BASIC (12-01)

A. Policy

Section 221(i) of the Social Security Act, as amended, requires a periodic continuing eligibility review for disabled beneficiaries at least every 3 years except where a finding has been made that such disability is permanent. Reviews of cases involving permanent disability are made at such times as the Commissioner determines appropriate. This review is called a continuing disability review (CDR).

Section 1614(a)(3) of the Act provides for periodic review of eligibility for Supplemental Security Income, based on disability or blindness. These reviews are either called CDRs or, in the case of the age 18 review, a redetermination.

B. Process

1. Mailer Form SSA-455 Disability Update Report

Form SSA-455 is a self-help mailer form designed to solicit key information from disabled beneficiaries about their medical conditions and recent treatment for same. "Recent" usually means within the last 2 years. The mailer form also asks for information about recent education or training, and recent attempts to (return to) work.

2. Who is Sent a Mailer Form

The mailer form is usually sent to beneficiaries who have a low probability of medical improvement were a full CDR done. Probability is determined on the basis of statistical analyses (called profiling ) of on-line beneficiary data. Data considered includes, but is not limited to: age; impairment(s); length of time in benefit status; basis (regulation-basis code and listing number, if applicable) for the initial determination; data on any prior CDR(s); recent earnings. Each case is assigned a score that reflects the results of the statistical analyses.

The cases with scores indicative of a low probability of medical improvement are often described simply as “LOWs”. A LOW profile generally equates with the same adverse medical and/or vocational factors that result in a DDS CDR determination that disability continues. However, because the mailer form process is a folderless analysis, it is dependent on on-line data to document those factors. To avoid incorrect selection, when data are not available or the data are inconsistent, the resulting profile score will be higher, and selection of the case for mailer form processing may not be possible.

In some instances, other groups of beneficiaries may be sent mailers. These groups are variously referred to as “HIGHs” or “MEDIUMs”, when differentiating between the “scores” of those who profile as potentially productive CDRs, or as a combined group may be referred to as “non-LOWs” or “not-LOWs”.

3. Mailer Form Processing Outcomes

Depending on the information received with the completed mailer, referral for a full CDR is initiated (commonly referred to as a “DO CDR ” action). This occurs in about 2.5% of the mailer forms received for processing. Much more frequently, a deferral action is made to defer doing a full CDR. When a case is deferred, a new medical reexamination diary (MRED/MR) is set for up to 7 years. The medical diary reason (MDR) at the time the case was selected for mailer form processing is used to determine how long the new MRED/MR should be. If there is no MDR value, a default value of “3” is established for the MDR and the MRED/MR is reset for 36 months/3 years.

4. Mailer Form Processing is Not a CDR

The action to defer a CDR or refer a mailer case for a CDR is not a CDR and is not an initial determination subject to administrative review, nor is a new comparison point decision (CPD) established.

5. The Scannable Mailer Form

An optically scannable self-mailer variation of the mailer form, the SSA-455-OCR-SM, is most frequently used. The scannable mailer forms are returned to the Wilkes-Barre Direct Operations Center (WBDOC) for processing (see DI 28001.003E.). Since October 1995, the scannable mailer form SSA-455-OCR-SM is used most of the time, although the standard “hard paper” form may be used by the processing centers (PCs) or field offices (FOs).

6. Question Sequencing on the Mailer Forms

a. General

The responses to the questions on the mailer form, as well as information and evidence submitted with the form, may be of use to the DDS adjudicator in the event the case is subsequently referred to the DDS for a full medical CDR.

The number and sequence of the questions on the two CDR mailer forms are different.

b. Questions on the SSA-455 "Hard Paper" Mailer Form

The hard paper form has a fixed report period format (the last 2 years). The questions were taken from the version of form SSA-454-BK, Report of Continuing Disability Interview, then in use, and were then modified to fit a self-mailer form design.

Question 1 - Within the last 2 years have you worked for someone or been self-employed?

Question 2 - Check the block which best describes your health within the last 2 years (Better, Same or Worse).

Question 3 - Within the last 2 years has your doctor told you that you can return to work?

Question 4 - Within the last 2 years have you attended any school or work training programs(s)?

Question 5 - Would you be interested in receiving rehabilitation or other services that could help you get back to work?

Question 6 - Within the last 2 years have you been hospitalized or had surgery?

Question 7 - Within the last 2 years have you gone to a doctor or clinic for your condition?

c. Questions on the SSA-455-OCR-SM Scannable Mailer Form

Each question on the scannable mailer is referenced to a specific time period unique to that mailer. This "report period" usually begins with the 24^th month prior to the month the mailer is sent and continues to the present, but may be a longer or shorter time period.

