TN 49 (08-08)

A. Procedure--application process

During the initial claims interview, secure the primary application and necessary disability information. For claims entered into the Electronic Disability Collect System (EDCS), see Creating Electronic Disability Collect System (EDCS) Cases - DI 81010.020 and Certified Electronic Folder Exclusions and Limitations - DI 81010.030. For paper cases secure SSA-3368 (Disability Report - Adult), SSA-3367 (Disability Report – Field Office), SSA-3369 (Work History Report), SSA-3820 (Medical History and Disability Report, Disabled Child), and SSA-827 (Authorization for Source to Disclose Information to the Social Security Administration) etc. If any outstanding non-medical development exists, advise the claimant of the proofs needed (e.g., workers compensation, proof of age, etc.) and that SSA will re-contact the claimant later to request any outstanding evidence. Accept any proofs offered. Request the claimant to submit proof of lag earnings per RS 01404.005 – Lag Period – and Lag Earnings. For claims submitted through the Internet Disability Insurance Benefits (DIB) process, see DI 81007.005 Internet Disability Report (IDR) Intake Overview and Commonly Used Acronyms, Reports, and Terms.

NOTE: Document allegations of lag earnings which may affect insured status on the Modernized Claims Systems (MCS) EARN and WORK screens of the claims path, or in the applicable sections of the SSA-16 (Application for Disability Insurance Benefits).

B. Establishing intent to file for auxiliaries and survivors

For general policy about protective filing, see GN 00204.010. Once the protective filing date is established for auxiliaries on the NH's disability application, the filing date remains protected if the disability claim is allowed at any level of adjudication, e.g., initial, reconsideration, or hearing. Take the auxiliary applications and initiate development if the NH or claimant insist on filing. In the event of an allowance, the auxiliaries would be paid immediately. If auxiliaries are present at the interview, you may choose to take the applications and any available proofs, particularly if recontact with the auxiliaries may be difficult. Enter the proofs the NH submitted during the interview into shared process.

NOTE: In border FOs, even though these cases are not DDS jurisdiction, if auxiliaries are present, secure the applications and any proofs the NH has brought along. Do not develop further until a medical allowance is received. The NH should name all auxiliaries on the application to protect their filing date if the NH is entitled. Obtain applications for any other auxiliaries when early notification of an allowance is received.

Use the following guidelines to establish protective filing.

1. Current spouse

Naming the current spouse who is potentially entitled to spouse benefits on the NH's Title II disability application, establishes protective filing. If the current spouse is living at a different address, take the following actions:

• Enter the spouse's address (if known by the NH), in the MCS RMKS screen or SSA-16, Application for Disability Insurance Benefits.

• Complete a SSA-5002, report of contact (RPOC) with the spouse's name and address. Also, document the RPOC that Form SSA-L445 (Social Security Notice) will be sent to the potentially entitled spouse if the claim is denied.

  NOTE: If the NH does not know the spouse’s address or refuses to give you this information, no additional action is needed. If the NH’s claim is denied, the denial letter (paragraph 245) informs the NH that no benefits can be paid to auxiliaries.

2. Divorced Spouse

Since the NH is not a proper applicant for the divorced spouse, naming a potentially entitled divorced spouse on the NH’s Title II disability application is a lead, not protective filing. Process the lead according to GN 00202.020.

See Also:

GN 00205.070C, RSDI Applications – Marital Relationship Questions

GN 00204.003, Proper Applicant

3. Children

Naming a child on a Title II disability application establishes a protective filing even if the filer is not a proper applicant. The filer is not required to be the representative payee. If a child is not specifically named, but the application includes enough information to identify the child, find intent to file for that child. For example, an unborn child whose birth is referred to on the NH’s application with a statement such as: “My wife is pregnant and expecting our baby in 4 months” receives the same filing date protection as the NH. The claims representative (CR) must prepare a manual diary to control and send out the closeout notice to the NH in the month of the child’s expected birth.

