on the claim.
* Develop additional medical evidence for the case, if necessary, which might include authorization of a consultative examination (CE) per DI 44001.120C.
* If the GLPSC-DPB determination would be in conflict with the RRB determination, coordinate with the RRB examiner who signed the conflicting determination per DI 44001.125C.2.b. in this section to see if the differences can be resolved.
3. RRB has a pending claim
If the RRB has a pending claim, the DPS should:
* Discuss with the RR examiner what medical evidence is already available in the RR claim, and ask for copies of any evidence not currently in the SSA file.
* Hold the SSA folder pending receipt of the medical evidence from RRB if it appears RRB has a significant amount of medical evidence not currently available to SSA. However, initiate medical evidence of record (MER) development from the medical sources on the claimant’s SSA-3368-BK (Disability Report – Adult) without waiting for RRB, if there is little or no medical evidence in the RR folder not currently available to SSA.
* If RRB has a CE scheduled for the claimant, ask the RR examiner to fax a copy of the CE to DPB upon receipt. Review the SSA case to determine if you need current medical development, such as MER development from a medical source not listed in the RR claim, ADL and third-party ADL forms, or SSA-3369 vocational documentation. If you do not need current medical development, set a diary “tickle” date for 2 weeks after the date of the RRB CE appointment to follow up on the CE report.
NOTE: If medical evidence received suggests a fully favorable determination, exercise medical judgment and immediately send the case for an assessment by the SSA medical staff without waiting for additional evidence from RRB.
C. Final coordination with RRB – DPS responsibilities
Upon completion of the disability determination, including an SSA-831-C3/U3 (Disability Determination and Transmittal) approved by the DPS and the regional MC physician, the DPS coordinates the determination with the RRB. The coordination required depends on whether RRB has a claim, and what stage of development the RR claim has reached.
The GLPSC-DPB always uses SSA-415 to coordinate the final determination with RRB. For completion of the SSA-415 see DI 44001.125E in this section.
NOTE: Whenever possible, make an effort to simplify and shorten the GLPSC-DPB/RRB coordination process by discussing the case with the RR examiner by phone and or e-mail.
1. RRB does not have a claim for disability
If RRB does not have a claim, the DPS should:
* Prepare an SSA-415.
* Dispatch the case to the MIDAS disability assistant (DA) for case closure following current procedures and transfer jurisdiction to the appropriate field office (FO).
* Burn a compact disk (CD) to include the SSA-415, the SSA-831 disability determination and all related medical and vocational information and send it to RRB.
2. RRB determination previously effectuated
If RRB has already made a disability determination for the same period of alleged disability review all the medical evidence from the RRB claims folder, including the RRB decision forms G-325 (Disability Decision Sheet) and G-325B (Disability Briefing Document).
a. GLPSC-DPB determination agrees with the RRB determination
* Prepare an SSA-415.
* Dispatch the case to the MIDAS DA for case closure following current procedures and transfer jurisdiction to the appropriate FO.
* Burn a CD with the SSA-415, SSA-831-C3/U3, and any medical evidence which is not a part of RRB’s file and send to RRB (Optionally, send paper copies of this evidence to RRB if there is little or no MER to provide).
b. GLPSC-DPB determination disagrees with RRB determination
* Identify the source of conflict and review all available evidence.
* If RRB cited new evidence in their determination, re-contact RRB to request the additional evidence. After review of the new evidence, send the case for a second MCS review to consider the conflicting RRB medical assessment. (Use your judgment to determine if you should send the case for a second MCS review if we received no additional evidence from RRB.)
* If SSA’s determination still disagrees with RRB’s determination, prepare an SSA-415 explaining the basis of the disagreement with RRB. In the “Remarks” section, ask RRB to notify you if they reopen their disability determination to conform to the DPB determination.
* Dispatch the case to the MIDAS DA for case closure following current procedures and transfer jurisdiction to the appropriate FO.
* Burn a CD with the SSA-415, SSA-831-C3/U3, and any medical evidence which is not a part of RRB’s file and send to RRB (Optionally, send paper copies of this evidence to RRB if there is little or no MER to provide).
3. RRB determination pending
If RRB has a disability claim and has not yet made a determination, attempt to coordinate the determination with RRB prior to processing. However, do not delay case closure for more than five days pending RRB’s reply. Contact the RRB examiner by phone or e-mail prior to case closure and discuss the status of the RRB claim.
NOTE: If the GLPSC-DPB receives new evidence from RRB, after case closure, review for possible reopening per DI 44001.125C.4. in this section.
a. RRB determination agrees with GLPSC-DPB determination (or RRB determination not yet completed)
* Prepare an SSA-415.
* Dispatch the case to the MIDAS DA for case closure following current procedures and transfer jurisdiction to the appropriate FO.
