TN 4 (09-17)

The processing center (PC) encounters cases involving WC/PDB offset in a variety of ways, including:

• awards with WC/PDB involvement at the Office of Disability Adjudication and Review (ODAR) Administrative Law Judge (ALJ) level or higher;

• certain initial disability insurance benefit (DIB) claims and other subsequent claims;

• correspondence received from beneficiaries that require obtaining missing proof or verification of alleged WC/PDB events;

• exceptions and alerts resulting from Modernized Claims System (MCS) and Interactive Computations Facility (ICF) inputs;

• WC/PDB Regular Transcript Attainment and Selection Pass (RETAP) alerts;

• Triennial Redetermination alerts; and

• post-entitlement (PE) adjustments, redeterminations, and LS settlements not completed in the field office (FO).

Technicians should exercise caution when attorneys or claimants are seeking assistance in preparing a WC settlement and ask what effect, if any, such a settlement would have on the number holder’s (NH) benefits. If attorneys ask for specific advice regarding proration terms used to avoid possible offset, see the NOTE: to exercise caution in DI 52140.001G.

A. PC responsibilities for WC/PDB offset

The PC is responsible:

• for identifying any potential WC/PDB offset situations

• documenting all allegations and obtaining all WC/PDB rates, dates, lump sum (LS) settlements; and any subsequent changes.

• Developing for proof of any alleged WC/PDB events.

• Use the most expeditious means available first, such as direct contact. For instructions regarding the requirement to obtain updated proofs prior to adjudication in appeals-level allowance cases see IMPORTANT NOTE on development needs in DI 52140.010B.1 below.

• Securing a repayment statement when necessary.

• Imposing, adjusting, or terminating offset data for WC/PDB events through MCS and ICF.

• Prorating LS settlements and adjudicating through MCS and ICF.

• Annotating the special message field of the master beneficiary record (MBR) regarding attempts to obtain proof, or the inability to obtain proof.

• Annotating ICF screens (WCEP) with specific WC/PDB paragraphs and notices. It is the Claims Specialist’s (CSs) responsibility to provide WC paragraphs. The paragraphs must adequately explain the reason for the change in benefit amounts. For WCP paragraphs, see NL 00720.395. When necessary, provide due process per instructions mentioned in Notices Required Before and After Taking a Title II Adverse Action in GN 03001.015.

• Preparing any necessary diaries, controls, and listing codes to help explain actions taken to expedite future processing.

• Retaining all WC/PDB proof for permanent retention by faxing or scanning into the paperless folder (selecting long retention) and retaining a copy of the source document in the official disability file. For retention of WC/PDB Proofs, see DI 52145.015.

• If a certified electronic folder (CEF) is established, always fax documents into the CEF. For paper folders, retain the proof in the paper folder (if it is available), and fax any new documentation into Non-Disability Repository for Evidentiary Documents (NDRed).

NOTE: Annotating the Shared Evidence (EVID) Screen or coding proof into ICF, by itself, is not sufficient documentation. WC/PDB proof involves complex, State-specific forms and documents that are difficult to decipher and routinely involve a high degree of interpretation. Permanent retention allows the review of the original document to verify whether the interpretation of the WC/PDB proof was correct.

B. Developing for proof of WC/PDB concurrently and establishing diaries for DIB awards processed in the Processing Center (PC)

Most claims initially adjudicated in the PCs by the CS are favorable decisions made at the ODAR hearing level or higher. The PC also processes initial or reconsideration claims occasionally that the CS also adjudicates.

1. Developing for proof prior to adjudicating the award

When processing an award at the appeals level, ALJ, AC, and Courts, check for current WC/PDB payment information. Review the folder (paper or electronic), the MCS screens, and NDRed to determine if a request for proofs was already done or to check that proof may already be in file.