Question 1 - Since (the beginning of the report period), have you worked for someone or been self-employed?

Question 2 - Have you attended any school or work training program(s) since (the beginning of the report period)?

Question 3 - Since (the beginning of the report period), have you and your doctor discussed whether you can work, and if so, what did the doctor tell you?

Question 4 - Place an "X" in only one box (labeled Better, Same, and Worse) which best describes your health now as compared to (the beginning of the report period).

Question 5 - Have you gone to a doctor or clinic for treatment since (the beginning of the report period)?

Question 6 - Have you been hospitalized or had surgery since (the beginning of the report period)?

Note that the scannable mailer does not include a question regarding interest in referral for rehabilitation or other vocational services.

d. What Is the Significance of the Difference Between the Two Versions of the Mailer Form?

The hard paper mailer form was the only CDR mailer form prior to fiscal year 1996. The sequence and wording of questions on form SSA-455-OCR-SM were modified from the original SSA-455 to reflect our experiences with the mailer form process from 1993 onward. The SSA-455-OCR-SM reflects the most current design and processing policies; however, the older form SSA-455 may be used. Both versions are under review by private contractors; a single sequence of questions and matching hard paper and scannable mailer forms will be prepared following completion of this review.

C. Procedure -- Sending Out the Mailer Form and Establishing Systems Controls

1. Sending Out the Mailer Form

The mailer form, a generic cover notice and instruction insert, and a reply envelope are sent to the beneficiary or representative payee. An initial mailer form or "1^st-request" form is sent. If it is not returned and receipted within a specific time frame, a "2^nd-request" mailer form is sent. If neither mailer is returned and receipted within a specific time frame, a nonresponder alert is generated to the servicing PC.

The four-page generic cover notice and instruction insert explains the mailer process and what outcomes may result when the Agency processes the mailer. The insert also stresses the importance of responding and specifies time frames for responding. The insert includes telephone numbers for contacting SSA if the individual has additional questions. The insert also includes two pages of instructions on how to complete the form, including sections on each question that provide more in-depth explanations (than can be included on the mailer form) as to what information is being requested.

2. When Mailer Forms Are Sent

a. Scannable Mailer Form SSA-455-OCR-SM

Central Office initiates five scheduled releases of large numbers of scannable mailer forms SSA-455-OCR-SM during the Agency's fiscal year (FY), which begins on October 1 and ends on September 30 of the following calendar year.

Scannable mailer forms SSA-455-OCR-SM are sent to Title II-only and concurrently entitled beneficiaries or their representative payees in October, February and June of the FY.

Scannable mailer forms SSA-455-OCR-SM are sent to Title XVI-only recipients or their representative payees in February and August of the FY.

The five scheduled mailings of scannable mailer forms in a FY, including 1^st-request and 2^nd-request mailer forms, often total in excess of 1,000,000 forms.

b. Hard Paper Mailer Forms SSA-455

Since FY 1996, SSA has not used the hard paper form for the large scheduled mailings. These forms are used on an as-needed basis by the PCs and FOs.

3. Establishing Systems Controls for Receipt of the CDR Mailer Form

When a case is selected to receive a Title II-only, concurrent Title II/Title XVI, or Title XVI-only mailer, time-sensitive controls are established on the Disability Control File (DCF) by means of posting an EVENT 001 - “T2 INITIAL MAILER SENT, T2/16 INITIAL MAILER SENT or T16 INITIAL MAILER SENT” or EVENT 002 - “T2 SECOND MAILER SENT, T2/16 SECOND MAILER SENT or T16 SECOND MAILER SENT” which can be viewed by querying the QCDR screen in the DCF.

For a detailed explanation of this process, see DI 13004.005C.3.

4. Responding to the Mailer Form

The mailer form is completed by the beneficiary or representative payee and returned to the WBDOC (form SSA-455-OCR-SM), or to the PC or FO (form SSA-455). The address of the SSA component to who the mailer form should be returned is printed on the reply envelope provided with the mailer form.

D. Procedure -- FO and DDS Involvement in the Mailer Process

1. FO Assistance in Completing Mailer Forms

FO assistance may include:

1. completion of the form if the beneficiary requests help or the PC requests assistance;

2. answering questions the recipient may have regarding the mailer form and the mailer form process;

3. explaining the need on the recipient's part to answer the questions, sign the mailer form and return it, and the consequences of not responding;

4. encouraging the recipient to respond when he or she receives a 2^nd-mailer after a 1^st-request mailer was completed and returned;

5. forwarding mailer forms to the correct processing component (see DI 28001.003D.3.).

For more detailed information on FO actions, see DI 13004.005.

