GN 01010: Adjudicative Policy and Standards
TN 21 (05-18)
A. Policy to delay claims
Delay an auxiliary or survivor claimant’s entitlement to benefits if no valid application or if insufficient evidence exists to adjudicate the claim and the claimant meets all of the conditions outlined in this section. Process delayed claims into delayed claimant payment status (PB) or terminated delayed claimant payment status (PT) on the Master Beneficiary Record (MBR). A Ledger Account File (LAF) code of PB or PT prevents the release of any payments to the delayed claimant until we obtain an application and establish all factors of entitlement. The delayed claim process allows us to award and pay non-delayed auxiliaries and survivors on the record who meet the conditions for entitlement. We include delayed claimants when calculating the distribution of the family maximum, but do not pay the delayed claimant(s) until they meet all factors of entitlement.
1. When to delay a claim
Process an auxiliary or survivor claim as a delayed claim if:
A proper applicant files an application for an auxiliary or survivor claimant and we are developing evidence for at least one factor of entitlement;
A potential auxiliary or survivor claimant with no valid application has a protective filing, per GN 00204.010; AND
The family maximum is involved and we would overpay other entitled auxiliary or survivor claimants if we do not include the delayed claimant in the initial benefit calculation; AND
Other entitled claimants are due immediate payment.
2. When not to delay a claim
Do not process an auxiliary or survivor claim as a delayed claim if it meets any of the following conditions:
We establish a lead for the potential claimant rather than a protective filing. Document development and dispose of the lead per GN 00202.020H.
B. Examples of delayed claimants
Example 1 – Delayed claimant with a valid application
James lists his son, George , on his initial application. James’ application is ready for adjudication along with the claims for his wife and two younger children. George lives in a separate household with his mother.
We are able to reach George’s mother to obtain a valid application for benefits. However, George is missing the student verification to prove he is eligible for benefits, and it is going to take weeks before he is able to provide us the proof. Therefore, process George as a delayed claimant because:
George’s mother is the proper applicant and filed a valid application, and
We are developing at least one factor of entitlement for George (student verification), and
An immediate payment is due to the other auxiliaries (George’s stepmother and siblings), and
We adjust the benefit amounts of the other entitled auxiliaries because of George’s entitlement (since the family maximum is involved).
Example 2 – Delayed claimant has a protective filing, but no valid application
James died on 11/12/15. His ex-wife, Martha, filed for benefits for two children. She also informed us of a third child, Sarah, living in another state with her mother. She provided us with the contact information of Sarah’s mother.
We have been unable to reach Sarah’s mother to obtain her application. By listing Sarah on the application with the other two children, Martha establishes a protective filing for Sarah.
Since we have a protective filing for Sarah, immediate payment is due to Martha’s children, and the family maximum is involved, pay Martha’s children as if Sarah had filed an application to avoid overpayments for the two entitled children. Establish and process a delayed claim in MCS for Sarah using placeholder information. Send Sarah’s mother a 6-month closeout notice and store the notice in ORS.
Example 3 – Claimant is a lead
Same scenario as Example 2, except that Martha only thinks there is another child, and she cannot provide enough information to identify the child. This is a lead, not a protective filing.
Initiate development for possible benefits for this child. If you are unable to confirm the existence of the child, then do not adjust the benefit amount when processing the award for Martha and the two other children. Document the development and dispose of the lead per GN 00202.020H. If we subsequently receive an application for this child and we establish entitlement, process the award as a late filer under the 202(j)(1) provision. For processing late filings, see RS 00615.760.
C. Procedure to establish delayed claims
There are two categories of delayed claims. The procedure for processing delayed claims depends on whether or not the auxiliary or survivor claimant or his or her proper applicant filed a valid application. Follow these instructions to establish a delayed claim.
1. To delay the claim with a valid application, take the following steps
Establish an application in the Modernized Claims System (MCS) with data provided by the proper applicant.
Enter a decision status (DEC STAT) code of “08 DELAY” on the Decision Input screen (DECI) in MCS.
Enter the applicable diary code on the DECI screen in MCS to diary for the outstanding evidence, per GN 01040.010, and explain the development that is pending in the diary reason field on the Diary Screen (DIAR) in MCS.
Establish a diary date of 60 days, or later, if you expect development to last more than 60 days. For additional information on the DIAR Screen, see MS MCS 009.015.
Add paragraph “ENT066” on the Notice 3 Screen (NOT3) in MCS, see NL 00720.145 and MS MCS 009.010.
