GN 01010.140: Delayed Claims

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~~Effective Dates: 03/13/2017 - Present~~
Effective Dates: 05/08/2018 - Present
~~TN 18 (01-17)~~
TN 21 (05-18)
GN 01010.140 Delayed Claims
~~A. Policy for delayed claims~~
A. Policy to delay claims
In a delayed claim situation, we process awards for claimants for whom we have established entitlement, while other auxiliaries or survivors are pending development that cannot be resolved immediately. The delayed claim process allows us to:
~~* Adjust benefit amounts for non-delayed beneficiaries by including delayed claimant(s) in the distribution of the family maximum, and~~
~~* Hold payments for delayed claimant(s) until entitlement is established and the claim is awarded.~~
Never use the delayed claim procedure to load a non-valid application (i.e., “dummy” or fictitious claim). A proper applicant must file a valid application.
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
Delay a claim for an auxiliary or survivor when they meet all of the following:
* A proper applicant files an application for an auxiliary or survivor claimant and we are developing evidence for at least one factor of entitlement, and
* Other entitled auxiliary or survivor claimants will be overpaid 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 delay a claim for an auxiliary or survivor when they meet any of the following conditions:~~
* The claimant files a valid application, meets all factors of entitlement, and submits all required evidence. For policy on valid applications, see GN 00204.001.
* The other auxiliaries or survivors on the record are not due immediate payment.
* The family maximum is not exceeded; and, therefore, does not affect the calculation of the benefit amount (e.g., the claimant is the only auxiliary or survivor).
* The family maximum is involved, but the delayed claimant lives in the same household as the entitled claimant(s). In this situation, we recover overpaid benefits to existing auxiliaries or survivors on the record from the underpayment due to the delayed claimant.
* The only outstanding issue is representative payee development. In this case, use a suspension event or diary, as appropriate, see GN 00504.110.
~~3. Handling leads for auxiliaries and survivors~~
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 lead for Title II benefits, as defined in GN 00202.001, is a written or oral indication of potential entitlement where there is no intent to file by the party who furnishes the lead information. Document development and dispose of the lead per GN 00202.020H. If we subsequently receive an application for the auxiliary or survivor and establish entitlement, process the award as a late filer under the 202(j)(1) provision.
OR
4. Handling protective filings for auxiliaries and survivors
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.
Naming a current spouse or specifically naming or sufficiently identifying a child of the Number Holder (NH) establishes a protective filing for the auxiliary or survivor per GN 00204.010C. However, the NH or applicant who is naming the auxiliary or survivor may not always be the proper applicant to file an application for the protected individual. If the NH or applicant who is naming the auxiliary or survivor is not the proper applicant, follow instructions in GN 00204.012C. to close out the protective filing. In order to establish entitlement, a proper applicant must file a valid application for an individual with a protective filing.
2. When not to delay a claim
If the NH or applicant who is naming the spouse or child is not the proper applicant for the auxiliary or survivor and you are not able to secure a valid application, you should do all of the following:
* Send the 6-month closeout notice to the protected claimant or proper applicant. Follow procedures in GN 00204.012C.
~~* Verify that all required evidence is in the file for claimants with valid applications. Refer to GN 01010.053 on Documenting the Adjudicative Decision.~~
* Process valid applications and award benefits using the Automated 101 (A101) process and partially award the claim. Follow instructions in GN 01010.110C.1.b. on how to adjudicate partial awards manually.
* Calculate the monthly benefit amount by distributing the family maximum among the beneficiaries including the protective filer(s) with no valid application(s) (to avoid future overpayments).
* Document the claim and explain why the claim cannot be adjudicated via the Modernized Claims System (MCS) Earnings Computation (EC) process (i.e., potential auxiliary or survivor with a protective filing, but no valid application filed).
* Set a follow-up diary for the appropriate processing center (PC) on the protective filing (see GN 01010.260A.2. bullet 4). Include instructions for the PC to add a Special Message about the protective filer(s) to the Master Beneficiary Record (MBR).
* Transfer the A101 to the PC for processing.
* After six months, if the protected filer has not filed a valid application, the PC will recalculate the payments for the auxiliaries or survivors on the record. The PC will adjust benefit rates and pay any underpayments due.
Do not process an auxiliary or survivor claim as a delayed claim if it meets any of the following conditions:
* The only outstanding issue is representative payee development. Use a suspension event according to GN 00504.110, or a diary code listed in GN 01040.010, as appropriate.
* 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 how to handle a delayed claimant with a valid application, a protective filing with no valid application, and a lead~~
B. Examples of delayed claimants
~~EXAMPLE 1 – Delayed claimant with a valid application~~
Example 1 – Delayed claimant with a valid application
James Hawkins lists his son, George Hawkins, on his initial application. James’ application is ready for adjudication along with claims for his current wife and two younger children, Thomas and Catherine. George lives in a separate household with his mother, James’ ex-wife.
