GN 01010: Adjudicative Policy and Standards

Effective Dates: 12/06/2011 - Present

TN 13 (11-11)

A. Introduction to adjudicative responsibilities

The adjudicator is responsible for fully developing and reviewing a claim to ensure that the claimant meets all factors of eligibility and the entitlement is processed in accordance with policy. The adjudicator must be impartial while reviewing all the factors, therefore at any time the adjudicator identifies the claimant as a family relative, friend, or discovers fraud, follow the instructions below.

B. Adjudicator responsibilities

1. Policy for handling claims involving relatives and friends

a relative (spouse, parent, child, or immediate member of the household);
a close friend;
has a personal interest; or
any other situation that could reasonably call into question the impartiality of an employee.

The employee must inform the appropriate supervisor about a situation that involves a claim that meets any of these criteria. The supervisor will

assign the claim to an employee who has no direct connection with the claimant; and
review the claim personally or direct someone else to review it before adjudication.

2. Policy for handling claims involving an SSA employee

The adjudicator and any other employee must disqualify himself or herself from acting on (i.e., interviewing, developing, adjudicating claims, or making systems inputs) any official matter that involves another SSA employee working in the same office or any former employee that previously worked for the office and is known by the adjudicator.

The employee must inform the appropriate supervisor about any situation that involves another SSA employee. The supervisor will assess the situation and take the necessary actions (e.g., direct someone else to review it before adjudication or assign the claim to another FO that has no direct connection with the claimant) at the discretion of local management.

3. Fraud awareness

The adjudicator should be alert to any indication of possible fraud by the claimant, an interpreter, a representative payee, or a third party (see GN 04110.005) by recognizing when any of the following may be at issue:

Furnishing false information or concealing facts.
Reporting fictitious earnings;
Identity misrepresentation (e.g., Identity theft); or
Forging or falsifying documents.

4. Impartiality

The adjudicator must consider claims impartially, fairly, and consistently with policy at each step of the adjudicative process. If the strict application of the Program Operations Manual System (POMS) and other instructional guidelines yields an unrealistic or inequitable result, bring such situations to Regional Office (RO)’s attention through appropriate channels.

C. Procedure for reviewing claims

1. General review

The adjudicator must examine the claims file in detail and:

Verify the identity of the claimant (see GN 00203.020).
Verify the presence of required proofs and supporting documents (see GN 00301.001).
Evaluate the information and consider possible entitlement to other benefits since a title II application is a claim for all benefits on all Social Security Numbers (SSN). See GN 00204.004 for more information. A title II application may also serve as an oral inquiry for title XVI (see SI 00601.027).
Look for omissions and resolve discrepancies between current and prior applications or forms. and;
Verify that the claimant's name, address, direct deposit, and telephone information are current and without obvious error (e.g., invalid phone number (999-999-9999), misspelling, or incorrect zip code).

2. Evaluating the evidence

The adjudicator must take the following actions:

Evaluate the evidence to determine its validity and meets evidentiary standards. Refer to GN 00301.040 for resolving any conflicts or discrepancies.
If the evidence file or information on the evidence (EVID) screen is insufficient, conflicting, or incomplete in any way, obtain additional evidence or information.
Identify unusual situations that call for reference to precedents or expert technical advice. Depending on local instructions, the adjudicator can obtain this information from the Assistant Regional Commissioner (ARC), Processing Center Operations (PCO) in the Processing Centers (PC)s, the, Management, Operations and Support (MOS) in the regional offices, or the Center for Program Support (CPS) in OCO.
Document SSA records as needed to explain facts established in evidentiary development.
Ensure that evidence supports the determination (e.g., age, dependency, relationship, and living arrangements) and that you proper annotate the information into the EVID screen or the Non-Disability Repository (NDR) system when appropriate.

NOTE: The evidence presented may be in the form of the original document, or record or a properly certified photocopy. When appropriate, include a full explanation of the reasons why necessary evidence is missing, showing the rationale used and the judgment made.

3. Clarifying the claim file

Annotate the claim file with any information that may clarify aspects of a claim, which may not be apparent to others reviewing the file.

Whenever possible, use the applicable electronic screen (e.g., Report of Contact (RPOC) or DROC, Remarks (RMKS), Benefit Continuity Remark Notice (BCRN screen) to record substantive data from the document(s) submitted.
When appropriate, use EVID to document the type of electronic or paper evidence used as proof and the applicable SSN or electronic system, screen, or field that houses the data (e.g., NMAR screen in Modernized Claim System (MCS); SP MSG in Master Beneficiary Record (MBR), etc.).
The adjudicator may document personal knowledge of events, facts, local customs, established practices of employers, and other similar information. Explain how the information relates to the evidence in file and the basis for the information.

NOTE: Once you transmit the information on the title II RPOC screen(s), you cannot alter it because the information input to the screen automatically locks. Adjudicators in the field office (FO) and PCs can subsequently add related data to the original issue or record a new issue before or after effectuation, but not after MCS archives the claim. There is however, a limit of only five total RPOC screens available per claimant (i.e., per MCS segment). See MSOM MCS 008.007 for more information.

For specific information on the title XVI DROC screen, refer to MSOM MSSICS 022.010.

4. Making a determination

The adjudicator must decide whether:

all the factors of entitlement or eligibility are met;
other factors affecting payment are established;
evidence has sufficient probative value; or
fraud is involved, see GN 04111.005.

You must prepare a special determination if a conclusion is not obvious from the evidence in the file. For instructions about special determinations, see GN 01010.360.

5. Adjudicating the claim