DI: Disability Insurance
A. Procedure — inquiries
If an individual contacts the FO about the Grant court case, follow the guidelines below.
1. In person
If the individual received the Grant notice and reply form (See DI 52530.095, Exhibits 1 and 2) and contacts the FO requesting review, take the individual's identifying information (i.e., name, Social Security Number (SSN), date of birth (DOB), current address and telephone number) and enter the information on the Civil Action Tracking System (CATS). (See DI 52530.006B.2. for specific CATS data entry instructions. MSOM CATS 002.001, for more information about CATS generally.)
If the individual has lost the reply form or did not receive one with the notice, consider the individual a responder. Take the individual's identifying information and enter it on CATS. See DI 52530.006B.2.
If an individual does not receive the potential class member notice but refers to the subject ALJ or mentions the Grant case, consider such a statement to be a request for assistance in completing a request for review and follow the above procedures.
NOTE: If an individual contacts any SSA office within 90 days (plus 5 days for presumptive receipt) after the date that the most recent potential class member notices are mailed to request Grant review, such an inquiry will be treated as a request for assistance in completing a request for review.
If an individual contacts SSA after the 95 day period, follow DI 52530.010C for good cause development.
2. By telephone
a. Individual received grant notice and reply form
If the individual received the Grant notice and reply form, follow DI 52530.010A.1.a.
b. Individual did not receive grant notice and relay form
If the individual did not receive the Grant notice and reply form, follow DI 52530.010A.1.b.
3. In writing
If the FO receives a written request for review under the Grant settlement agreement, follow DI 52530.010A.1.a.
B. Procedure — undeliverable notices
If an undeliverable potential class member notice is returned to the FO, return the notice to OCO at the address in DI 52530.005B.3. No other FO action is necessary.
C. Procedure — late replies
When an individual files an untimely request for review under the Grant settlement agreement, an alert is generated containing the legend “LATE RESPONDER - GOOD CAUSE DETERMINATION NECESSARY.” Take the following actions:
Develop for good cause per GN 03101.020.
Make a good cause determination.
2. Good cause established
If good cause is established in:
Title II Only and Concurrent Title II/XVI Cases
Route the good cause determination to OCO at the address in DI 52530.005B.3. for folder retrieval.
Title XVI Only Cases
Retrieve any prior title XVI folders that are in the National Records Center (SSANRC). Associate the alert/query package with all prior folder(s) and any title XVI folders which are currently in the FO. Route the good cause determination, alert/query package and all title XVI folders to OHO for screening. See DI 52530.005B.7. for the mailing address.
3. Good cause not established
If good cause is not established in:
Prepare and release the good cause denial notice (DI 52530.095G, Exhibit 7) if good cause is not established regardless of the title of the claim.
Attach a copy of the notice and any related documentation that supports the good cause denial to the alert/query package and route to:Office of Disability Adjudication and Review
Office of Appellate Operations
Attn: OARO Class Action Coordinator
5107 Leesburg Pike, Suite 701
Falls Church, VA 22041-3200
D. Procedure — folder retrieval
After receiving the alert/query package, take the following actions to retrieve the folders:
Review the queries. The alert/query package should contain a FACT, SSIRD, AR-25, OHAQ, SEQY and a SSA-831/832/833-U3 query. Obtain a full PCACS query and any other necessary case control queries in order to obtain the most current folder location(s).
Locate and retrieve all available title XVI medical folders covered by the Grant timeframes (this includes folders filed in other FOs) as well as subsequent claims. Some of the claim files may currently be pending at OHO. In such cases, route the title XVI folder to OHO at the address in DI 52530.010C.3.
NOTE: If at least one folder is in SSANRC and another folder is in the FO, OCO will send the alert/query package to SSANRC. OCO will instruct SSANRC to associate the alert/query package with any folder(s) in SSANRC and send the folder(s) to the FO to associate with any folders in the FO.
Associate the alert/query package with the retrieved folder(s) and send to OHO to screen for class member eligibility to the address in DI 52530.010C.3.
If the folder cannot be located within 120 days of the initial folder request, follow DI 52530.015C.4.
NOTE: When a folder(s) cannot be located, it is imperative that the FOs conduct a thorough search to locate the folder(s). A thorough search may eliminate the need to unnecessarily reconstruct claims.
Document all efforts to locate the folder(s) on a Court Case Folder Retrieval Worksheet (see DI 52530.095D, Exhibit 4).
E. Procedure — folder reconstruction
Take the following actions when it is determined that an individual is presumed to be a class member and the Grant claim(s) cannot be located:
Review the alert/query package.
Contact the presumed class member and obtain copies of all ALJ decisions or dismissals or Appeals Council orders from any claims in the Grant period.
Initiate reconstruction beginning with the period covered by the earliest Grant claim that cannot be located and continuing through the date of the final decision on the last Grant claim under review.
Contact the individual or his or her representative to obtain any medical sources/records for the period covered by the Grant claims that cannot be located. Use a SSA-3368-BK (Disability Report - Adult) to record this information. Also request any notices that the individual may have in his or her possession relating to the Grant period.