IMPORTANT NOTE: To expedite case processing, technicians should utilize concurrent development efforts by contacting both the beneficiary or their representative, the WC payer, insurance carrier, or WC attorney to obtain simultaneously all available sources of WC/PDB proof. There is no need to wait until you have exhausted one resource of WC/PDB information before contacting another. This means calling the NH directly, calling their attorney, calling the WC attorney, and calling the WC carrier simultaneously. In addition, you may need to get permission from the beneficiary in order to receive any information from another party. When contacting a beneficiary, advise them which other parties you will be contacting for WC/PDB proof. Always verify the WC/PDB amount prior to adjudication to avoid payment errors. Use direct contact (DIRCON) procedures to all available WC resources in GN 01070.305 through GN 01070.335 to obtain allegations of WC/PDB payments, or to find out what proof is readily available from WC/PDB resources. Make two contact attempts per resource and document all calls each time, whether the contact was successful or unsuccessful or if the outcome resulted in a voicemail message.

Take the appropriate actions based on the situation, as follows:

a. The WC/PDB claim is still under appeal

1. Obtain an SSA-795 repayment statement, if not already in file, and an expected decision date per DI 52140.001F.

2. Annotate MCS or ICF as appropriate, with any new WC/PDB claim information that you received.

3. Adjudicate the claim; and

4. Establish a diary control to follow-up on the status of the appeal. For PCACS diaries, provide contact names, telephone numbers and any necessary WC/PDB claim information in the narrative portion of the diary.

b. Worker has proof of WC/PDB

1. Ask the NH to fax the proof directly to you or take it to their local FO as soon as possible; and

2. hold the case no longer than five business days before follow-up.

c. Worker does not have acceptable proof or you are unable to contact him or her by phone

1. Check eView and Claims File User Interface (CFUI) to determine if the FO already obtained a signed SSA-1709 for authorization to obtain WC/PDB proof.

2. Simultaneously attempt to contact the WC carrier, PDB payer, or the WC/PDB attorney by phone.

3. Request that the carrier or third party resource submit WC/PDB proof to SSA by faxing it directly to you or mailing it to the applicable PC address.

For more information on developing WC/PDB proof, see Verification/Proof of WC/PDB in DI 52145.001F. and Obtaining Verification/Proof from Outside Sources in DI 52145.005.

d. You cannot obtain proof within 10 business days

1. Adjudicate the claim using the current allegation of WC/PDB payments. If you do not have an alleged rate, use the State WC maximum at the time of the WC/PDB injury or illness.

2. Include MADCAP paragraph WCPR27 in the award notice or use dictated language that asks the beneficiary to provide proof of WC/PDB.

3. If the beneficiary has an attorney or non-attorney representative, send neutral language paragraphs in GN 03940.075.

4. Establish a 30-day diary to follow up on the response to our request for proof.

5. If no response is received, continue development on a post-adjudicative basis.

2. Developing for proof after adjudicating the award

When the 30-day diary alert matures, the PC should do the following:

1. Check Paperless and the CFUI to determine if the beneficiary or third party submitted proof of the WC/PDB payments while the follow-up diary was pending.

2. If there is no proof in paperless or CFUI, attempt to verify the WC/PDB payments via State WC online access. Check the Workers’ Comp Resource Page for a list of individuals in each PC with online access to individual State WC records.

3. Follow concurrent development instructions in DI 52140.010B.1 in this section to make contacts with all available WC/PDB resources to obtain WC/PDB proof.

4. If the initial telephone contact is unsuccessful, send a DIRCON letter. Be sure the letter includes a request for the NH to give us permission to obtain proof directly from the WC/PDB payer, carrier or WC attorney or enclose a Form SSA-1709 (Request for WC/PDB Information). See Direct Mail Contact (DIRCON) in GN 01070.320.

5. Send the action control record (ACR) to DHF for 30 days from the date you issued the DIRCON letter.

If you do not receive information within the 30 days, telephone the beneficiary to determine if he or she received the material, send one follow-up request, and set a follow-up diary for an additional 30 days.

