BASIC (08-03)

The following actions occur when a case is returned to an FO following an OHO redetermination which results in a reversal from a denial to an allowance.

A. Procedure - non-medical updates - reversals

1. Title II

1. Review all non-medical factors of entitlement.

2. Develop for suspension, deduction, and termination events, including complete workers' compensation/public disability payment history, government pension offset, work deductions, etc.

3. Obtain evidence needed for entitlement.

2. Title XVI

1. Follow SI 00603.002 if non-disability development was completed when the claim was processed initially.

2. Follow SI 00603.035 if non-disability development was deferred when the claim was processed initially.

3. Work activity

When developing work activity, consider the following:

1. Develop per DI 10501.025, DI 13010.000 and DI 23010.005 as applicable to determine if any work activity is substantial gainful activity (SGA).

2. If SGA necessitates an onset change, return the folder to the appropriate HO.

3. If SGA resumed within 12 months of established onset and continues throughout the Grant period, develop all periods of work activity, but do not prepare an SGA determination. Route the Grant folder and all work activity development to the appropriate HO.

4. If SGA does not preclude entitlement (e.g., SGA begins more than 12 months after established onset), establish 1619 status for title XVI, if applicable, and trial work period or extended period of eligibility status for title II claims.

B. Procedure - affirmations

Take the following actions if the redetermination results in an affirmation of the prior determination.

1. DO NOT input to the Modernized Claims System (MCS). Make systems input only for reversals.

2. Follow the procedures in SI 00603.002 and SI 00603.035, where applicable.

3. Take no action on the notice. (OHO prepares and releases the notices.)

4. OHO will retain the folder during the appeals period. The next level of appeal is to the Appeals Council.

5. When no appeal is filed, OHO will route the folder to the appropriate folder storage facility.

C. Procedure - processing title II benefits - reversals

Take the following actions when the Grant review results in a reversal from a denial to an allowance:

1. Computing benefits

Consider the following when computing benefits:

• Medicare premiums;

• Overpayments;

• Attorney fees;

• Offsets, including complete workers' compensation/public disability payment history, government pension offset, work deductions, etc.

2. Allowances

Title II allowances are processed as District Office Final Adjudication (DOFA).

1. MCS Earnings Computation

   • Annotate the Development Worksheet (DW01) by entering “New” in the issue field and “Grant Court Case” in the remarks field.

   • Suppress the notice and prepare a manual notice including the language shown on the SSA-865 (Disability Instruction Notice).

2. A101 or Form SSA-101-U3 (Determination of Award)

   • Enter “Grant Court Case” in the remarks field on the A101 or in item 11 of the SSA-831-C3/U3 (Disability Determination and Transmittal)

   • Prepare a manual notice and include the following language. “This determination is based on a review of your claim(s) under the settlement approved by the court in Grant v. Commissioner of Social Security.”

   • Follow attorney fee petition/agreement procedures, if applicable.

3. Routing the Case

   Route the case to OCO or the appropriate PSC. Annotate the route slip, “Grant Court Case for Payment.”

4. Form SSA-1418 (Claims Control Data)

   Prepare Form SSA-1418 for folder movement.

D. Procedure - processing title XVI payments - reversals

Take the following actions when the Grant review results in a reversal from a denial to an allowance:

1. Computing payments

Consider any overpayments and offsets when computing payments. (GN 02610.010B., GN 02610.064 and SI 02006.000)

2. Interim Assistance Reimbursement (IAR) involved

Follow SI 02003.000 when IAR is involved.

3. Initial denial posted/no record online

1. Reopen using MSSICS, if possible.

2. If MSSICS cannot be used, process a start date record with SSA-450-SI (Supplemental Security Income Data Input).

3. Show Grant in the CG field.

4. Record in T-30, T-31, or T-33 status.

Refer to SM 01005.020D.

5. Initial denial - record in pay status based on subsequent claim

1. Change the application date to agree with the application date shown on the latest SSA-831-U3/C3.

2. Show Grant in the CG field on the SSA-450-SI.

3. Process A-OTP to pay retroactive amount back to the Grant date of entitlement per SM 01901.150.

6. Notices

Prepare and release the appropriate Supplemental Security Income (SSI) notice with a copy to the representative, if applicable.

E. Procedure - processing concurrent title II/title XVI payments - reversals

Take the following actions when the Grant review results in a reversal from a denial to an allowance:

1. Process each title following DI 52530.010I and DI 52530.010J, as appropriate, making sure that any applicable offset is applied.

2. See GN 02610.005, GN 02610.010B and GN 02610.064 for offset considerations.