TN 13 (11-11)

A. Policy on adjudicating claims

The adjudicator is responsible for fully developing and reviewing a claim to ensure that the claimant meets all factors of eligibility prior to adjudication. Once you complete the development, process the entitlement in accordance with policy. In addition, some claims may require additional development due to special considerations involving complex issues (e.g., third party representatives, duplicate claims, benefit conversion, Worker’s Compensation, etc.). Follow the instructions below to ensure proper claim development.

B. Procedures for representative payee claims

For instructions on determining the need for developing and selecting a representative payee, see GN 00502.001. For information regarding the Representative Payee System (RPS), see GN 00502.120 and MSOM RPS 001.001 thru MSOM RPS 006.001

1. Due Process in representative payee claims

In representative payee determinations, provide an advance notice to the incapable beneficiary and his or her representative before you finalize the determination, see GN 00503.100. Do not adjudicate (trigger) representative payee claims requiring the mailing of advance notice until the 15-day “protest” period has elapsed.

NOTE: Disability claims requiring a written advance notice are exclusions to the MCS “Auto-Initiate” (SPORT) program (see DI 11010.030E).

2. Advance notice

Release the advance notice as soon as the individual's entitlement and incapability are established and you selected a payee to minimize delay. Refer to procedures in GN 00503.120 that includes protest cases and their resolution.

3. Accrued funds

Follow the guidelines in GN 00603.070B and document the method of payment when required in representative payee claims where there are accrued funds. This situation arises more frequently in disability (DIB) claims. If we are paying the total accrued funds in a lump sum, process the claim using the Modernized Claims System (MCS) Earning Computation (EC) process. If we are withholding the accrued funds or in installments, you must exclude the claim from MCS EC, see MSOM MCSEC 001.001.

4. Notices

For complete notice instructions, see GN 00503.130.

C. Representative fee claims

See GN 03920.001 for general instructions regarding SSA's fee authorization process. The following instructions are not to be confused with “representative payee” claims. However, an attorney or non-attorney can also represent a claimant as representative payee. Representative fee cases are those in which the claimant has appointed (in writing) a representative (i.e., an attorney or a non-attorney) to act on his or her behalf in pursuing a claim or asserting a right before SSA, and the representative has not waived his or her fee.

• There are two methods for authorizing representative fees:

  1. FEE AGREEMENTS - Complete instructions are in GN 03940.001.

  2. FEE PETITIONS - Complete instructions are in GN 03930.001.

• Refer to MSOM MCS 009.009 notice 2 (NOT2) for EC input requirements to determine if you can process a case via MCS. Also, see the list of MCS exclusions and exception remarks in MSOM MCSEC 001.001, and MSOM MCSEC 001.036.

• See GN 03910.040H.7 for procedures on annotating the claims file (e.g., SSA-1128 or flag for an electronic folder). Include the appropriate remarks on a report of contact (RPOC) (e.g. “FEE AGREEMENT CASE” or “FEE PETITION CASE”).

• See GN 01070.330 for instructions regarding a representative who is unavailable or unresponsive.

NOTE: Representative fee claims are “Auto-Initiate” (sport) exclusions (see DI 11010.030E).

D. Procedures for survivor claims

Follow the instructions below when processing survivor claims.

1. Duplicate Lump Sum Death Payment (LSDP) Claims

Carefully question an individual who inquires about the LSDP to be sure that another individual has not filed or is not eligible, see RS 00210.010. Screen the Master Beneficiary Record (MBR) and the MCS record (cleared or archived), for a possible prior LSDP claim. If the applicant is entitled to the LSDP payment previously paid to another beneficiary, obtain an application using MCS, but process it via automated 101 (A101). Ensure to add the proper instructions for the processing center (PC) indicating overpayment recovery or benefit adjustment. For liability and recovery, see GN 02205.003. In situations where a LSDP award results in an adverse action, follow the instructions for adjudication of adverse claims found in GN 01010.320.

2. Earnings exemption amounts in death cases

For determining annual earnings test exempt amounts in the year of death, see RS 02501.025B.3.