2. DDS Contact With Mailer Recipients

In the rare event that an individual contacts the DDS about a mailer form, the DDS should refer the individual to the generic insert and the toll free telephone numbers provided therein for calling SSA. If the individual indicates that personal contact is necessary, the DDS should encourage the individual to visit a local Social Security Administration field office.

3. Forwarding Mailer Forms (and Any Attachments)

a. Forward Scannable Mailer Forms SSA-455-OCR-SM to the Wilkes-Barre Direct Operations Center (WBDOC)

The FO or DDS forwards all scannable mailer forms SSA-455-OCR-SM (and any attachments) to the WBDOC for processing. Although mailer forms should only rarely be misrouted to the DDS, it is very important that the mailer forms are sent to the correct processing component as soon as possible. The mailing address for the WBDOC is provided at the top of the front side of every form SSA-455-OCR-SM.

NOTE that SSA-455-OCR-SMs sent to Title II/concurrently entitled beneficiaries have a different Post Office Box number than do mailer forms sent to Title XVI-only recipients.

The address to send Title II-only and concurrent Title II/Title XVI scannable mailer forms SSA-455-OCR-SM to is:

NOTE that one way to identify SSA-455-OCR-SM mailer forms that have been sent to Title II-only or concurrently entitled beneficiaries is that the five numbers in the red box at top of the front of the form will be 11111, 22222, 33333, or 44444. In addition, a Title II claim number is on the front of the form. A Title II claim number consists of a Social Security Number followed by a Beneficiary Identification Code (BIC) (e.g., 999-99-9999A, or 888-88-8888C2, or 777-77-7777W).

The address to send Title XVI-only scannable mailer forms SSA-455-OCR-SM to is:

NOTE that one way to identify SSA-455-OCR-SM mailer forms that have been sent to Title XVI-only recipients have numbers 55555, 66666, 77777, or 88888 in the red box at the top of the front of the mailer form. In addition, a Title XVI claim number is on the front of the form. A Title XVI claim number consists of a Social Security Number followed by an Individual Beneficiary Identification code (ID) (e.g., 999-99-9999DI, or 888-88-8888BI, or 777-77-7777DC).

b. Forward Hard Paper Mailer Forms SSA-455 to the Servicing Processing Center (PC)

The FO or DDS forwards “hard paper” SSA-455s (and any attachments) to the servicing PC for processing. Title XVI-only hard paper SSA-455 mailer forms are sent to PC-1 though PC-6 only, while Title II-only and Title II/concurrent hard paper forms are sent to PC-1 through PC-7. To determine type of entitlement and the servicing PC, it may be necessary to query the DCF, MBR or Supplemental Security Record (SSR). PC jurisdiction is described in GN 01050.055 and GN 01070.245.

The addresses for sending hard paper mailer forms SSA-455 to the PCs are:

NEPSC/PC-1:

MATPSC/PC-2:

SEPSC/PC-3:

GLPSC/PC-4:

WNPSC/PC-5:

MAMPSC/PC-6:

ODO OCO/PC-7:

c. Send Mailer Forms and Any Related Materials Only to the WBDOC or a PC

It is important that the completed mailer forms, and any information that may be submitted with the form, be sent only to either the WBDOC (all scannable mailer forms SSA-455-OCR-SM) or the servicing PC (all hard paper forms SSA-455) as soon as possible. Misrouted or late-forwarded forms can cause substantial delays in processing the form, result in the generation of a 2^nd-request mailer (see DI 28001.003C.1.), and may cause a nonresponder alert to be generated on a case.

Do not send mailer forms to:

1. Central Office;

2. Detailed Office/Organization Resource System (DOORS) location FO 732, or;

3. any folder storage facility or federal record center, including but not limited to the National Records Center (SSANRC), the Rolling Heights Building (the Megasite), or the Office of Disability Adjudication and Review Megasite.”

E. Procedure -- Wilkes-Barre Direct Operations Center (WBDOC) Processing

The WBDOC reviews and processes most scannable CDR mailer forms. The WBDOC:

1. attempts redelivery of forms returned by the United States Postal Service (USPS) as undeliverable;

2. obtains an acceptable signature (see GN 00201.010) when a CDR mailer form is received with no signature or an unacceptable signature;

3. secures missing responses to unanswered questions by using the Agency's direct telephone contact (DIRCON) procedures (see GN 01070.305 and GN 01070.800) and the mail;

4. refers damaged and unscannable CDR mailer forms to the servicing PC for manual processing;

5. refers a report of death, a name change, a change of address to a foreign country, or fraudulent activity to the servicing PC for necessary action;

