TN 20 (04-18)

A. Adjudicator’s performance quality

While there are various checks in the claims process to provide some measure of quality control, the quality of the process is substantially a reflection of the quality of the adjudicator's performance.

B. Policy on adjudicating claims

1. District Office Final Authorization (DOFA)

DOFA refers to the action taken by a claims technician at the FO level to make an adjudicative determination on a claimant’s Title II application for benefits. Most initial claims are DOFA. There are four types of DOFA exclusions per GN 01010.027D.

2. Adjudicator responsibilities

Responsibilities include, but are not limited to the following:

1. Review the claim and identify discrepancies that need development.

2. Refer potential criminal violations to the Office of the Inspector General (OIG) per GN 04111.005.

3. Identify cases where additional development may be needed for:

   • Earlier protective filing dates;

   • Protective writings for auxiliary entitlement;

   • Names of potential auxiliaries;

   • Potential anomalous claims displaying ‘ANOML’ issue on the Modernized Claims System (MCS) Development Worksheet (DW01) screen;

   • Totalization benefits;

   • Non-citizen status of the number holder (NH);

   • Allegation of disability;

   • Allegation of childcare dropout years;

   • Allegation of pre-1968 military service;

   • Supplemental Security Income (SSI) eligibility;

   • Medicare eligibility, including Medicare Qualified Government Employee (MQGE);

   • Medicaid eligibility;

   • Prisoner status;

   • Special Veterans Benefits (SVB);

   • Workers’ Compensation (WC) or Public Disability Benefits (PDB);

   • Windfall Elimination Provision (WEP) or Government Pension Offset (GPO); and

   • Indication of Removal/Deportation.

4. Review the earnings record (E/R) with the claimant for gaps or inconsistencies and develop potential earnings record inaccuracies when required by GN 01010.011.

5. Develop lag earnings only if needed for insured status, application of the annual earnings test (AET), or any other situation listed in RS 01404.005B.1.

6. Identify the presence of non-covered earnings on the E/R that may require additional development for WEP and GPO purposes and may adversely affect the claimant’s benefits.

   For the applicability of WEP and GPO, see

   • RS 00605.360 WEP Applicability; and

   • GN 02608.100 Government Pension Offset (GPO) Provision

7. Make adjustments to resolve the MCS edits or alerts including Numident corrections, and resolve conflicting Person information for internet claims (iClaim).

8. Ensure that direct deposit or direct express data is present in MCS as required by Treasury’s all-electronic payment initiative. For information on how to initiate direct deposit or direct express, see

   • GN 02402.005C. Direct Deposit Information for All Types of Interviews; and

   • GN 02402.007F. Direct Express Debit Card Program

9. Examine prior claims information relevant to the current claim using one or more of the following:

   • Cleared or archived Title II screens (e.g., MCS);

   • Cleared or archived Title XVI screens (e.g., Modernized Supplemental Security Income Claims System (MSSICS));

   • The Evidence (EVID) screen;

   • The Claims File User Interface (CFUI) per SM 08001.001;

   • Electronic View (eView) per DI 81005.005; and

   • FO records per GN 01010.032.

10. Identify possible entitlement to other benefits. Refer to

    • GN 00204.004 Considering Possible Entitlement to Retirement Insurance Benefits (RIB) when a Claimant Files an Application for Spouse’s Benefits

    • GN 00204.022 Explore Entitlement on Another Earnings Record or to Another Class of Benefits; and

    • VB 00102.001 Qualification Requirements

11. Examine the month of election (MOEL) date and option code, especially MOEL option code B when an iClaim is involved per GN 00204.041. Verify MOEL and option codes for AUXSPO claimants previously established as RIB or DIB claimants via iClaim.

12. Identify and take appropriate action to resolve prior overpayments (O/P), underpayments (U/P), and uncollected annual earnings test (AET) penalties.

