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SI 00603.040: Special Adjudication Procedures for Disability Claims

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  • Effective Dates: 06/18/2012 - Present
  • Effective Dates: 05/14/2018 - Present
  • TN 11 (05-98)
  • SI 00603.040 Special Adjudication Procedures for Disability Claims
  • A. Procedure - Effectuating Payment
  • 1. General Rule
  • Effectuate payment when you have completed the PERC and necessary development and determined the claimant is eligible.
  • 2. Exceptions
  • a. Capability Development Pending
  • Effectuate payment priorto completing development when capability development is the only issue pending. (See GN 00502.020A.1. for a further discussion of this policy.)
  • Effectuate payment prior to completing development when capability development is the only issue pending. (See GN 00502.020A.1. for a further discussion of this policy.)
  • b. Representative Payee Development Pending
  • Effectuate payment priorto completing development when the claimant has been determined incapable and you are still developing for a representative payee when all other development is complete. Follow instructions in GN 00504.105 to pay current benefits while withholding retroactive benefits if permitted by GN 00504.105.
  • c. Administrative Law Judge (ALJ) Decision Is 60 Days Old
  • If 60 days have passed since issuance of an ALJ decision and development is not complete, effectuate payment based on documentation in file and continue to develop.
  • d. Windfall Offset Claims
  • You may limit development in certain windfall offset claims following the instructions in SI 02006.005.
  • B. Procedure - Reconsideration Allowance
  • When effectuating a favorable reconsideration determination on the issue of disability, suppress the systems generated notice per SM 01301.675. Issue a manually prepared SSA-L8455-U2 (SSI Notice of Reconsideration) for situations with eligibility for one or more months (situations 1. and 2. below). Issue a manually prepared SSA-L8456-U2 for ineligibility for all months (situation 3. below).
  • Send a copy to the claimant's representative payee, legal guardian, and/or authorized representative under cover of an SSA-L4031 (Correspondence Cover Letter).
  • 1. Eligible for All Months
  • Begin the notice with:
  • “The Disability Determination Services decided on (month/day/year) that you meet the medical requirements to receive Supplemental Security Income (SSI). Because of this, you are now eligible for SSI checks as a (type of payment). The rest of this letter explains what this means to you.”
  • Follow the format for an SSA-L8025-U2 (Notice of Award). (See NL 00802.015 for the format.)
  • 2. Eligible for Some Months
  • Begin the notice with the language shown in 1. above.
  • Follow the format for an SSA-L8025-U2. (See NL 00802.015 for the format.) Explain the periods of ineligibility.
  • 3. Ineligible for All Months
  • If the claimant is being denied because of an unappealed issue, follow the format for an SSA-L8030-U2 (Notice of Disapproved Claim). (See NL 00802.025 for the format.)
  • Begin the notice with the following language:
  • “The Disability Determinations Services decided on (month/day/year) that you meet the medical requirements to receive Supplemental Security Income (SSI). However, on reviewing your case, we found that you do not meet all of the other requirements. Therefore, we cannot pay you. The rest of this letter explains what this means to you.”
  • Give a detailed explanation of ineligibility.
  • C. Procedure - Hearing Allowance
  • 1. Review Decision
  • In hearing disability allowances, review the decision and folder to assure yourself that the decision is correct and that the folder does not contain any new or conflicting evidence. (See SI 04030.060 for policy guidance and procedures for questionable hearing decisions.)
  • (See SI 04030.050B.5. and C. for policy guidance on reopening and revising prior determinations or decisions.)
  • 2. Issue Notice
  • a. General
  • When effectuating a favorable hearing decision on the issue of disability:
  • * suppress the systems generated notice per SM 01301.675 and issue a manually prepared SSA-L8165 (Important Information) or the ALJ reversal notice on the Field Office Notice System (FONS);
  • * use the format and appeals language as explained in b. - d. below; and
  • * send a copy to the ALJ and, if applicable, to the claimant's representative payee, legal guardian, and/or authorized representative under cover of an SSA-L4031.
  • b. Eligible for All Months
  • Begin the notice with:
  • “The administrative law judge decided on ( month/day/year ) that you meet the medical requirements to receive Supplemental Security Income (SSI). Because of this, you are now eligible for SSI checks as a ( type of payment ). The rest of this letter explains what this means to you.”
  • Follow the format for an SSA-L8025-U2 (see NL 00802.015 for format) and include the appeals language used for an SSA-L8025-U2 (NL 00804.224).
  • c. Eligible for Some Months
  • Begin the notice with the language shown in b. above.
  • Follow the format for an SSA-L8025-U2. Explain the periods of ineligibility. Include the appeals language used for an SSA-L8025-U2 (NL 00804.224).
  • d. Ineligible for All Months
  • If the claimant is being denied because of an issue that was not decided on appeal, follow the format for an SSA-L8030-U2 (SSI Notice of Disapproved Claim). (See NL 00802.025 for format.)
  • Begin the notice with the following language:
  • “The administrative law judge decided on ( month/day/year ) that you meet the medical requirements to receive Supplemental Security Income (SSI). However, on reviewing your case, we found that you do not meet all of the other requirements. Therefore, we cannot pay you. The rest of this letter explains what this means to you.”
  • Give a detailed explanation of ineligibility.
  • Use the appeals language for the SSA-L8030-U2 (NL 00804.224).
  • D. Procedure - Posting Medical Data
  • 1. Introduction
  • When ALJs, the Appeals Council, or courts allow a disability, there will probably be no SSA-831-C3/U3 prepared. Since the systems record must contain the permanent disability indicator, medical diagnosis code, and medical review period, this information must be determined in another manner. The procedures which follow fill this gap.
  • 2. Title XVI Only Claims
  • NOTE: Some regions have different procedures for posting medical data in title XVI only claims. Refer to regional procedures where they exist.
  • a. Systems Input
  • For ALJ and AC decisions, use the diagnosis codes found on the Office of Disability Adjudication and Review (ODAR) Case Processing Management System (CPMS) or the diagnosis found in the medical findings of the ALJ or AC decision.
  • Follow the instructions below to make an interim entry when making the payment effectuating input for US District court cases only. For non-MSSICS claims, complete the medical data (MD) field of the 1719B (SSI Posteligibility Input) per SM 01305.900 ff. with an interim entry of N00103.
  • For claims in MSSICS, enter a non-permanent disability, a diary reason of 3 and a medical diagnosis code of 0010.
  • b. Do Not Send the Folder to the Disability Review Section (DRS)
  • It is not necessary to forward the claim folder(s) to the Disability Review Section for the diagnosis coding and medical diary information.
  • 3. Concurrent Claims
  • a. Master Beneficiary Record (MBR) Established
  • If an MBR has been established for the title II claim and a new record is being established to pay the claim, input this medical data postadjudicatively per SM 01005.140.
  • b. MBR Not Yet Established
  • If the MBR has not yet been established for the title II claim when you are about to adjudicate the title XVI claim, complete the MD field of the 1719B (SM 01305.900 ff.) with an interim entry of N00013.
  • CAUTION: Do not leave the interim data on the system as the Social Security Administration relies on the diagnosis code for statistical purposes. In addition, an incorrect medical review period may generate unnecessary alerts to the DRS.
  • E. References
  • * Interim benefits in cases of delayed final decisions, SI 02007.001 ff.
  • * Windfall offset, SI 02006.001 - SI 02006.100
  • * Fee Agreement Process, GN 03940.001 ff.
  • * Past-due benefits payable to an individual under age 18, SI 02101.010
  • * Installment payments of large past-due benefits, SI 02101.020
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