6. processes MBR update inputs for Title II name corrections (but not name changes), Title II change of addresses (with or without a corresponding change of telephone number), and reports of death for Title II cases, and refers such reports on Title XVI cases to the servicing FOs for action;

7. analyzes the mailer responses, including remarks and any attachments that are received with the CDR mailer forms;

8. encodes the results of the analysis for use by the OCDRS decision logic program (see DI 28001.003G.1.);

9. scans and keys the information on the mailer form to create an electronic data file and confirmation file for each mailer form;

10. identifies "actionable" mailer forms that need to be referred to the servicing PC (see GN 01050.055 and GN 01070.245 for PC jurisdiction information) for translation or other action(s);

11. sorts forms for shipment to the servicing PC by PC and Title (Title II-only and concurrent Title II/Title XVI, or Title XVI-only);

12. mails forms to the PCs in specially marked containers;

13. transmits electronic confirmation files and data files to the Agency's National Computer Center (NCC).

For a more detailed description of WBDOC actions, see DI 13004.005E. or DI 40502.001E.

F. Procedure -- National Computer Center (NCC) Processing of Confirmation Files and Data Files

The NCC:

1. receives, prepares and routes the confirmation file data to the appropriate program for updating the DCF to clear the control that if not cleared will cause the case to be selected for a 2^nd-mailer or nonresponder alert;

2. receives and prepares the data files for OD to retrieve and process through OCDRS's decision logic program.

G. Procedure -- Office of Continuing Disability Reviews Support (OCDRS) Decision Logic Actions

As part of OCDRS decision logic processing, OCDRS:

1. retrieves the data files prepared by the NCC on the basis of receipt of data files from the WBDOC;

2. processes the data through a decision logic program, resulting in one of three actions (deferral, DO CDR, or PC Review. (Approximately 80% of mailer form electronic data files received by OCDRS can be processed directly to a deferral or DO CDR action. The rest require PC Review.)

3. makes the appropriate input to update the DCF to reflect the results of decision logic processing.

   1. When the OCDRS Decision logic action input is a deferral action, the DCF shows EVENT 018 "T2 CDR DEFERRED BY AUTOMATED REVIEW", "T2/T16 CDR DEFERRED BY AUTOMATED REVIEW", or "T16 CDR DEFERRED BY AUTOMATED REVIEW". The input also causes a deferral notice (see NL 00705.355) to be printed and sent to the beneficiary (or representative payee).

   2. When the OCDRS Decision logic action input is a DO CDR action, the DCF shows EVENT 014 "T2 CDR INITIATED BY AUTOMATED REVIEW", "T2/T16 CDR INITIATED BY AUTOMATED REVIEW", or "T16 CDR INITIATED BY AUTOMATED REVIEW".

   3. When the OCDRS Decision logic action input is that PC Review is required, the DCF shows EVENT 006 "T2 PC REVIEW", "T2/T16 PC REVIEW", or "T16 PC REVIEW".

4. For each case requiring PC Review, OCDRS creates electronic files containing:

   1. an output CDR MAILER PSC REVIEW ALERT sheet;

   2. an electronic facsimile of the completed, scanned mailer form, and;

   3. a profile sheet that includes much of the data used to profile the case.

5. makes the electronic PC Review files available to the PCs.

For a very detailed description of OCDRS decision logic, see DI 40502.001F.

H. Procedure -- Processing Center (PC) Processing of the Mailer Form

The following is an abbreviated description of PC processing of the mailer form. For a thorough description, see DI 40502.001, especially DI 40502.001I. and DI 40502.001J. The PC:

1. processes hard paper forms initiated by and returned to the PC, including undeliverable hard paper forms;

2. sorts and processes forms referred to the PC by the WBDOC;

3. processes nonresponder alerts that are generated when a response (a confirmation file) is not received in response to the 1^st-request and 2^nd-request mailer forms within a specified time frame (see DI 13004.005C.3.), using the PC direct telephone contact (DIRCON) procedures in GN 01070.305 and GN 01070.315. Two DIRCON attempts are made; busy signals are not counted as attempts.

   1. if DIRCON is successful, the PC obtains the answers to the questions, sends out the mailer form and controls for a signature/response, and upon receipt processes the mailer to a deferral action (see DI 28001.003H.11.) or a DO CDR action (see DI 28001.003H.11.).

   2. if DIRCON is unsuccessful because the individual cannot be located or is located but refuses to cooperate, the case is processed as a "DO CDR" to the servicing field office (see DI 28001.003H.11.).