References:

GN 00204.010C, Protective Filing

GN 00204.013, Third Party Non-proper Applicant and Protective Filing

RS 00203.050, Protecting Interests of Child

C. Procedure - earnings record review

Obtain most earnings record information with an Earnings Computation (EC) request or with the Informational/Certified Earnings Record System (ICERS). Review the Earnings Alert Query (EARQ); see Earnings Alerts (EARQ) Overview - SM 00355.001. Review the earnings record for insured status prior to sending the disability claim to DDS. In situations, where there is a delay in receipt of the earnings information, review it when received. If earnings development is in progress or available evidence indicates insured status is met if such development is done, initiate or continue this development while the DDS continues the medical development. If, however, insured status is not and cannot be met, recall the official folder from the DDS immediately. Development of earnings discrepancy begins as soon as the discrepancy is detected since it must be resolved regardless of the medical decision. See Resolving Earnings Discrepancies in Disability Insurance Benefits (DIB) Claims - DI 11010.050.

NOTE: If, at any point in the claims process, the FO becomes aware that the claimant is ineligible for any non-medical reason, recall the case from the DDS immediately and if appropriate, the FO does a determination, see Field Office (FO) Development and Evaluation of Apparent Technical Denials - DI 11010.040. For spell out (CEF) cases see Processing Field Office (FO) Determinations - DI 81010.140.

D. Procedure--MCS non-medical completion

Follow current non-medical completion criteria, except as noted below. If sufficient non-medical development is complete prior to the DDS decision, the FO, following existing instructions, triggers the claim to be processed through EC by doing a non-medical completion input.

Along with discretion to defer non-medical development, FOs have authority to delay payment for a short period of time (e.g., 5 working days) if deferred auxiliary development can be completed within that time.

The most efficient way to accomplish this delay is to withhold the non-medical completion. When the CR chooses to defer development, but allowance seems possible, and there are auxiliaries involved, the FO may delay or remove the non-medical completion input.

When proof of age is not critical to eligibility, as explained in Proof of Age (POA) for Disability Insurance Benefits (DIB) Claims - DI 11010.055, trigger for non-medical completion without completing proof of age development. However, evidence of citizenship or lawful presence is developed before non-medical completion input to prevent the case from being placed into suspension status. Citizenship or lawful presence is not an entitlement factor; it is required for payment of benefits. See Eligibility for Disability Insurance Benefits (DIB) or the Disability “Freeze”- DI 10105.005B. If the FO adjudicates the claim without proof of citizenship it results in a LAF S9 (NOUSCP). If the FO then reinstates the claimant via the Postentitlement Online System (POS), in most cases the input changes the LAF code from “S9” to “C” and release any retroactive benefits due with a notice that is posted to ORS (Online Retrieval System). Certain conditions shown on the MBR, (e.g., SSI Windfall Offset, Attorney Fees, etc) prevents the action from automating. In these cases POS generates an on-screen message that the case is an exclusion and is being sent to PC for manual processing. CRs should use caution when triggering a claim without proof of citizenship

NOTE: To expedite payment to the claimant, certain FO requirements are modified as explained below. These modifications do not apply to concurrent Title II/ XVI cases because the correct Title II benefit amount is needed to compute the windfall offset, reducing the amount of the retroactive Title XVI benefit by the amount of the retroactive Title II benefit. Process claims involving windfall offset after workers compensation (WC) is verified.

The following instructions apply when evaluating WC and lag earnings:

• WC development need not be completed prior to the FO non-medical completion trigger. If the actual amount of compensation has not been verified at the initial interview, the FO may trigger for non-medical completion using the claimant's allegation or the State maximum amount until proof is provided, unless lag earnings affecting the Average Current Earnings (ACE) are involved. If lag earnings are involved, request evidence per RS 01404.005 – Lag Period – and Lag Earnings. If not received, do not input non-medical completion, and do not initiate development until a favorable disability determination is reached.

• Always request the claimant to submit proof of lag earnings. If evidence is not submitted per RS 01404.005 – Lag Period – and Lag Earnings, do not include lag earnings in the FO non-medical completion trigger. This applies to cases where lag earnings affect benefit amount but not insured status. If insured status is in question, lag development is critical to eligibility and must be pursued. See Guidelines for Deferral of Non-Medical Development - DI 11010.025 and Responsibilities of Field Office (FO) and Disability Determination Services (DDS) - DI 11010.140.