* Burn a CD, including the SSA-415, SSA-831-C3/U3, and any medical evidence that is not part of RRB’s file and send it to RRB.
b. RRB determination disagrees with GLPSC-DPB determination
* Identify the source of conflict and review all available evidence.
* If RRB cited new evidence in their determination, ask the RR examiner to fax a copy of the new evidence to your attention.
* If the new evidence is received, send the case for a second MCS review to consider the conflicting RRB medical assessment. (Use your judgment to determine if you should send the case for a second MCS review if we received no additional evidence from RRB.)
* If the determination still disagrees, prepare an SSA-415 explaining the basis of the disagreement with RRB. In the “Remarks” section, ask RRB to notify you if they reopen their disability determination to conform to the DPB determination.
* Dispatch the case to the MIDAS DA for case closure following current procedures and transfer jurisdiction to the appropriate FO.
* Burn a CD with the SSA-415, SSA-831-C3/U3, and any medical evidence that is not part of RRB’s file and send to RRB.
NOTE: For paper modular disability folder (MDF) cases, follow the instructions in DI 44001.125C.1.-DI 44001.125C.3. in this section, for coordination with RRB, except send photocopies of the SSA folder material to RRB using an SSA-415. Route the MDF folder to the FO for effectuation and case closure following coordination with RRB.
4. RRB evidence received after DPB case closure
For handling, any evidence received from RRB following GLPSC-DPB case closure follow DI 81020.140 and DI 22520.001. Also, for a discussion of the conditions for reopening a final determination see DI 27505.000.
If new and material evidence is received, which results in any significant change to the GLPSC-DPB disability determination send a copy of any new determination to RRB upon case closure.
D. Conflict Cases – Dual eligibility cases
A conflict exists when there is a difference between the SSA and RRB disability determinations and the difference is material.
1. Background
SSA follows a 5-step sequential evaluation process to determine disability as described in DI 22001.001B and DI 22001.001C. Steps 4 and 5 of the process assess the claimant’s residual functional capacity (RFC) for work. Step 4 considers whether the claimant’s impairment(s) prevents performance of Past Relevant Work (PRW). Step 5 considers whether a claimant can make the vocational adjustment needed to perform other work.
RRB awards two categories of disability annuities based on various factors of the claimant’s RR work including total number of RR service months and recency of RR employment.
* Occupational disability annuity
Under Sec. 2(a) 4 of the Railroad Retirement Act (RRA). An allowance of an occupational annuity is permitted based on a finding that the claimant’s impairment(s) would not permit a return to his past RR job(s). This determination does not consider the claimant’s capacity to perform other work as generally performed in the national economy (i.e., Step 5 in the SSA sequential evaluation process).
* Total and Permanent (T & P) disability annuity
Under Sec. 2(a) 5 of the RRA. A finding of T & P disability indicates that RRB followed SSA’s 5-step sequential evaluation process in arriving at its determination.
2. Conflict processing
A conflict exists when:
* The RRB T & P determination differs from the SSA allowance or denial determination and the difference is material.
* RRB denies an occupational disability and SSA allows.
If RRB allows an occupational annuity and SSA denies generally, there is no material conflict. In addition, if the disagreement between the determinations is not significant to an award of disability benefits, there is no conflict; e.g., the agencies disagree on the onset date, but both dates are in the same calendar month (excluding the first day of the month).
SSA and RRB attempt to resolve any conflicts by coordinating their disability determinations. Conflicts are frequently resolved by coordinating with the RRB examiner who signed the conflicting determination.
Keep in mind that a RRB disability determination is not binding on SSA, nor is an SSA disability determination binding on RRB.
For final processing in conflict cases, see DI 44001.125C.2.b. in this section.
E. Completion of SSA-415 (Notice of Disability Determination and Transmittal)
GLPSC-DPB and RRB use the SSA-415 to exchange information and coordinate disability determinations on dual eligibility claims. GLPSC-DPB also uses it as a transmittal to route copies of medical and vocational evidence to RRB:
* On electronic cases, the SSA-415 is downloaded to Section B of the CEF upon case closure and the DPS burns a CD containing copies of the SSA-415, SSA-831-C3/U3 and all medical and vocational evidence and sends the CD to RRB.
* On MDF cases, the DPS uses the SSA-415 as a cover sheet to send paper copies of the SSA-831-C3/U3 and other evidence from the SSA disability claim to RRB.
1. Preparation
Prepare the SSA-415 using MIDAS document V05. For paper MDF cases, a “Word” version is available on the GLPSC-DPB shared drive in DPB LETTERS – RAILROAD LETTERS.
The DPS is responsible for the completion of Items 1 through 4 (and Item 5, if appropriate) of the SSA-415. A folder copy of the form is prepared for paper MDF claims.
Item 1
* Check the box in the left column that identifies the type of communication either “Coordination” or “Information.” The “Consultative” box is no longer used.
