TN 3 (01-07)

A. Background

Most individuals who meet the requirements for EXR also meet the requirements to file a new initial claim. As explained in DI 13050.020, DI 13050.045, and DI 13050.050, the FO should conduct a thorough discussion with the individual to inform him or her of the ramifications of requesting EXR versus filing a new initial application. The individual must decide which avenue he or she wishes to pursue.

The process of requesting and processing EXR and initial claim actions is expected to be a sequential process. The individual should file under the process that will be the most advantageous and then possibly pursue the other avenue if the first approach is denied. However, an individual may wish to file for both approaches immediately.

If an individual wishes to file a request for EXR and an initial claim, explain that only one action can be processed to completion. If the individual files both and requests provisional benefits (and Medicare in the provisional period), the initial claim can only be processed to allowance if the individual withdraws the EXR request and refunds benefits and Medicare payments in accordance with normal withdrawal policy and procedures.

The DDS makes medical determinations on both the initial claim and the EXR request. If a favorable medical determination is made on both, the FO must contact the claimant for a decision on which action he or she wants to continue processing before processing either award action.

B. Definition - Filing For the Same Benefit

These are cases where an individual has an EXR request and a new initial application for the same benefit pending at the same time. This could occur at the point of intake if the individual insists on filing for both EXR and a new application on the same account. This could also occur when an individual's EXR or initial claim is denied and the individual then wishes to pursue his or her appeal rights on that issue while also pursuing the other avenue.

C. Procedure – Sending Cases to the DDS

1. Send Files to DDS

Send both the EXR request and initial application to the DDS for medical determinations in the same file, if possible. Start provisional benefits per DI 13050.025.

2. Attach an EXR Flag to the File

1. If possible, release both actions under one EXR flag. Use the flag in DI 13050.105 Exhibit 4 to denote:

   • DDS action needed on the EXR request and initial claim; and

   • DDS is to return the folder to the FO when both actions are complete.

2. If either action is already pending at the DDS, state this on the flag so that the actions can be associated within the DDS.

3. Action Escalated to Reconsideration

When reconsideration on one issue is being sent to DDS and the other issue requires a medical decision, combine the cases and escalate to the reconsideration level. Advise the DDS on the EXR Flag of the action that is needed.

4. Systems Issues

Establish these actions independently. Establish and process initial applications (and associated appeals) according to normal claim procedures. Establish and process EXR requests according to the instructions contained in this section.

D. Procedure - DDS

1. The DDS can recognize these cases by the information on the EXR folder flag (see DI 13050.090C.2.).

2. If both the application and EXR request are received in one Modular Disability Folder and the actions cannot be kept together, the DDS will photocopy material as necessary.

3. The DDS customizes receipt and clearance procedures to accommodate variations in DDS adjudicative protocols and system limitations that preclude controlling multiple actions on the same benefit. The DDS establishes manual control processes if necessary.

4. The DDS adjudicates the initial application/reconsideration following normal procedures. It adjudicates the EXR request/reconsideration following DI 28057.020.

5. The DDS faxes (or use a locally arranged expedited processing procedure) the SSA-831 for initial applications or the SSA-832/833 for EXR requests, as appropriate, to the FO when it makes a favorable medical determination.

6. The DDS returns the folder to the FO when both decisions have been made. If the EXR decision is unfavorable, the DDS places the personalized explanation inside the folder so the FO can issue the denial notice.

E. Procedure – FO - Approval of EXR and/or Initial Claim

When a favorable medical determination is received on either the initial application or the EXR request process the action according to the decision(s).

1. Approvals on Both EXR and Initial Claim

a. Procedure for Beneficiary/Recipient Choice

If a favorable medical determination has been made on both the EXR request and initial application within the same title, the individual must decide which action he or she wants processed and must withdraw the other action.

Take the following steps to reconcile.

• Contact the individual to discuss the situation. See DI 13050.020 for the various issues that the individual should consider in making this decision.

• Use follow-up timeframes and closeout procedures that follow current claims processing guidelines.

• If the claimant does not respond consider failure to cooperate and whereabouts unknown processing. See GN 01010.300, GN 01010.410, DI 11018.005, DI 13015.001 through DI 13015.025, and SI 00601.110.

• Explain that both actions cannot be processed, one must be withdrawn.

• The individual must decide which action to pursue to completion.

• Inform the claimant of the advantages and disadvantages of EXR versus an initial claim.

• Explain that an approved request to withdraw an application or EXR withdraws that action, including (provisional) Medicare/Medicaid coverage associated with the application or EXR request.

• Document the claimant's decision on a signed form SSA-795 or SSA-521, as appropriate.

• If the individual had Extended Medicare at the time EXR was requested, Extended Medicare coverage does not terminate with the withdrawal of the EXR request since the medical decision was favorable.

NOTE: Although Medicare is withdrawn on either the EXR or initial claim; Medicare and/or Medicaid will be available on the other action when it is processed. When an individual previously had Medicare and entitlement ended within 5 years (which would be EXR cases), the individual does not serve another qualifying period for Medicare. The individual should understand that Medicare coverage is not lost.

b. Repayment of Benefits

Repayment of benefits is determined under normal withdrawal processing. See GN 00206.005 and SI 00601.050.

c. Individual Chooses EXR

If the individual decides to continue with EXR, process as below.

• Before adjudication of initial claim, process the initial claim in the same manner as a withdrawal before adjudication (GN 00206.005 and SI 00601.050). Process the EXR allowance in accordance with DI 13050.060.

• After adjudication of initial claim, the initial claim must be withdrawn under normal withdrawal processing procedures, see GN 00206.100 and SI 00601.050.