Complete a SSA-3367-F5 (Disability Report - Field Office) and make sure to document any closed periods of disability, prescribed periods and alleged onset dates.
If the Grant claim is a continuing disability review case, complete a SSA-454-BK (Report of Continuing Disability Interview) and obtain the appropriate medical releases.
Send all material to the Disability Determination Service (DDS) for development of medical evidence for the Grant time period(s). When development is complete, the DDS will send the file to the appropriate HO for redetermination.
Follow all other normal procedures for reconstructing claim files.
F. Procedure — subsequent applications
Generally, pending (new) claims will be processed separately from the Grant claim(s). However, in some cases, OHO may consolidate the Grant claim with the pending claim. Claims pending in the FO awaiting additional development (both medical and nonmedical) before release to the DDS and those in which the DDS has completed development will be processed according to normal procedures.
G. Procedure — miscellaneous FO actions
OHO Headquarters will screen for class membership eligibility for relief. If it is determined that the individual is a class member eligible to relief, OHO Headquarters will forward the claim via Grant route slip (See DI 52530.095H, Exhibit 8) to the appropriate Hearing Office (HO) for redetermination. The HO will schedule a new hearing, or if necessary, forward the claim file to the appropriate FO for needed development if the evidence of record is insufficient to make a redetermination. If the HO determines that the claimant is disabled during the redetermination period, the FO will update the medical history and sources of medical evidence in the file and forward the file to the DDS to secure any updated medical evidence. After the DDS has updated the medical evidence in the file, it will forward the file back to the appropriate HO for readjudication.
1. Claimant has representative
Examine the folder for current or prior indication of representation. Review SSA-1696-U4 (Appointment of Representative) correspondence or statements made by the individual.
If indication of representation is different from a prior file, ask the class member whether he or she is still represented by the same party.
Send SSA-1696-U4 to the individual for completion if:
indication of representation is found on other than SSA-1696-U4, or
class member indicates representation by someone other than the representative of record.
NOTE: If the claimant has a representative, copies of all correspondence must be sent to that representative unless the claimant either appoints a different representative or states that he/she is no longer represented by the individual. Any development must be made through the representative unless the representative states otherwise.
2. Medical development
In cases where medical development is necessary, proceed as follows:
Contact the individual and/or his representative to obtain updates of the claimant's medical history and medical sources. The time period to be developed is as follows:
Title II - From the alleged onset date in the earliest class claim through the period covered by the Grant claim(s). However, if it is determined that the claimant is disabled during the period covered by the Grant claim(s), development should occur through the date of the new hearing decision or the date of the later allowance or the date that the claimant attains full retirement age, whichever is earlier.
Title XVI - From the date of application in the earliest class claim through the period covered by the Grant claim(s). However, if it is determined that the claimant is disabled during the period covered by the Grant claim(s), development should occur through the date of the new hearing decision, or the date of the later allowance or the date that the claimant attains full retirement age, whichever is earlier.
Cessation cases - From the date of termination through the current date of adjudication (or the established date of onset of a subsequent allowance).
Use SSA-3368-BK (Disability Report) to obtain updated information for initial cases. In CDR cases, use an SSA-454-BK (Report of Continuing Disability).
Obtain SSA-827s (Authorization to Release Medical Information to the Social Security Administration) for authorizations as necessary.
Forward the folder including an updated SSA-3368-BK (Disability Report) or SSA-454-BK (Report of Continuing Disability) evidence to the DDS for development of medical evidence.
NOTE: The DDS servicing the individual's current residence is responsible for re-developing the medical evidence.
3. Work activity development
Record periods of work activity on SSA-820-F4 (Work Activity Report - Self Employed) or SSA-821-BK (Work Activity Report - Employee) to document the file.
Do not develop work activity prior to the receipt of a favorable OHO decision unless the work appears to represent substantial gainful activity (SGA) beginning either from the alleged onset date (AOD) to the present (or to the established onset date of a subsequent allowance), or the SGA apparently began within 12 months of the AOD and later stopped.
If SGA has been continuous, develop work activity. Do not prepare an SGA denial. Forward the development and Grant folder to OHO.
4. Claimant deceased
If the claimant is deceased, take the following actions:
If there is no eligible party or estate to receive any potential underpayment, or there is no Medicaid issue, annotate the alert, if available, or record this information on a SSA-5002 and send it to the OHO Class Action Coordinator. (See DI 52530.005B.7. for the address.)
Return the folder(s) to the appropriate component for filing. Do not return the folder to the Class Action Section (CAS).
5. Whereabouts unknown/failure to pursue
If the class member's whereabouts are unknown or the class member does not wish to pursue his or her request for Grant review, take the following actions:
Follow DI 11018.005.
Annotate the alert “Whereabouts Unknown” or “Failure to Pursue,” if available, or record this information on an SSA-5002 as appropriate, and forward to the OHO Class Action Coordinator at the address in DI 52530.005B.7.
Return the folder(s) to the appropriate folder storage facility for filing. Do not return the folder to CAS.