BASIC (03-86)

A. General

Under the “due process” rules for title XVI or concurrent title II/title XVI disability/blindness cases, a beneficiary can request payment continuation within a specified time frame, pending the decision of an ALJ on the issue of cessation of disability/blindness. These rules presuppose that any resulting payments will be stopped expeditiously if the ALJ affirms the determination of cessation. However, various national and regional studies have revealed that in many cases title II and title XVI payments have been continued erroneously once an unfavorable hearing decision has been made. Therefore, it is necessary to identify any cases on which payments have continued erroneously following an adverse hearing decision.

The ODAR provides monthly tape files of SSN's for cases on which an ALJ has affirmed the cessation of disability/blindness under title II and/or title XVI. The tapes are run against the Disability Case Control System to identify cases on which title II and/or title XVI payments continue to be paid following the unfavorable hearing decision. Any cases on which payments continue to be made are then displayed on printouts and a listing, showing the SSN, type of claim (HA or SD), surname, DO code, DDS code, payment status, and folder location.

B. ODO examiner/DRS review of claims folder

A benefit authorizer in ODO will sort the offline case control output, based on location of the claims folder. The output will be sorted by internal ODO locations (functional and modular operations), PSC's and field locations DDS's, DO's, Disability Quality Branches—DQB's, ODAR, and Federal Records Center—FRC). Output for folders in ODO and the PSC's will be forwarded to the responsible component for association with the related case folder and subsequent action. For all locations other than ODO or a PSC, ODO will make a teletype request for action by the servicing DO/BO.

Disability examiners in ODO and the DRS should review the folders which are in ODO or a PSC, to determine whether current payments are correct. DO's will review any folders which are in a field location (see GN 02201.001).

These procedures deal with a termination of payments after a period in which something may have occurred to justify current payments, e.g., the ALJ may have established a subsequent period of disability or a date of cessation different from the date established by the DDS, the AC may have reversed the ALJ's unfavorable decision to a continuance, or current payment may be based on a subsequent claim. Therefore, it is essential that the folder be reviewed by someone who can interpret the hearing decision and any subsequent action, to make certain that a termination of benefits is in order. This folder review will eliminate any improper terminations which might result based strictly on a review of systems documents on an SSN.

C. ODO examiner/DRS DEC action after review

If current title II payments are erroneous, handcarry the folder to a benefit authorizer requesting termination of title II payments effective with the third month following the month of cessation. Prior to releasing the folder to the benefit authorizer, send a notice to the beneficiary.

If the file reflects erroneous title XVI payments either being made or in suspense due to a nonmedical factor, advise the benefit authorizer to use the Processing Center Action Control System (PCACS) to request assistance from the servicing DO/BO advising of the title XVI medical cessation decision. The following information will be provided: “Title XVI status previously continued pending hearing decision on medical cessation of disability. Hearing decision affirmed the medical cessation determination. Please review the file and DO copy of hearing decision. If erroneous title XVI payments are being made, prepare systems input to terminate title XVI payments effective with the third month following the date of medical cessation shown in the hearing decision. If title XVI payments are in suspense, prepare systems input to record the medical cessation. Also send a notice to the recipient. Initiate recovery of an overpayment. See GN 02201.001.”

NOTE: Review of the hearing decision may show that the SSN was incorrectly shown on the ODAR listing, e.g., the adverse hearing decision may have affirmed an I&R suspension or other action not related to disability cessation, and current title II payments may be appropriate. In this case, place the printout in the folder (right side) annotated with the date of review and “title II payments appropriate.” Return the folder to the Module Files Component.