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 (the student verification), and
* George’s stepmother and siblings are due immediate payment, 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 – Protective filing, but no valid application filed~~
James Smith died on 11/12/2015. 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 address of Sarah’s mother.
We have been unable to reach Sarah’s mother to obtain her application. Since Martha is not a proper applicant, she cannot file a claim for Sarah. By listing Sarah on the application with the other two children, Martha establishes a protective filing for Sarah.
We send Sarah’s mother a 6-month closeout notice and store the notice in ORS. We do not input or process a “dummy” claim for Sarah. Since immediate payment is due to Martha’s children and the family maximum is involved, we must follow instructions listed in section A.4 of this chapter. We must pay Martha’s children as if Sarah had filed an application to avoid overpayments for the two entitled children.
~~EXAMPLE 3 – Lead~~
~~Same scenario as Example 2, except 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.~~
We initiate development for possible benefits for this child. If we are unable to confirm the existence of the child, we do not adjust the benefit amount when processing the award for Martha’s children. Document development and dispose of the lead per GN 00202.020H. If we subsequently receive an application for this child and establish entitlement, process the award as a late filer under the 202(j)(1) provision.
~~C. Field Office (FO) procedures for delayed claims~~
Example 2 – Delayed claimant has a protective filing, but no valid application
When processing a delayed claim, we place the claimant in delayed payment status (i.e., ledger account file (LAF) code P, PB, or PT) because we cannot release any payments until we establish all factors of entitlement. When delaying a claim, we include the delayed claimant when we calculate the distribution of the family maximum.
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.
~~To delay the claim, take all of the following actions:~~
* Load a valid application in MCS using data provided by a proper applicant.
* Develop for any outstanding evidence per instructions in GN 01010.410.
~~* Enter a decision status (DEC STAT) code of “08 Delay” on the decision input (DECI) screen in MCS.~~
* Establish a diary to follow up on the outstanding development per instructions in GN 01040.010 and GN 01010.260.
* Adjudicate the claim and transfer the claim via MCS EC, if possible. If not, process via A101.
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.
IMPORTANT: It is vital that the FO establish a control (e.g., MCS DW01 and a PC diary) so that we can process the claim to completion. These diaries serve as the only control mechanism for delayed claims. No workload management system (WMS) controls remain after we award the entitled (i.e., not delayed) beneficiaries and effectuate payment.
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.
Although a listing of claimants in delayed status is generated in the PC, it is solely to identify claimants remaining in delayed status for unreasonable amounts of time.
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.
1. Completing an A101 when the delayed claim cannot be adjudicated via the MCS EC process
F. Special considerations to process delayed claims
Follow the instructions below to establish and transfer the claim via A101:
* Input A101 per instructions in MSOM MS MCS 014.001;
* Enter “Y” in the DELAYED CLAIMAINT field of the Beneficiary Data (BENE) screen of the A101;
* Follow standard procedures for completing the A101 screens. Be sure to include the proper diary codes, notice information and explanation of development on the appropriate screens.
1. Representative fees
IMPORTANT - Include protective filer(s) in the distribution of the family maximum when calculating monthly benefit amounts (MBA) for the beneficiaries being entitled.
2. Making an evidence determination on delayed claims
After securing all required evidence, or the SSA-1045-U2 closeout period has expired, make an initial determination on entitlement. Always query the MBR and claims file before making the decision. Use the MCS DW01 and report of contact (RPOC) screens to document details of the claim.
~~a. Delayed claim awards~~
Review the evidence provided by the applicant and SSA records (i.e., MCS application), and make an initial entitlement determination for the delayed claimant. If the evidence provided supports awarding the claim, take the following actions:
* Annotate the RPOC screen in MCS to explain any changes in the PIA or entitlement data for the delayed claimant or currently entitled beneficiary;
* Document specific details of the delayed claimant’s entitlement on form SSA-5002. Include any relevant information (e.g., representative payee for a minor child, applicant lives in a separate household than the beneficiary, etc.) The SSA-5002 must also include a request to release benefits to the delayed claimant;
* Fax a copy of form SSA-5002 to CFRMS via NDRED;
* Annotate on form SSA-3601 (Claims Routing), “BA ACTION NECESSARY FOR DELAYED CLAIMANT BIC XX/BENEFIT IS NOW PAYABLE – SEE RC DATED XX/XX/XXXX IN FILE” and fax it to the appropriate PC via paperless.
~~b. Delayed claim denials~~
If after proper development, you determine that the delayed claimant is not entitled to benefits, or the applicant did not submit the requested information, deny the claim. Take all of the following actions to deny a delayed claim:
* 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 will result in a MADCAP exception, which serves as an electronic transfer of the action to a BA in the PC.
