DI 12095: Appeals Processing Exhibits
TN 2 (10-06)
Exhibit 1 - Appeals Council Request for Payment Status (FRONT);
Appeals Council Request for Payment Status (BACK)
Exhibit 2 - Hearing Office Remand Memorandum
Exhibit 3 - Hearing Office Termination of Payment Continuation Memorandum
Exhibit 4 - Appeals Council Termination of Payment Continuation Memorandum
EXHIBIT 1 - APPEALS COUNCIL REQUEST FOR PAYMENTS STATUS (FRONT)
SSI Payment Status Request -- Please Expedite
Part 1. (To be completed by AC)
The case of the individual named below has been remanded to an Admisntrative Law Judge for further proceedings. A copy of the remand order is attached.
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Date of Remand Order
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Date of Prior Request for Hearing
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Date of Prior Decision of Dimissal Order
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This case was remanded to:
. HO
. Address
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. Telephone
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(Commercial with area code)
Name of Hearing Office
Manager or other contact person
Part 2. (To be completed by FO)
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Please perform SSI queries, check off the appropriate category, and take the actions indicated so that the individual may be promptly notified of his or her rights to continued payments.
(Check one)
| a. | Individual received continued payments before at the ALJ hearing level, but is not receiving payments now. HO will send Notice #1. FO will reinstate payments prospectively, will complete a redetermination and will then issue a check retroactive to the first month of nonpayment following the date of the prior decision or dismissal order shown in i.e. If the individual wants to waive continued payments, the FO will have the individual complete a written waiver, which will be sent to the HO for association with the claims folder and the FO will stop the payments. | |
| b. | Individual received continued payments before at the ALJ hearing level, and is receiving payments now. HO will send Notice #2. No FO action necessary; payments should continue uninterrupted. If the individual wants to waive continued payments, the FO will have the individual complete a written waiver, which will be sent to the HO for association with the claims folder and the FO will stop the payments. | |
| c. | Individual did not receive continued payments before at the ALJ hearing level. HO will send Notice #3. If the individual contacts the FO to request continued payments, the FO will have the individual complete a written request, which will be sent to the HO for association with the claims folder. The FO will then complete a redetermination, and will reinstate payments, effective for the month of the remand order shown in i.e. |
Please telephone the HO shown in l.f. above and send them a copy of this form as followup. For the telephone contact give the following information:
Name of individual (l.a.)
SSN (l.b.)
Date of Remand Order (l.c.)
Which category checked off in Part 2. above (a. or b. or c.)?
Name and telephone number of FO staff person making the call.
EXHIBIT 2 - HEARING OFFICE REMAND MEMORANDUM
DEPARTMENT OF HEALTH & HUMAN SERVICES
Social Security Administration
Refer to
Memorandum
| Date: | |
| From: | HO |
| Subject: | Response to Inquiry by Individual/Representative Regarding Title XVI Payment Continuation |
| To: | DO/BO Re: SSN |
| 1. | a. | Individual initiated action on (date). or |
| b. | Representative of individual initiated action on (date). . . Name of Representative |
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| 2. | a. | Do not reinstate continued payments - a final decision or dismissal order has already been issued for this remanded on . .(date) or |
| b. | The remand is still pending without a final action. The individual has been referred to your office to complete a written request for continued payments. Please perform SSI queries to determine whether or not the individual received continued payments before at the ALJ level. | |
| (1) | If yes, reinstate payments prospectively, complete a redetermination and make retroactive payments beginning for the first month of nonpayment following the date of the prior decision or (date). | |
| (2) | If not, complete a redetermination and reinstate payments effective for the month of the remand order, which was issued on (date). |
| NOTE TO DO/BO | The HO will not send a notice to the individual regarding continued payments, since the individual/representative initiated the process. |
EXHIBIT 3 - HEARING OFFICE TERMINATION OF PAYMENT CONTINUATION MEMORANDUM
DEPARTMENT OF HEALTH & HUMAN SERVICES
Social Security Administration
Refer to
Memorandum
| Date: | |
| From: | Appeals Council, CHA, |
| Subject: | Termination of Continued Disability Payments/Benefits - ACTION |
| To: | DO/BO |
| Attached is the DO copy of my decision/order of dismissal on the appeal of Title II , XVI , II/XVI (check one) |
| (Name of Individual) | SSN |
The individual in this medical cessation case had disability payments/benefits continued through the hearing level. My decision/dismissal of (date) is unfavorable; disability ceased on (date) | |
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Administrative Law Judge |
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Attachments
cc:
CF(s)
EXHIBIT 4 - APPEAL COUNCIL TERMINATION OF PAYMENT CONTINUATION MEMORANDUM
DEPARTMENT OF HEALTH & HUMAN SERVICES
Social Security Administration
Refer to
Memorandum
| Date: | |
| From: | Appeals Council, CHA, |
| Subject: | Termination of Continued Disability Payments/Benefits - ACTION |
| To: | DO/BO |
| Attached is the DO copy of my decision on the appeal of |
| SSN | |
| (Name of Individual) | Social Security Number |
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Title II , XVI , II/XVI (check one) (Check One) | |
| The ALJ issued a favorable decision, which is now being reversed. | |
| The ALJ issued a recommended decision and payments/benefits continue until the Appeals Council issues the final decision. That final decision is my decision of (date) which is unfavorable; disability ceased on (date). | |
Please terminate disability payments/benefits immediately. | |
Member, Appeals Council
Attachment
cc:
CF(s)