Process the claim through MCS Earnings Computation (EC).
If the claim will not process through EC, see GN 01010.140C.3. in this section.
2. To delay the claim with no valid application and a protective filing only, take the following steps
Establish an application in MCS with available information provided by the NH or other applicants, when possible. Use actual or alleged data. If the claimant’s SSN is unknown, key in “?” or “NONE” in the claimant SSN (CL SSN) field on the MCS Systems Menu Screen (MENU).
Entering a “?” in the CL SSN field on the MCS MENU Screen will generate the Claimant SSN Unknown (CLUNK) issue on the DW01 or DW02 Screen. Resolve the issue by following the Management Override (MOVR) instructions found in MS MCS 011.010.
Input placeholder information to advance through the MCS screens. Do not use a fictitious Social Security Number. Use the Alpha-Index Query (ALPH) to locate an auxiliary or survivor’s SSN; for additional information see MS QUERIES 003.003.
Enter a “?” or “NONE” in the claimant SSN field on the RSDHI Claims Application Screen (APPL) in MCS, if the claimant’s SSN is unknown. For additional information on the APPL Screen, see MS MCS 005.009.
Receipt in the application issue in the receipt field (REC) on the MCS Development Worksheet Screen (DW01). Do not enter “X’s” in the application issue receipt field.
Enter “X’s” in the attestation issue (ATTEST) receipt field (REC) on the DW01. Do not enter the date in the attestation issue (ATTEST) receipt field (REC).
Add the following remark to the Remarks Screen (RMKS) in the MCS application screen path, “THIS IS NOT A VALID APPLICATION. A PROTECTIVE FILING DATE OF MM/DD/YYYY HAS BEEN ESTABLISHED FOR (NAME OF CLAIMANT). NO CLAIM HAS BEEN FILED AND NO INFORMATION HAS BEEN ATTESTED TO. 6 MONTH CLOSEOUT NOTICE SENT ON MM/DD/YYYY.” Store a copy of the claim in the Online Retrieval System (ORS) via the Print and Store Screen (PRST), see MS MCS 008.001.
Enter a decision status (DEC STAT) code of “08 DELAY” on the Decision Input (DECI) screen in MCS.
Enter diary code “023”on the DECI screen in MCS to indicate we are developing for an auxiliary or survivor claim, and explain that development is pending for a delayed claimant’s application in the diary reason field on the Diary (DIAR) screen in MCS.
Establish a diary date of 6 months to correspond with the date on the protective filing closeout notice stored in ORS, see GN 01010.140C.4.b. in this section.
Consider the need for a payee, per GN 00502.070, and enter payee information on the Notice 1 Screen (NOT1). If the payee is unknown, key “UNKNOWN” in the applicant name field on the APPL Screen in MCS.
Complete the representative payee fields on the NOT1 Screen in MCS. If the payee is unknown, key “?” for the payee name and applicant SSN on the NOT1 Screen.
Suppress the notice by entering “Y” (YES) in the SUPPRESS (Y/N) field on the MCS Notice 3 Screen (NOT3).
Process the claim through MCS Earnings Computation (EC).
If the claim will not clear through EC, see GN 01010.140C.3. in this section.
Add a Special Message to the MBR via Miscellaneous Online Edited Transactions (MONET), once the MBR is established, stating, “BIC XX PROTECTIVE FILING ONLY (MM/DD/YYYY). OBTAIN VALID APPLICATION. CLOSEOUT SENT MM/DD/YYYY”
3. To process an Automated 101 (A101)
Complete the A101 following instructions in MS MCS 014.001;
Enter “Y” in the DELAYED CLAIMAINT field on the Beneficiary Data Screen (BENE) of the A101;
Include the delayed auxiliary or survivor claimant(s) on the Monthly Benefits Screen (MBEN) when you compute the benefit amounts, if the family maximum is involved;
Enter “BIC [insert BIC] – Delayed” in the REMARKS field of the Beneficiary Claim Remarks Notice Screen (BCRN). Specify in the remarks if the delayed claim is a valid application or no valid application with a protective filing only;
Enter the diary code(s) in the REMARKS field on the BCRN screen; and
Enter notice information in the NOTICE field of the BCRN screen for claims with a valid application. Suppress the notice for delayed claims with no valid application based on a protective filing only.
4. Field Office (FO) actions after processing the delayed claim
a. After you process the delayed claim with a valid application
Establish a Modernized Development Worksheet (MDW) to your FO to monitor the delayed claim until you process it to completion.
