TN 2 (03-04)

A. Introduction

The routing of the claims file in claims for U.S. Totalization disability benefits will vary depending on whether the worker is, or appears to be, insured. These procedures are designed to eliminate unnecessary development when the number holder (NH) is unlikely to meet insured status requirements even taking into account his or her alleged foreign coverage. Section GN 01702.410B. provides the routing procedures based on whether the NH meets or will probably meet insured status requirements.

B. Procedure

1. NH insured based on U.S. Quarters of Coverage (QCs) alone

When the NH meets insured status requirements based on U.S. QCs alone and Totalization could not establish an earlier month of entitlement, Totalization benefits are not payable. In this case, develop and route the claim in accordance with normal procedures. If Totalization could establish an earlier month of entitlement, route the claims folder to the Office of International Operations (OIO) at the address in GN 01702.310C. after adjudication of the claim. OIO will obtain the foreign coverage record and establish an earlier month of entitlement, if applicable.

2. NH has less than 6 QCs

When the NH has fewer than 6 QCs, entitlement to Totalization benefits is not possible since the NH must have at least 6 QCs before foreign coverage can be considered (see GN 01701.110). If the applicant insists on filing, take the following actions:

• Take the appropriate application(s) but do not develop medical evidence.

• Process the insured status denial.

• Retain the claims folder in the field office (FO).

3. NH has at least 6 QCs but does not appear to be insured even when alleged foreign coverage is considered

When the NH has at least 6 QCs but, in the judgment of the FO, would not be insured even when the alleged foreign coverage is considered, take the following actions:

• Take the appropriate application(s) but do not develop medical evidence.

• Process an initial insured status denial (see GN 01702.315).

• Forward the claims folder to OIO at the address in GN 01702.310C.

• Complete the Modernized Development Worksheet (MDW) screen to show the date the claim was forwarded to OIO. Show “Totalizatio” as the ISSUE when completing the MDW screen.

Upon receipt of the claims folder, OIO will request the foreign coverage record. If, after receiving the foreign coverage record, the NH is insured, OIO will initiate medical development. If, after receiving the foreign coverage record, the NH is still not insured, OIO will send a final insured status denial.

4. NH has at least 6 QCs and appears to be insured when foreign coverage is considered

When the NH has at least 6 QCs but not enough to be insured and, in the judgment of the FO, would be insured when the foreign coverage is considered, take the following actions:

• Take the appropriate application(s).

• Process an initial insured status denial (see GN 01702.315).

• If the applicant is:

  • an SSI beneficiary, photocopy the medical evidence and disability determination. If the folder is in another FO, request copies of the medical evidence and determination from the FO housing the folder. Forward the claims folder to OIO at the address in GN 01702.310C.

  • also applying for SSI, send the SSI disability material to the DDS for a disability determination. Upon receipt of the determination, photocopy it and the medical evidence and forward the photocopies with the title II claim to OIO at the address in GN 01702.310C.

  • not an SSI beneficiary and is not applying for SSI, send the disability material to the DDS to develop medical evidence with the notation, “Totalization Claim—No Determination Necessary—See DI 23550.001.”

• Upon receipt of the medical evidence, forward the claims folder to OIO at the address in GN 01702.310C.

• Complete the MDW screen to show the date the claim was forwarded to OIO. Show “Totalizatio” as the ISSUE when completing the MDW screen.

Note: If the applicant has no sources of medical evidence, do not forward the disability material to the DDS. Forward the claim to OIO. Advise the applicant he or she will be contacted later concerning the need for medical evidence. OIO will develop medical evidence if it is determined the NH is insured after obtaining the foreign coverage record.