13. Develop and document all issues and record evidence electronically using MCS, MSSICS, or the Evidence Screen (EVID) per GN 00301.286. Fax documents that you cannot record into MCS, MSSICS, or the EVID Screen using the Non-Disability Repository for Evidentiary Documents (NDRed) or eView, if disability is involved.

14. Make the final determination to approve, disallow, or deny entitlement or eligibility to Title II benefits, Title XVI payments, or Title VIII Special Veterans Benefits (SVB) payments.

15. Complete the appropriate decision screen or sign and date the completed adjudicative form per GN 01010.007C.5.

16. Alert the processing center (PC) of the need for post adjudicative review of relevant issues in the claim.

17. Effectuate SSA's initial determination on entitlement, usually via MCS earnings computation (EC), per GN 01010.205. If effectuation through MCS EC is not possible, prepare an award manually via an A101 or EF101 or a denial via manual adjustment, credit and award process (MADCAP) and manual adjustment credit and award data entry (MACADE).

18. Provide the proper notice to the claimant.

19. Prepare and establish PC diaries or listings per GN 01010.260.

20. Recognize when an amended award is necessary.

21. Post SVB information for Title VIII here concerning the application filed and maintain jurisdiction of the SVB claims file until the claimant establishes and proves foreign residency per VB 04001.001.

3. Obtain additional information for iClaims

If you need additional information to complete the MCS screens (e.g., the Windfall Elimination Exclusion (WEPX), or to verify lawful presence information per GN 00303.440), contact the claimant or appointed representative per GN 03910.050.

If the claimant is eligible for spouse benefits (AUXSPO), determine and obtain the type of proofs necessary to fulfill the marriage certification requirement per RS 00202.065.

For instructions on passive question mark (?) entries propagated to MCS from the iClaim application, see GN 00204.055P.

Generally, no action is necessary when a passive “?” is propagated to MCS. However, see the exception in GN 00204.055P for “Public (Y/N)” and “Religious (Y/N)” on the MCS Identification Screen (IDEN) when “A” (alleged) is propagated from iClaim for “Record of Birth Before Age 5.”

Also, see the exception for “Select U.S. Proof of Citizenship Country is U.S.” on the U.S. Citizenship Screen (CLCZ) when “4” (Development Pending) is propagated.

C. Procedure for annotating routing screens and forms

1. Alert PC of special actions

To alert the PC of any special action requests, use

• Report of Contact (RPOC) screen,

• BCF/Remarks/Notice (BCRN) screen in the A101, or

• Remarks/Notice (EFBCRN) screen in the EF101 system

Store all related information in the Claims File User Interface (CFUI) or eView, as appropriate.

2. PC action is required

Fax a written request to the PC of jurisdiction via the paperless processing system.

For instructions on how to submit actionable material to a PC, refer to the guide here.

Store all related information in the CFUI or eView, as appropriate.

3. Establish a diary

If the PC needs to establish a diary and no RPOC screens are available, annotate the printed routing screen or paper form with a detailed description of the diary reason, including the evidence code, and prepare a paper report of contact (RC) with the detailed diary rationale. Include the remarks, “PC MUST ADD DIARY” or “REMARKS - RPOC NOT AVAILABLE, SEE RC IN FILE” on the printed or paper routing form and fax it into the paperless system to the PC of jurisdiction.

4. Do not send documents to be filed at the PC

Do not mail or fax documents to the PC, “to be filed.” Use NDRed to store documents or eView if disability is involved.

D. References

• GN 01010.040 Prior Overpayments - Adjudication

• GN 01010.042 Prior Uncollected Annual Earnings Test (AET) Penalties

• GN 02607.500 Processing Claims When a Prisoner Update Processing System (PUPS) Record Exists

• NL 00603.005 General Component Responsibility for Disability Notices

• RS 02635.001 Effects of Removal (Deportation) on Retirement or Disability Beneficiaries

• VB 00102.001 Qualification Requirements