TN 13 (11-11)

A. Policy on PC claim screening

The role of the PC is generally limited to payment effectuation activities. However, Benefit Authorizers (BAs) usually perform limited reviews, often in conjunction with other technicians and clericals (e.g., CAs, BAs, TSTs, CCEs, CSs, etc). Therefore, any reference to BAs in this section will include these delegated personnel.

B. BA responsibility

1. Limited review

• Examine the claims transmittal screen or form (paper) for any special instructions or remarks. An example of a special remark is a reference to a report of contact (RPOC), Benefit Continuity Remarks/Notice (BCRN) screen , or paper forms SSA-795, SSA-5002, etc. in file for actions such as a special paragraph to be added to the award notice.

• Prepare any necessary diaries, listings or notices not established by the Field office (FO). You will sometimes discover the necessity for such actions when handling other alerts and exceptions.

• Perform other special post adjudicative actions (e.g., claims folder cross-reference) as indicated by the FO on the screen or paper form. For the Office of Disability Operations (ODO)'s responsibilities in reviewing non- District Office Final Authorization (DOFA) end-stage renal disease (ESRD) Medicare claims, see DI 45001.005C.

2. Lump-Sum Death Payment (LSDP) claims

• You must process or coordinate any adjustments for outstanding checks or underpayments;

• Input coding and preparing notices (indicated by the FO) in disallowances; and

• Resolve any outstanding alerts or exceptions.

C. Claims Authorizer (CA) responsibility

1. Follow the instructions below when performing a limited or full CA adjudicative review in the PC. Limited Review

Focus on resolving the problem(s) identified in the screening process. That is, review the claim’s material related to the problem identified.

Ordinarily, the CA review is limited to:

• Applicable queries (e.g., Master Beneficiary Record (MBR), Payment History Update System (PHUS), etc.);

• The latest electronic or paper report of contact (RC) in file;

• The printed transmittal screen or paper form; and

• The current claims determination action.

NOTE: Review of the decision (DECI), interface (INTE), notice (NOT2 and NOT3) screens is discretionary.

You must indicate that you performed a limited review on a District Office Final Authorization (DOFA) claim. Annotate electronically the claims file with the remark “CA/LR”, the CA's initials and the date when the review was done.

2. Full Adjudicative Review

a. Criteria for Conducting a Full Adjudicative Review

• An Automated 101 (A101) or Electronic Form 101 (EF101) is transferred to the PC but is not adjudicated;

• The A101 or EF101 routing screen does not show whether or not it is DOFA; or

• An alert or exception condition needs to be resolved.

NOTE: A full adjudicative review is not required merely because of referral from the screening operation. Do not do an unnecessary review.

b. Full Adjudicative Review due to an alert or exceptions

If you determine that, a full adjudicative review is necessary, obtain the approval of the Assistant Module Manager (AMM), or other designated personnel and provide suitable documentation. For instance, if a problem is identified that affects a basic entitlement factor (e.g., proof of age); a full adjudicative review might be deemed necessary.

D. Screening manual claims

1. General review

When reviewing manually processed awards:

• Note any remarks made by the FO on the routing screen or paper form (e.g., references to RPOC, A101, etc.) for special actions such as a dictated paragraph to be added to the award notice; and

• Prepare any necessary diaries, listings or notices not indicated by the FO.

2. EF101 Review

Review EF101 entries and correct or complete obviously incorrect, incomplete or omitted entries when possible see GN 01010.220. In questionable situations (i.e., errors other than consistency errors), refer to a CA or other appropriate technician for review of the erroneous situation.

3. Subsequent claims

Compare the prior file or MBR with the current claim. For example, checking for such things as the payment status of the number holder (NH) in the case of a subsequent auxiliary claim or for the presence of an outstanding overpayment could reveal situations where corrective action is required.

Check for intervening actions (e.g., Automatic Earnings Reappraisal Operations (AERO)) that occurred between FO adjudication and PC screening that might affect the accuracy of the claims determination input. Review a current MBR to determine if intervening actions have occurred.

4. Routing the claims

Route manually processed claims appropriately, depending on what you find when screening the claim. You may have to route a few of these claims to a CA for resolution of a particular problem.