E. Processing allowances

The Workload Management Information (WMI) list has a representative payee development indicator to assist in early development and faster payment when processing allowances. See Resolving Representative Payee Issues - DI 11055.215. If a claim is processed using Non Medical Completion and MCS cannot finalize the allowance, the MCS DW01 screen alerts the FO that additional evidence is needed. For example, if capability is unresolved, the DW01 shows DDSRV.

Discrepancies between the Primary Insurance Amount (PIA) on the MBR and on EC must be resolved per Special Considerations in Subsequent Claims - GN 01010.100. Review trial computations in EC. If one agrees with the MBR PIA (the guarantee), EC has correctly used the PPD.

NOTE: If the case is in DQB, hold the input for effectuation until the official folder is returned from the DQB section if the decision is on the WMI listing but the official folder is pending in a review section. For CEF cases review the EDCS Action Page or case return and the Case Review, Case Action History, and the SSA-831 in eView to verify the DQB decision.

In allowed claims, take the following action immediately upon receipt of the “AL” indicator code on the WMI list, or other alert from DDS/ Disability Quality Branch (DQB):

1. Initiate all non-medical development (including auxiliary claims).

2. For CEF cases, open the case in eView. Look at the eView Status/History to make sure the case has been transferred to the FO and is not still pending in the DQB.

   NOTE: If the case is still pending in DQB, review the Assistance Request History or the EDCS Actions page to see if FO development has been requested. Do not process the award until DQB has completed its review and the case has been transferred to the FO.

   NOTE: For non-CEF cases, do not process the award until DQB has sent the award to the FO.

3. Check eView messages, the EDCS Actions page, and SSA-831 remarks for any special notice, routing, or other processing instructions. (See EDCS Action Page -DI 81010.100 for CEF cases, or receipt of the official folder, whichever is received first.)

4. Refer to Partial Adjudication - GN 01010.110; this is a method of awarding benefits to a claimant before all development is complete. It constitutes an initial determination for all issues except those still being developed. Any partial award must be annotated accordingly in the claims file and the outstanding issue controlled until is resolved. For examples of partial adjudication situations, refer to GN 01010.120 — Common Partial Adjudication Situations.

5. If the DDS (or DQB) did not trigger payment, when the non-medical development for the NH is complete, process to payment.

6. Most auxiliary claims (including Childhood Disability Benefits (CDB) and Disabled Widow(er)s Benefits (DWBs)) can be processed as subsequent claims through Earnings Computation (EC) unless there is a processing limitation. FOs have authority to delay the claimant's payment for a short period of time (e.g. 5 working days). If deferred or not deferred auxiliary development can be completed within that time, the FO may trigger all claims through EC. If the case has not been triggered for non-medical completion, and the claimant has a future month of entitlement at the time of the DDS allowance (e.g., case is still in the waiting period), the FO delays the claimant trigger until the auxiliary development is complete. This enables all the claims to be triggered together through EC.

   NOTE: This optional procedure reduces the number of subsequent auxiliary claims requiring Manual Adjustment Credit and Award Process (MADCAP) processing. However, use this procedure only when the EC trigger of the primary and auxiliary claims are done soon enough to assure timely payment to the claimant.

F. Processing denials

The following instructions apply to denied claims:

• The DDS inputs the decision and releases the notice. Use the WMI code showing the disallowance reason when processing the denial without the official folder. When the DDS decision is made, the disability determination appears on the EDCS Action page. View the decision and take appropriate action.

  NOTE: Hold the input for effectuation until the official folder is returned from the DQB section if the decision is on the WMI listing but the official folder is pending in a review section. For CEFs, review the EDCS Action Page for case return and the Case Review, Case Action History, and the SSA-831 in eView to verify the DQB decision. Do not effectuate the decision until the case is completed by DDS or DQB.

• Follow usual procedures for denials if the case had not been triggered for non-medical completion at the time of the DDS input.

• Resolve any earnings discrepancies that may exist per Resolving Earnings Discrepancies in Disability Insurance Benefits (DIB) Claims - DI 11010.050. Process the denial through MCS and follow the usual closeout procedures for earnings corrections if proof is not submitted.

• If the official file is paper, hold the file pending appeal or disposition according to DI 11010.370 Field Offices (FO) Retaining and Shipping Paper Modular Disability Folders (MDF).