* Check the “Information” box if the GLPSC-DPB determination is not in conflict with RRB’s determination, RRB does not have a claim, or the RRB determination is unknown.
* Check the “Coordination” box if the GLPSC-DPB determination is in conflict with RRB’s determination.
* Check the box in the right column that identifies the type of determination involved (“Initial,” “Reconsideration,” or “Continuing”).
Item 2 -- Identification
* Enter the date of preparation.
* Enter the claimant’s Social Security number.
* Enter the claimant’s RRB claim number. If the claim number is not available, enter the claimant’s date of birth.
* Enter the claimant’s name. If the RRB claim number is unknown, also enter the claimant’s address.
Item 3
Enter the date of the SSA disability application. If SSA has made a determination, enter the date of the disability determination.
Item 4 -- Status of SSA Disability Determination
* Check one of the five boxes following “SSA decision is” and complete as necessary.
* Use the “Remarks” portion to inquire about, explain, or expand any of the preceding entries on or the attachments to the SSA-415.
* Check the “Attachments” box when transmitting evidence to RRB. For electronic claims, show “CD” if evidence is contained on a CD. For MDF claims, which require sending paper evidence to RRB, identify the attachments by form number or type e.g., “SSA-831-C3/U3, SSA-4734, MER.”
* Enter your name and phone number.
* Check “Remarks Continue” box whenever the remarks are continuing on a separate sheet.
Item 5 -- RRB Reply
RRB may not return the SSA-415 with a reply. If coordination was accomplished by phone or e-mail between the DPS and RR examiner, the DPS may annotate the RRB reply in Item 5:
* “Phone call to RR examiner Jim Fayes (#123-4567), 5/2/08. Jim says no disability claim at RRB.”
* “Per RR examiner Mary Smith (#987-6543), RRB will award disability beginning 4/25/09 since impairment meets Listing 2.03 based on evidence in file. She is sending the MER plus copies of RR award to my attention today.”
F. RRB Forms RR-5 and RL-34B
RRB uses the following forms to transmit information to SSA or to request information from SSA:
1. Form RR-5 (Request for SSA Medical Evidence)
Disability examiners from the RRB Disability Benefits Division (DBD) and RRB field office representatives use the RR-5 to request medical evidence from SSA. The RRB examiners transmit the form by fax or e-mail to the GLPSC-DPB for processing.
Upon receipt of the RR-5, the DPS take these actions:
a. CEF claims
* If there is no SSA-415 in the CEF, prepare an SSA-415 and complete Part II (SSA Reply) of the RR-5. Fax these two documents into Section B (Red) of the CEF using the MISC Jurisdictional Documents Barcode (MDF B).
* Burn a CD containing any documents pertinent to the disability determination in the CEF, including the SSA-831-C3/U3, the SSA-415, MC’s opinion/RFC, and medical and vocational evidence.
* If the CEF indicates that GLPSC-DPB previously sent a CD copy of the folder to RRB, annotate the RR-5 Part II with the date we sent the medical evidence, and return the RR-5 to RRB.
b. MDF claims
* Request the paper disability folder following local instructions.
* Prepare an SSA-415 per DI 44001.125E in this section, and file a copy of the form in the folder. Photocopy the SSA-831-C3/U3, SSA-415, MC’s opinion/RFC, and all medical and vocational evidence pertinent to the disability determination, and return the evidence package to RRB.
c. SSA claim pending
If the SSA claim is still pending in GLPSC-DPB, to coordinate the medical evidence and disability determination with RRB follow DI 44001.125B and DI 44001.125C, both in this section.
2. Form RL-34B (Reply to Social Security Administration Request for Evidence and Disability Information)
RRB uses the RL-34B to forward a copy of the RRB determination (and medical evidence, earnings information, etc.) to GLPSC-DPB upon request by the GLPSC-DPB disability specialist.
Upon receipt, the DPS take these actions:
a. CEF claims
~~Fax any new disability documents and medical evidence into the CEF according to the instructions in DI 80850.050.~~
Fax any new disability documents and medical evidence into the CEF according to the instructions in DI 81010.090.
b. MDF Claims
File the evidence from the RRB claims folder in the official MDF folder, unless the evidence is an exact duplicate of evidence already contained in the SSA claims folder.
c. Review the new evidence from RRB
If the SSA claim is still pending in GLPSC-DPB, to coordinate the disability determination with RRB follow DI 44001.125B and DI 44001.125C both in this section.
If GLPSC-DPB previously effectuated the disability determination, follow DI 44001.125C.4. in this section, and DI 28030.040 and review the RRB evidence to determine whether it has an effect on the SSA determination. Reopen the SSA claim as appropriate based on the Conditions for Reopening a Final Determination or Decision DI 27505.001.

POMS Reference

DI 44001.125: Coordination of Dual Eligibility Cases with Railroad Retirement Board (RRB)