* 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) due to currently entitled beneficiaries and release the underpayment to the remaining auxiliaries or survivors on the record.
* Fax form SSA-5002 under cover of form SSA-3601 to the paperless fax number of the servicing PC for action.
* Fax a copy of form SSA-5002 to CFRMS via NDRED for documentation.
~~3. Handling situations when an MBR shows a claimant in LAF PB or PT, but a valid application was never filed~~
When an MBR shows a beneficiary in LAF PB (delayed claimant processing) or PT (delayed claimant terminated), and the individual or proper applicant alleges never having filed an application for benefits, it is an indication that an interim or “dummy” claim may have been loaded into MCS. In these situations, take the following actions:
* Determine if the individual is responding to a closeout notice, and if benefits are due him or her;
* Review all SSA records to determine if a proper applicant filed a valid application for the individual in delayed status;
* Secure a valid application if the individual is due benefits and the individual or his or her proper applicant never filed a valid application. Follow processing instructions in GN 01010.140C.2. in this section accordingly;
* If the individual is not due any benefits and no valid application was filed, contact the PC to remove the “dummy” claim from the MBR, and instruct the PC to release any underpayment due to other beneficiaries on the record.
~~D. Processing Center (PC) procedures for delayed claims~~
~~Upon receiving a diary alert, FO notification, or A101 application for a delayed claim, PC technicians should take the following actions:~~
* Review the claims file to determine if we sent an SSA-L1045-U2 for the outstanding evidence (e.g., MCS segments, ORS, CFRMS, eView, and paper folders).
* Process an award for the delayed claim if we have received all of the required evidence and can establish eligibility.
* Process a denial if we did not receive the evidence within the period stated on the SSA-L1045-U2, or if the period specified in the SSA-L1045-U2 has expired.
* Send the Action Control Record (ACR) to a benefit technical expert (BTE) or benefit authorizer (BA) for processing.
* Provide the applicable award or denial code and remind the BTE/BA to adjust benefits for other auxiliaries or survivors on the record.
~~E. Special Considerations for processing delayed claims~~
~~1. Attorney fees~~
When an attorney is involved, attorney fees may be due if the delayed claim is approved and the maximum fee has not already been paid to the attorney. If fees are due, withhold attorney fees from the delayed claimant for the same attorney fee period as the Number Holder (NH) and provide the relevant paragraphs in the notice. Include the appropriate attorney (ATY) code on the MCS DW01 per MSOM MCS 008.004. If denying or disallowing the delayed claim, withhold the fee amount from the remaining beneficiaries, pay the attorney, and provide the appropriate notices.
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 offset using the interactive computation facility (ICF) as though the new number of beneficiaries were receiving benefits for the first month we imposed or considered WC/PDB offset. See DI 52150.070 for additional guidance on how changes in family composition affect WC/PDB offset.
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 will receive a higher benefit based on the combined maximum. When denying a delayed claim, a rate increase is due to the remaining auxiliaries or survivors on the record. For guidance on simultaneous entitlement, refer to RS 00615.770.
~~4. Alien tax withholding~~
Consider the possibility of adjustments needed for alien tax withholding. Alien tax withholding may apply to foreign delayed claims. Process these cases in accordance with the current alien tax withholding procedures in GN 05010.010.
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.
~~F. References~~
~~* DI 52150.070 How Changes in Family Composition Affect WC/PDB Offset~~
~~* GN 00202.001 Leads and Inquiries~~
* GN 00202.020 Processing Leads
* GN 00204.003 Proper Applicant
* GN 00204.010 Protective Filing
* GN 00204.012 How to Close a Protective Writing
* GN 00504.110 When We May Suspend Benefits
* GN 01010.053 Documenting the Adjudicative Decision
* GN 01010.110 Partial Adjudication
* GN 01010.260 Listings, Diaries, and Notices
* GN 01010.410 Failure to Submit Essential Evidence
* GN 01040.010 Diary Codes
G. References
* GN 00204.001 Valid Application
* GN 03920.030 Representative’s Fee – Title II Past-Due Benefits
* GN 05010.010 Beneficiaries Subject to the Withholding Tax
* RS 00615.760 Benefits Under Section 202(J)(1)
* RS 00615.770 Simultaneous Entitlement of Children on More Than One SSN
* MS MCS 008.004 Development Worksheet (DW01)
* MS MCS 014.001 Automated SSA-101 Process - Overview
* SM 00619.054 LAF PB Delayed Claimant Processing Alert (Code D)
* SM 006190.060 LAF PT Delayed Terminated Claimant Processing Alert (Code J)

POMS Reference

GN 01010.140: Delayed Claims