3. Claims involving survivor conversion and change of payee

If, at the time of death, the number holder (NH) was payee for a spouse or child, the death termination program (TATTER) will not convert the auxiliary benefits to survivor benefits because there is no proper payee. If you select a new payee, input the change of payee action before processing the death termination action so the system converts the auxiliaries to survivors with no break in payment.

4. Concurrent widow “D” and LSDP claims

Ideally, you must process concurrent widow(er) and LSDP claims together as one action. However, if processing concurrently and Supplemental Security Income (SSI) windfall offset applies on the widow(er) award, process the LSDP separately to prevent it from the offset.

Also, if the LSDP can be paid immediately to the Living in the Same Household (LISH) spouse but the widow(er) claim will be delayed (e.g., outstanding development, MCS exclusion, etc.), process the two claims independently. Send a notice to the claimant that includes universal text indicator (UTI) “CLOR05” advising that SSA will contact them later regarding the pending widow(er)'s award. Include the remark “LSDP-ONLY PROCESSED ON (DATE)” on the Benefit Continuity Remarks/Notice (BCRN) screen when processing the widow(er) claim via A101.

NOTE: Do not consider the procedure above as partial award.

E. Procedures for other special conditions

1. Worker’s Compensation (WC)/Public Disability Benefits (PDB) claims

Input WC/PDB entries on the offset (WCCL) screen in MCS per DI 52155.001. For manually processed claims, see DI 52155.025. These entries are necessary whenever WC/PDB offset is involved or potentially involved so that you can establish the appropriate identification and control system for future action.

2. Railroad (RR) certified claims

For RR Certified claims that you can process via MCS EC, see RS 01602.000.

For manually processed claims, identify RR Certified cases by entering the proper code on the RR Certification Factor on the Benefit Continuity Factor (BECF) screen for each beneficiary whose monthly benefit are certified by the Rail Road Board (RRB).

NOTE: If the proper RR code does not propagates to the A101 screens, it must be input manually, see MSOM MCS 014.004.

3. Title XVI windfall offset

For instructions on the use of the Windfall (WF) Factor (FAC) code to withhold retroactive title II benefits pending a possible title XVI offset, see MSOM MCS 009.003 BECF and GN 02610.010.

4. Claim abatements

For instructions on claim abatement processing, see GN 01010.475. Suppress the notice if the abatement is due to death and the deceased claimant was the applicant.

CAUTION: Only denial codes 67, 68 and 96 apply to abatements (see SM 00380.040 and SM 00510.195). Do not use any other codes for an abatement action.

5. Pre-Effectuated withdrawals

Approve pre-effectuated withdrawals in the FO. However, withdrawals received after the effectuation of benefit payments are post-entitlement actions that require PC approval. If the claimant is entitled to railroad or veterans benefits, see GN 00206.025. For conditional withdrawals, see GN 00206.055.

CAUTION: Only reason codes 200 - 207 apply to withdrawals (see SM 00380.040). Do NOT use any other codes for a withdrawal.

If the NH withdraws a retirement (RIB) claim and there are unprocessed auxiliary claims still pending that will be disallowed consequently, process the disallowance for the auxiliary claimant(s) using MCS EC (see MSOM MCS 009.013);

6. Medicare-only claims with multiple disallowance codes

For Medicare-only claims when insured status (I/S) is a factor of entitlement (e.g., a BIC “T” or aged claimant - not a BIC “M), and the claimant does not meet the residency requirement, input the disallowance code for residency (i.e., 103) in the MCS Benefit Continuity Factors (BECF) screen. Additionally, use the special message (SP MSG) field in MONET to indicate the disallowance reason, see MSOM T2PE 007.001.

Although the BECF screen in MCS allows up to three disallowance codes to be input, the system does not transmit derived codes to this screen. Therefore, if the claimant subsequently attains I/S and re-files a new claim, the MBR SP MSG annotation will provide a lead about the residency issue at a quick glance during initial contact with the claimant. Otherwise, an incorrect Medicare allowance could result and an unnecessary re-contact with the claimant may be required.

For a list of denial codes and their priority, see SM 00380.090.

CAUTION: Since the MCS action should process immediately, input the SP MSG action at the same time. However, if the disallowance action is delayed and the MONET action is processed before the MBR is established, an MBR no in file “NIF” exception will be generated to the FO. This exception will not reflect the input language.