DI 52145.001: Verification of Proof of Workers’ Compensation/Public Disability Benefits (WC/PDB)

changes
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~~Effective Dates: 12/20/2017 - Present~~
Effective Dates: 12/26/2017 - Present
TN 1 (06-17)
DI 52145.001 Verification of Proof of Workers’ Compensation/Public Disability Benefits (WC/PDB)
The following sections provide instructions on verifying proofs of WC/PDB.
To identify and develop WC/PDB for initial claims and post-entitlement actions also review:
* DI 52140.001 FO Responsibilities for Processing WC/PDB
* DI 52140.010 PC Responsibilities for Processing WC/PDB
A. When verification is not required
Verification is not required in the following situations:
* The number holder (NH) states disability is not work-related, no known WC/PDB plan or law applies, and a check of our online systems indicates the same.
* A lump sum (LS) proration ends or periodic WC/PDB payments ceased at least one year prior to the first possible month of offset, and the NH alleges no appeal or further payments are pending.
* When a State has reduced WC/PDB under a reverse offset plan, we do not verify the reduction was actually applied on the state’s part.
See Also
DI 52105.001 for instances when we do not need to verify in reverse offset situations.
B. When to defer development of WC/PDB payments
Defer development of WC/PDB payments until the individual is found disabled. See Guidelines for Deferral of Non-Medical Development in DI 11010.025.
If deferred development applies:
* Accept the claimant’s allegation of the WC/PDB rate for coding purposes.
* If WC/PDB payments are alleged, but the claimant does not know the rate, use the applicable State Maximum. See Chart of States’ Maximum Workers’ Compensation (WC) Benefits in DI 52150.045.
* Verify the WC/PDB payments and awards as described in subsection D.
* for months up to age 62 (per 1965 Amendments), or
* age 65 (per 1981 Amendments), or
* until full retirement age (FRA) (per 2015 Amendments).
See Also
DI 52101.005 Social Security Amendments related to WC/PDB offset.
* Establish the WC/PDB diary on the DECI screen in MCS.
See instructions
* DI 52140.001H Establishing controls for WC/PDB in the FO
* DI 52155.005 Initial Claims and Appeals Requiring Diary Control for Workers’ Compensation/Public Disability Benefit (WC/PDB)
C. When verification is required
Verify
* each payment when the NH receives more than one WC/PDB payment
* medical, legal or related expenses per DI 52150.050
* all allegations of WC/PDB received or applied for in these situations:
* High average current earnings (ACE) postpones offset.
* PDB covered employment exclusion met. See Public Disability Benefits in DI 52125.000.
* Most reverse offset situations. Generally, verify the type of WC/PDB received if the State involved does reverse offset on some but not all types of WC/PDB. For additional information about verification, see Reverse Offset Plans in DI 52105.001. For WC/PDB that is subject to reverse offset, there is no need to verify the State actually applied their reduction.
* LS settlements (except as noted in DI 52145.001A.)
* Any alleged amount that exceeds the State maximum amount. See WC Maximum chart in DI 52150.045.
D. Acceptable evidence
Use the following evidence to prove WC/PDB rates:
* A signed and dated copy of the court order awarding WC/PDB payments.
* A notice or mailer insert enclosed with the WC/PDB check that explains payments.
* A WC/PDB check or check stub showing the exact periodic rate and the effective date of change.
* A WC/PDB check or stub that verifies a current ongoing rate if payment began before entitlement to DIB and continues at the same rate. CAUTION: Only accept the check or stub if it shows the gross amount.
* Obtain a signed and approved LS settlement copy that shows:
* the exact date entitlement to periodic payments ended;
* the gross amount of the LS;
* the rate at which to prorate; and
* the medical, legal, or related expenses.
References
* DI 52150.060 Prorating a Workers’ Compensation/Public Disability Benefit (WC/PDB) Lump Sum Settlement
* DI 52150.065 Complex Lump Sum (LS) Awards and Settlements
* DI 52120.000 State Specific WC Procedures in
* Accept a computer printout or copies of WC/PDB documents submitted by the WC payer in lieu of completing the SSA-1709 if they contain all the same information normally found on the SSA-1709.
* A completed SSA-1709, signed by the NH and received from the agency or the WC carrier, see DI 52145.010.
E. Unacceptable evidence
Do not accept the following evidence to prove WC/PDB rates:
* The NH’s allegation of rates and payment dates.
* SSA-1709 completed by an attorney for the worker.
* SSA-1709 signed on the back by the worker.
* An unsigned compromise or settlement agreement.
* An allegation from an attorney as to the amount of benefits received, even if on the attorney’s letterhead.
* A bank statement submitted by the NH.
* Faxed information from an attorney, per GN 00301.031A.3.
F. Sources of verification
1. NH as primary source
The NH is always the first contact for securing verification of WC/PDB. If the NH does not have verification, they should provide contact information and give SSA permission to contact the employer or insurance carrier.
* Ask the NH to provide the amount and effective date of any entitlement to, changes in, or termination of WC/PDB payments. See Acceptable Evidence in DI 52145.001D.
* Ask the NH to submit verification as soon as possible to avoid incorrect payments.
2. Attorney verification
The worker’s attorney may submit the following as verification:
* A statement of the amount of legal fees, unless it exceeds the amount provided by the award, which will require further development.
* Approved copies of award notices or settlement agreements.
3. Outside sources
Use outside sources to verify WC/PDB payments only if the worker or attorney cannot or will not provide verification. Attain verification of WC/PDB payments from any of the following sources:
* Insurance carrier;
* State WC agency, WC board, or WC commission;
* Self-insured employer;
* Courts; or