• Retroactive and the current month benefits to be paid under EXR will be offset against benefits already paid under the erroneous initial claim.

• Any excess payments made under the initial claim will need to be refunded.

• The withdrawal of the claim will also withdraw Medicare entitlement that was based on that claim. Medicare premiums and outlays will need to be refunded under normal withdrawal procedures.

• Equitable relief provisions apply to Medicare SMI under EXR in the same manner they apply to other Medicare SMI entitlement, if more than 5 months of retroactive premiums are due (HI 00805.170 through HI 00805.195).

• Process the EXR allowance in accordance with DI 13050.090G.

d. Individual Chooses Initial Claim

Explain to the individual that he/she must withdraw the EXR request and that reinstated benefits (or provisional payments made (including Medicare during the provisional period) if the EXR request hasn't been finally processed) will be recovered. Take the following steps.

Obtain a withdrawal request that includes the following:

• the individual understands that approval of the withdrawal request ends provisional benefits (and Provisional Medicare/Medicaid if applicable) and requires payments made be recovered before the withdrawal is approved;

• the individual understands that he/she will have Medicare/Medicaid on the initial claim and a new Initial Enrollment Period (IEP) will also apply;

• when Medicare is involved, the withdrawal will include: “I understand that I will no longer have Medicare coverage based on my expedited reinstatement request. However I will have Medicare coverage on my initial claim. I have been advised that I will receive additional information about Medicare on my initial claim, and will receive a new Medicare enrollment package in the mail and that my new claim gives me a new initial enrollment period for Medicare, Part B, Medical insurance.” Extended Medicare, ESRD Medicare, and Aged Medicare are not affected by the withdrawal of the EXR request;

• document that the request to withdraw the EXR request is “approved” and include the name, date, and position title of the SSA employee approving the request; and

• record that the beneficiary was advised of the month of the last check and last month of Medicare coverage on the EXR request (i.e., Medicare coverage ends the last day of the following month.). Extended Medicare, ESRD Medicare, and Aged Medicare are not affected by the withdrawal of the EXR.

• Process the initial claim per DI 13050.090F.

  NOTE: Excess provisional payments are recovered under normal withdrawal procedures.

• Retroactive and current month benefits to be paid under the initial claim will be offset against provisional benefits already paid under the erroneous EXR.

• Any excess provisional payments made under the EXR will be refunded.

• Medicare entitlement issues will be handled as they would in a normal withdrawal situation.

• Equitable relief provisions apply to Medicare SMI under the initial claim in the same manner they apply to other Medicare SMI entitlement, if more than 5 month of retroactive premiums are due (HI 00805.170 through HI 00805.195).

2. DDS Approval on EXR and Initial Claim Denial

Handle the EXR allowance using the procedures in DI 13050.090G.

Handle the initial claim denial using normal procedures.

3. DDS Approval on Initial Claim and EXR Denial

Handle the initial claim allowance per DI 13050.090F.

Handle the EXR denial per DI 13050.090G.

F. Procedure - Initial Claims

Use critical payment procedures when appropriate. Initiating CPS does not reinstate Medicare coverage; it is important to expedite these cases to insure minimal disruption in Medicare coverage and monthly benefits.

1. Title II Initial Claim Awards

1. If current entitlement exists on the initial claim, do not stop provisional benefits, if still being paid. This will avoid interruption of benefits and Medicare coverage. OCO/PC will take necessary termination, recovery and entitlement actions when it processes the award.

2. Prepare the award and adjudicate the initial claim in accordance with current operational procedures (EF-101, as appropriate, due to the need to offset benefits paid).

3. Annotate the MBR with a special message, and remark on the EFBCRN screen of the EF-101, stating “EXR filed mm/dd/yy withdrawn mm/dd/yy”, if appropriate.

4. Annotate remarks regarding the need to offset appropriate provisional or reinstated payments made against initial claim benefits due.

5. Alert OCO/PC to the withdrawal, if appropriate, of the EXR and advise OCO/PC to initiate recovery of excess provisional and/or reinstated benefits paid under normal withdrawal procedures.

6. Expedite the claim to insure prompt reinstatement of Medicare benefits if they have terminated or are about to terminate.

7. Provide Medicare entitlement data in accordance with normal procedures.

8. Forward the claim to the appropriate PC of jurisdiction.

9. OCO/PC will expedite all EXR related cases.

2. Title XVI Initial Claim Awards

If necessary, terminate provisional payments in accordance with SM 01701.080. Use normal initial claim procedures for a title XVI award, taking into account provisional payments and/or reinstated payments that have been made. The same considerations cited in the title II provisions in this section apply to adjusting SSI payments made under EXR with those due based on a new SSI initial application.

3. Title II and Title XVI Initial Claim Denials

Use normal initial claim procedures for a title II or title XVI denial determination received from DDS.

G. Procedure - EXR Cases

1. Title II EXR Awards

1. If current entitlement will exist on the EXR request, do not stop current initial claim benefits. This will avoid interruption of benefits and Medicare coverage. OCO/PC will take necessary termination, recovery and entitlement actions when it processes this award.

2. Prepare the award form (EF-101) and process the EXR award. Award procedures for title II EXR are described in DI 13050.060.

3. Alert OCO/PC to the withdrawal of the initial claim with a remark on the EFBCRN screen of the EF-101 to remind it of activity needed in relation to the initial claim withdrawal, if appropriate. Advise OCO/PC regarding the need to recover any initial claim benefits paid that exceed the retroactive EXR benefits due under normal withdrawal procedures.

2. Title XVI EXR Awards

Follow procedures in DI 13050.060 and SM 01701.080.

3. Title II and Title XVI EXR Denials

Follow procedures in DI 13050.065 for title II and title XVI denials.