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GN 01010: Adjudicative Policy and Standards

Effective Dates: 01/05/2017 - Present

TN 17 (01-17)

A. Policy on documenting the adjudicative decision

An improperly documented adjudicative decision can result in an erroneous adjudicative decision. You can only use material documented in the claims file (for example, Non Disability Repository (NDR) or the electronic Disability (eDIB) folder), or on the Evidence (EVID) screen, as evidence to establish a fact.

Failure to record necessary information results in subsequent development required to obtain the missing information that supports the adjudicative decision. Documentation consists of two parts:

  1. Evidence and rationale to support an adjudicative decision; and

  2. A “signed” adjudicative screen or a paper form by a person with adjudicative authority as defined in GN 01010.001.

B. Procedure for documenting the adjudicative decisions

1. Documenting the adjudicative decision for all claim types

All adjudicative decisions must reflect the documented facts for the entitlement. We cannot establish an element of entitlement or a factor affecting payment if you do not properly document it based on the adjudicative policy and standards in GN 01010.001 and evidentiary standards in GN 00301.001. Use the following list as a guideline for supporting the adjudicative decision:

  • Document personal observations during the interview if they are material to the claim;

  • Document facts that support the decision even when the adjudicator has personal knowledge about a claim;

  • Use the Report of Contact (RPOC) screen in Modernized Claims System (MCS) when possible. For preparing special determinations see GN 01010.360;

  • Follow the legal precedent instructions in GN 01010.810 when applicable;

  • Document the Title II claims files with a reference to regionally issued instructions. These instructions supplement regular POMS guidelines and in some instances may support the adjudicative decision;

    NOTE: Since the same region reviews the Title XVI claims within their jurisdiction, documentation of regionally issued instructions is not usually necessary.

  • Document all efforts to obtain evidence. If you make an unfavorable decision due to lack of evidence to support the claimant’s allegations, the file must include documentation to support your determination.

2. Documenting the adjudicative decision for concurrent claims

The following procedures explain the extent of documentation you need when you process concurrent or related claims simultaneously, one shortly after the other, or at completely different times. Regardless of the claims file jurisdiction or whether the Social Security numbers (SSNs) are the same, these instructions apply to all claim types under the following titles:

  • Title II Retirement, Survivors, and Disability Insurance (RSDI)

  • Title XVI Supplemental Security Income (SSI); and

  • Title XVIII Medicare (hospital or medical).

a. Related claims

If you process the claim electronically, record the evidence on the appropriate MCS screen(s) (for example, Remarks (RMKS), Number Holder Marriage (NMAR), RPOC). For paper claim(s):

  • Maintain required evidentiary documents in one of the claims files and annotate in the REMARK section of the application (or on an SSA-5002 (Report of Contact form) that the needed evidence is in the other claim file; and

  • Include the SSN and the system, screen or field which houses the evidentiary information (for example, NMAR screen in MCS; Evidence (EVID) screen in Shared Processes).

Fully support the adjudicative decision associated with each claim by:

  • Recording readily available or retrievable electronic documentation in one claim file with sufficient cross-references to the information in the related file;

  • Documenting the EVID screen for both claims files with sufficient cross-references to the applicable information. For Electronic Evidence Documentation see GN 00301.286 and for instructions on completing the EVID screen see MSOM EVID 001.001.

  • Preparing special determinations for auxiliary spouses (AUXSPO) claims with the marital information or any other questionable issues needing clarification

NOTE: For instructions for when you can use information on the SSA systems screens as acceptable proof of a previously established entitlement factor, see GN 01010.038.

b. Entitlement or non- entitlement on another SSN

Document a claimant's non-entitlement or technical entitlement as a spouse by comparing the claimant earnings record (E/R) with other E/Rs and Master Beneficiary Records (MBRs) in the following situations:

  • Comparison between claims

    Determine if the claimant's own Primary Insurance Amounts (PIA) equals or exceeds half of the spouse's PIA. If the claimant's own PIA precludes entitlement to spouse benefits, document the claimant's file (for example, RPOC screen) with the comparison results. Indicate which source (for example, MBR or Earnings Computation screens) you used to derive the spouse PIA or Monthly Benefit Amount (MBA).

  • Deemed filing

    When a claimant is eligible for Retirement Insurance Benefits (RIB) and spouse’s benefits, he or she may be required to file for both benefits based on the rules for deemed filing. Therefore, document discussions about multiple filing and the adjudicative decisions of both applications (for example, application for RIB and divorced spouse’s benefits taken but we deny the divorced spouse’s claim for failure to provide evidence) on the RPOC screen in MCS. For information about the rules for deemed filing refer to GN 00204.035.

    IMPORTANT: Deemed filing does not apply to Widow(er)’s Insurance Benefits.

  • Restricting the scope of the application

    The following applicants can restrict the scope of an application if they are age 60 or older:

    1. Widow(er), and

    2. Surviving divorced spouse.

    The following applicants for RIB or spouse’s benefits can restrict the scope of an application if they are FRA or older and were born prior to January 2, 1954:

    1. Number Holder (NH),

    2. Spouse,

    3. Divorced spouse, and

    4. Independently entitled divorced spouse.

    These applicants may choose the benefit he or she wants to receive now and defer entitlement to the other benefit. For example, the applicant can defer filing for his or her unreduced RIB to earn delayed retirement credits (DRC) while receiving spouse’s benefits. You must explain the available options to the claimant and document his or her decision per GN 00204.020.

  • Comparison of primary insurance amounts (PIA) for survivor claims

    Determine if the claimant's own RIB equals or exceeds the applicable deceased NH's PIA (for example, death PIA, Deemed PIA or WINDEX PIA) and include the number of DRCs used in the file documentation. For the process on computing a widow(er)’s benefit with DRCs see RS 00615.706.

  • Lag earnings

    Consider whether lag earnings on the other SSN are material to determining the claimant's auxiliary or survivor entitlement on that record. Note that you must consider lag earnings for the NH on this SSN following the instructions in GN 01010.011 and RS 01404.005.

C. Signature requirements

The adjudicator must properly sign all adjudicative decisions (electronic or paper) before final processing. The adjudicator's PIN serves as the electronic signature when he or she establishes, adjudicates, or effectuates a claim, via MCS, the Automated 101 (A101), the Electronic Form 101 (EF101) process or the applicable adjudicative direct input screens. For instructions about signatures on adjudicative forms, see GN 01010.275.

Properly store any related paper documentation or adjudicative decisions in the Claims File Records Management System (CRFMS).

D. References

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