      In addition to the DCF input described in DI 28001.003H.11., the PC annotates in the special message field (SP MSG 1) on the MBR, or the remarks section of the CDR PC Input Screen B (IPCB, see Modernized System Operations Manual (MSOM CDR 001.006) of the DCF, that the beneficiary was a nonresponder and the case is being referred to the FO to initiate a full CDR per DI 13005.000.

      NOTE: The mailer form process is not a CDR. Consequently, an inability to locate an individual to complete a mailer form, or an individual's refusal to provide responses to questions on the mailer form is not a basis for a cessation or suspension action under the PCs' whereabouts unknown (WU) or failure to cooperate (FTC) procedures of the CDR process. It is, however, a basis to refer the case to a FO to initiate a CDR. Once a CDR is initiated, it may then be appropriate to apply the FOs' WU or FTC procedures in DI 13015.001 through DI 13005.025 and/or the DDSs' WU or FTC procedures in DI 28075.000.

4. obtains answers to questions, or to resolve conflicting responses;

5. receives, prints and associates the OCDRS decision logic alert, facsimile and profile sheet;

6. obtains translations;

7. obtains query responses;

8. resolves reports of work and earnings received in connection with the mailer form;

9. in rare situations, obtains a claim folder in order to process the mailer form;

10. reviews the alert message, the mailer form or mailer facsimile, any attachments or other information, and the profile sheet;

11. processes the mailer form to either a deferral or DO CDR action:

    1. Deferral Action - The appropriate DCF input is made (see DI 40502.001J.3.), which causes an automated notice (see NL 00705.355) to be generated and mailed to the beneficiary (or representative payee), and sets a new medical reexamination diary date.

       The DCF will show EVENT 013 "T2 CDR DEFERRED BY PC", "T2/T16 CDR DEFERRED BY PC", or "T16 CDR DEFERRED BY PC".

       The medical diary reason (MDR) code at the time the case was selected for mailer form processing is used to reset the medical reexamination diary date. Note that if the MDR was/is blank, the default MDR value of “3” is used and a medical reexamination diary 36 months in the future is set.

       In the unusual situation in which the claims folder has been obtained to do the PC review, it is returned to the National Records Center (SSANRC).

    2. DO CDR/Full Medical CDR Referral Action - The appropriate DCF input is made, and the case is referred to the FO to notify the beneficiary and the representative payee, if any, that a CDR is being initiated.

       1. In Title II cases, if a full medical CDR is needed, update the mailer in DCF to DO CDR and transfer the CDR to the FO. The FO can request the folder if needed.

       2. In Title XVI cases, if a full medical CDR is needed, update the mailer in DCF to DO CDR and transfer the CDR to the FO. The FO can request the folder if needed.

       The DCF will show EVENT 009 "T2 CDR INITIATED BY PC", "T2/T16 CDR INITIATED BY PC", or "T16 CDR INITIATED BY PC".

I. Procedure -- CDT Coding on the SSA-5526-U2-OP2

The current version of the SSA-5526-U2-OP2 does not have pre-printed Continuing Disability Review Type (CDT) codes for mailer form cases that were initiated after fiscal year (FY) 1999. For DO CDR actions involving mailer forms initiated FY 2000 or later, print the appropriate CDT code in the CDT section of the SSA-5526-U2-OP2 or route slip. The possible CDT codes are:

• 40 – CDR mailer released in FY 2000

• 41 – CDR mailer released in FY 2001

• 42 – CDR mailer released in FY 2002

• 43 – CDR mailer released in FY 2003

• 44 – CDR mailer released in FY 2004 or later

A complete list of CDT codes is in SM 06001.120B.11. It is important that the PC use the correct CDT code when referring the DO CDR action to the FO. It is equally important that the FO use the correct CDT code when the FO refers the CDR to the DDS, and that the correct CDT is entered by the DDS when input is made to the National Disability Determination Services System (NDDSS) DDS Receipt (DREC) data input screen (see SM 06001.000 and SM 06001.120).

J. Procedure -- FO Action Upon Receipt of the DO CDR Referral

The FO:

1. obtains the claims folder if it is not forwarded by the PC (see DI 13015.030 - DI 13015.080);

2. reviews the claims folder to determine if the case should be screened out and the CDR discontinued for one of the reasons described in DI 13005.020;

3. if the case cannot be screened out, determines if it can be processed under the MINE or MINE-equivalent procedures in DI 13005.022, and if so refers it to the servicing DDS for processing under DI 28040.000;

4. if the case cannot be screened out or processed under the MINE or MINE-equivalent procedures, notifies the beneficiary and representative payee, if any, that a CDR is being initiated and conducts a CDR interview in accordance with DI 13005.025 - DI 13005.040, and forwards the CDR to the DDS for processing under DI 28000.000.