Set a tickle of 15 days for the outstanding evidence (i.e., proof of age, medical decision, etc.) unless the expected completion date is later.
Follow-up 15 days after the claimant fails to respond to the initial development request. When the claimant fails to submit essential evidence, see GN 01010.410.
b. After you process the delayed claim with no valid application and a protective filing only
Determine if we sent a protective filing closeout notice or if other evidence is available in our records that we disposed of the protective filing or writing (e.g., special messages on the MBR, ORS, CFUI, eView, MCS segments, and paper folders).
If we have not sent a closeout notice, prepare a closeout notice in the Document Processing System (DPS) and send the notice to the delayed claimant, his or her payee, or the applicant who listed the claimant per GN 00204.012C. Store the notice in ORS. If the individual’s address is unknown, follow the instructions in GN 00204.012F.2.
Add a closeout issue of “T2CO” on the DW01 or DW02 Screen and receipt in the closeout issue with the date we sent the closeout. Enter the name of the delayed claimant to whom we sent the closeout in the REMARKS field corresponding to the T2CO issue on the MCS DW01 or DW02 Screen.
Establish an MDW to your FO to monitor for receipt of the application.
Set a tickle of 6 months to correspond with the closeout date on the 6-month closeout notice.
When the 6-month closeout period expires and we have not received the application, document the Report of Contact Screen (RPOC) in MCS to note that we did not receive a valid application from the protected auxiliary or survivor. If MCS is archived, prepare a Report of Contact (Form SSA-5002) explaining that we did not receive a valid application from the protected auxiliary or survivor claimant and fax it into the CFUI.
Fax the prepared SSA-5002 to the PC via the Paperless barcoding system. Include the necessary disallowance data shown in the example in SM 00842.019E.8. and instruct the PC to:
Recalculate the monthly benefit amounts for the remaining beneficiaries on the record;
Release any underpayment due to the remaining beneficiaries on the record;
Send the Action Control Record (ACR) to the benefit authorizer (BA) to process a disallowance; and
Provide the denial code and information needed to complete the Beneficiary Denial/Disallowance Screen (DNY) in MACADE. Refer for details SM 00842.019E.8.
D. PC receives a delayed claimant processing alert
The Regular Transcript Attainment and Selection Pass Alerts (RETAP) system produces the LAF PB delayed claimant processing alert or the LAF PT delayed terminated claimant processing alert when a beneficiary is located on the MBR who is in LAF PB or PT and whose Date of Entitlement Current (DOEC) is greater than 6 months before the current month. Upon receiving a LAF PB or PT Delayed Claimant Processing Alert, PC technicians take the following actions:
Determine if we closed out the protective filing or writing (e.g., special messages on the MBR, Online Retrieval System (ORS), Claims File User Interface (CFUI), eView, MCS segments, and paper folders.)
If there is no protective filing closeout, request assistance from the servicing field office (FO) to obtain a valid application, including obtaining a payee application for minor children.
If the PB/PT processing alert is received on a claim with a valid application, request assistance from the servicing FO to obtain the required evidence.
If there is a protective filing closeout, process a disallowance if we did not receive the application within the period stated in the protective filing closeout notice.
Suppress any disallowance notice if we did not receive a valid application within the 6-month closeout period.
Send the ACR to the BA to process a disallowance.
Provide the denial code and information needed to complete the DNY Screen in MACADE. Remind the BA to adjust benefits for other auxiliaries or survivors on the record.
E. Process the delayed claim
After you secure all applications, developments, and required proofs for the delayed claim, make an initial determination on entitlement. If the delayed claim was established based on “placeholder” information, the delayed claimant must file an application and attest to the information in the application.
Always query the MBR and ORS before making a determination. The LAF code on the MBR for the delayed claimant is PB or PT. If an MBR is not established, make an initial determination on entitlement based on information available on the MCS Development Worksheet (DW01/DW02) and Worksheet Remarks screens (DW04).
1. Delayed claim awards
When the MBR shows a beneficiary in LAF PB or PT, it is an indication that an SSA technician adjudicated a delayed claim. Review the records (i.e. MCS application) and make an initial entitlement determination for the delayed claimant. Review ORS to determine if the delayed claim was established using “placeholder” information due to a protective filing.
If we already secured a valid application from a proper applicant and there are no changes in the primary insurance amount (PIA), entitlement data for the delayed claimant or any other currently entitled beneficiary, do not load a new claim in MCS or prepare an A101.