* Federal, State or local government entity established to pay PDB.
NOTE: There may be instances when a request for WC/PDB evidence by the processing center (PC) results in a request for payment of a fee prior to releasing the evidence to SSA.
PCs have no mechanism for making such payments.
If the request for payment of a fee may be an error on the part of an individual employee, speak with a supervisor to verify that payment is actually required.
If payment of a fee is required, request the WC/PDB evidence through the parallel field office (FO), and explain exactly what evidence is needed. Parallel FOs have developed well-established liaisons with various sources in their area and can obtain reports, records, and other information based on a special arrangement situation, thereby circumventing fees.
4. Online verification
Some PCs and FOs have direct online access to certain State, U.S. Territory and Federal WC records.
* Verification must include all data necessary to impose, adjust or remove offset.
* Provide advance notification (due process) if the information from the online access will cause an adverse action.
G. Developing WC/PDB proof on a post-entitlement (PE) basis
When processing a current PE action involving an incoming WC/PDB source document, technicians must re-verify the WC/PDB information on the record if the WC/PDB proof in the file is over two years old. Such situations may include:
* triennial redetermination alerts, or
* reconsideration requests, or
* recomputation of benefits cases caused by a WC/PDB change, or
* WC/PDB RETAP alerts, or
* mature WC/PDB diary alerts, or
* any other suspension, deduction or termination events involving WC/PDB, or
* subsequent auxiliary applications see DI 52140.001J., or
* report of new WC/PDB claim filed or change in rate (see DI 52140.001L.), or
* NH elects to change from DIB to RIB or RIB to DIB due to receipt or change in WC/PDB, see DI 52150.030C.
EXCEPTIONS: Technicians must re-verify the WC/PDB proof in file every year in either of the following two situations:
* State WC proof is readily available online; or
* Involves a known yearly WC/PDB COLA.
Either situation requires an adjustment action taken annually.
1. Steps to develop WC/PDB proof
* Review all existing evidence, including the paper claims file and all electronic records, for WC/PDB documentation. Electronic records include:
* Paperless Processing Center (PPC) (both In Progress and Completed),
* Modernized Claims System (MCS) segments,
* Interactive Computation Facility (ICF),
* Shared Process,
* Modernized Development Worksheet (MDW),
* Online Retrieval System (ORS),
* Certified Electronic Folder (CEF), and
* Claims File User Interface(CFUI).
* Claims File User Interface (CFUI).
When reviewing the paper file, review medical reports for pertinent information such as the WC claim number, the name of the carrier, the date of the injury.
* Determine if the current documentation in file is more than two years old. If so, develop to obtain a current re-verification of WC/PDB payments using direct contact. REMINDER: we describe two exceptions to the two-year re-verification requirement in this section.
* Develop for proof if the existing documentation in file does not cover the full offset period (from the beginning of offset through termination of offset), or the beginning of offset up to a year prior to the date of the original WC/PDB determination.
* When the latest proof indicates any of the following situations, do not re-verify documentation:
* The rate is permanent.
* The case is closed and final.
* There is no appeal.
* The state no longer pays benefits, or no further payments or awards are expected.
* When a LS “Final Decision/Final Settlement” is issued.
NOTE: In Puerto Rico and some other States, a LS award does not automatically terminate the periodic payments. Before discontinuing development, ensure that no other WC/PDB claim exists.
2. Previous proof of WC/PDB available, but unable to obtain current proof
* If the claim includes a previously-proven WC/PDB rate but we are unable to secure current verification after all attempts from all available sources have been exhausted, WC/PDB COLAs should be applied to the previous proven rate (if usually applied to the payments in question), offset should be imposed and triennial redetermination of the ACE should be applied. (Obtain COLAs by checking the individual state chapters in DI 52120.001 or DI 52135.001 or by contacting the WC/PDB payer).
* Fully document all attempts to secure proof using an SSA-5002 Report of Contact, SSA-924 Folder Documentation or a generic form in paperless (with long term retention). Store documentation in the Non-Disability Repository for Evidentiary Documentations (NDRed) or any appropriate form/screen set for permanent retention. NOTE: If an electronic folder (EF) exists, always store WC/PDB proof and documentation in the EF, not NDRed.
* Post a Special Message to the MBR explaining that a WC/PDB determination was made based on the evidence available. Include in the message where the documentation attempts are available for view and which WC/PDB rates are the result of the determination (e.g., “the rates effective MMYY are based on COLAs added to the last proven rate of $$$cc dated MMDDYY”).
NOTE: During the course of routine development for re-verification of WC/PDB proof, do not suspend benefits pending receipt of the WC/PDB information requested.
H. References
* GN 01070.305 - GN 01070.330 - Use of Direct Contact (DIRCON) and guidelines
* GN 00301.286D.and E.3a. - Electronic Evidence Documentation and Retention
* GN 00301.310 - The Non-Disability Repository for Evidentiary Documentations (NDRed) Application--Overview
* DI 81010.135 - Storing Non-Medical Evidence in the Electronic Folder (EF)
* DI 52101.005 - Social Security Amendments with Workers’ Compensation/Public Disability Benefits (WC/PDB) Offset Provisions
* DI 52150.080 - Triennial Redetermination (Redet) of Average Current Earnings (ACE)
* DI 52145.005 - Obtaining Verification/Proof from Outside Sources

POMS Reference

DI 52145.001: Verification of Proof of Workers’ Compensation/Public Disability Benefits (WC/PDB)