Annotate the Report of Contact (RPOC) screen in MCS to explain that there are no changes in the PIA or entitlement data for delayed claimant or currently entitled beneficiary.
If the RPOC screen in MCS is not available, input a Special Message on the MBR and explain that there are no changes in the PIA or entitlement data for delayed claimant or currently entitled beneficiary.
Document the specific details of the delayed claimant’s entitlement on form SSA-5002. Include any minor data change(s) and information regarding the representative payee for a minor child, if applicable.
The claims specialist (CS) or claims technical expert (CTE) signs form SSA-5002.
Fax a copy of form SSA-5002 to the CFUI.
Fax a request including the SSA-5002 to the PC using the Paperless barcode system. Select “Claim Delayed-Delayed Claims” from the paperless barcode dropdown options. Annotate the paperless barcode coversheet remarks with, “BA ACTION REQ/BENEFIT PAYABLE-SEE RPOC IN FILE.”
Manually clear (MANCLR) any pending application in MCS or eRPS to your office.
If we already secured a valid application from a proper applicant and there are changes in the PIA, entitlement data for the delayed claimant or any other currently entitled beneficiary:
Load the claim in MCS and process the claim via an A101.
If an A101 exclusion exists, MANCLR the MCS claim and process via an EF101.
NOTE: If we initially established an application using placeholder information for the delayed claimant, secure an application from a proper applicant before you make an initial determination. Load the claim in MCS and process the claim via an A101. Update the electronic Representative Payee System (eRPS) with the correct payee information.
2. Delayed claim denials
After proper development, if you determine that the delayed claimant is not entitled to benefits or we did not receive an application, then take all of the following actions.
Manually clear (MANCLR) any pending application in MCS or eRPS for the delayed claimant; and
Input a manual adjustment credit and award data entry (MACADE) denial with the applicable denial code. Use miscellaneous code “064” if no other code applies. The MACADE denial results in a MADCAP exception, which serves as an electronic transfer of the action to a Benefit Authorizer (BA) in the Processing Center (PC); and
Prepare and release a denial notice to delayed claimants who filed a valid application. Do not issue a denial notice to delayed claimants with no valid application who we established using “placeholder” information; and
Prepare and sign form SSA-5002 to document the basis for denying the delayed claim. Include instructions for the PC to adjust the monthly benefit amount (MBA) for currently entitled beneficiaries; and
Fax form SSA-5002 under cover of form SSA-3601 to the PC via the Paperless barcoding system; and
Fax a copy of form SSA-5002 to the CFUI via NDRed for retention purposes.
F. Special considerations to process delayed claims
1. Representative fees
When we process an allowance for a delayed claim and a representative is involved, consider whether the maximum fee has already been authorized to the representative. If the maximum fee has not already been authorized, and the auxiliary beneficiary’s effective filing date is the same as the primary claimant and the auxiliary was not individually represented, calculate past-due benefits for the auxiliary based on the effectuation date of the primary beneficiary, refer to GN 03920.035. Ensure that we send the proper notice to the claimant and representative containing the relevant paragraphs. Include the appropriate code on the MCS DW01 Screen per MS MCS 008.004. If denying the delayed claim, authorize the appropriate fee amount from the remaining beneficiaries and provide the applicable notices.
2. Workers’ compensation (WC) and public disability benefits (PDB)
The addition or deletion of a beneficiary may cause the total family benefits (TFB) to become the applicable limit for offset or cease to be the applicable limit for offset. When the family composition changes, re-compute the offset. Use the interactive computation facility (ICF) as though the new number of beneficiaries were established and entitled for the first month we imposed or considered WC/PDB offset. For additional guidance on how changes in family composition affect WC/PDB offset, see DI 52150.070.
3. Simultaneous entitlement
Consider a combined family maximum whenever a simultaneously entitled child or other beneficiary receives a higher benefit based on the combined maximum. If combined maximums apply and you deny a delayed claim, consider whether a rate increase is due to the remaining auxiliaries or survivors on the record.
GN 00204.001 Valid Application
GN 03920.030 Representative’s Fee – Title II Past-Due Benefits
RS 00615.770 Simultaneous Entitlement of Children on More Than One SSN
SM 00619.054 LAF PB Delayed Claimant Processing Alert (Code D)
SM 006190.060 LAF PT Delayed Terminated Claimant Processing Alert (Code J)