At the same time, when telephone contact is unsuccessful, simultaneously attempt to obtain proof from any third-party WC/PDB resource, as indicated directly below.

3. Obtaining proof from a third party

If the NH does not have the WC/PDB proofs, but gives permission to contact all third parties, simultaneously:

• call the insurance carrier directly, or

• send a direct contact letter to the insurance carrier and enclose the SSA-1709 signed by the NH, and

• also attempt simultaneous contact with the WC/PDB attorney or the WC payer.

For specific guidelines on contacting carriers, see Obtaining Verification/ Proof from Outside Sources in DI 52145.005F.

In post-adjudicative cases, set up a PCACS diary for 30 days.

If you do not receive the requested information:

1. make one follow-up request;

2. set a follow-up diary for an additional 30 days; and

3. document the electronic or paper folder with reports of contact and record all attempts to obtain WC/PDB proof.

As a last resort, when you still have not received proof after exhausting all WC/PDB resources and have documented all unsuccessful attempts, see DI 52140.010B.4. in this section for contacting the FO.

a. Obtaining proof from NH’s attorney

The NH’s attorney may submit the following as verification:

• a statement of the amount of legal fees, unless it exceeds the amount provided by the award;

• approved copies of award notices, or settlement agreements; and

• Form SSA-1709 signed by the attorney retained by the insurance carrier or self-insured employer, is acceptable proof.

NOTE: Form-SSA-1709 signed by the worker’s attorney is not acceptable proof.

b. Obtaining evidence via State online access

Once you are certain the evidence is not already in file, check the State POMS or the Workers’ Comp Resource Page in DI 52140.020 to see if that State is one that provides SSA with online access to its WC records. The value of the online records can vary from State to State and some development may still be required. However, the sites usually provide contact information for the employer, WC carrier or the WC attorney, which can help jumpstart the development process. Check for a list of individuals in each PC with online access to individual State records.

See also:

• DI 52120.001 - Introduction to State Specific Workers' Compensation (WC) Procedures

• DI 52135.001 - Introduction to State Specific Public Disability Benefits (PDB)

• DI 52140.020 - Workers’ Compensation Resource Intranet Page

• GN 03910.050 - Contacting a Represented Claimant

• GN 03940.036 - Fee Agreement Process - FO and PC Procedures - Partial Adjudication Involving Deferred Development, Including Workers’ Compensation or Public Disability Benefit Information

4. Obtaining evidence by contacting the FO

Do not refer WC/PDB development to the FO. If you are unable to obtain proof through direct contact by phone or mail and attempts to other third-party sources, contact the FO only as a last resort. You must exhaust all other attempts to obtain proof and fully document your attempts.

PCs must only contact a FO when the following special circumstances occur:

• Face-to-face contact with the NH is required.

• The need arises to make a final determination on an issue such as a representative payee determination.

• Some agencies would normally charge SSA for searching and providing information, but they have an arrangement with the local FO that allows them to obtain the information free of charge. For example, requests requiring information from the Alabama Department of Industrial Relations should be made via the servicing FO per DI 52120.005E.2.

• A state agency refuses to provide information to any SSA component other than a specific FO.

If the case meets any of these special circumstances:

1. Input a development request through the PCACS Request for Assistance (RQFA) or input an RQFA through the paperless system.

2. Create a diary in PCACS or RQFA for the FO response.

3. Instruct the FO that you attempted all the required DIRCON contacts to the NH by phone, mail and the concurrent development requests to all WC/PDB resources to try to obtain all WC/PDB proof.

4. State clearly what information is needed and provide the following information:

   • List every attempt made to obtain WC/PDB proof and document all unsuccessful attempts;

   • Provide the name of the insurance company, agency, or public entity making the WC/PDB payments, if known;

   • Provide the WC/PDB claim number, if known;

   • List the date of WC/PDB injury or illness (which is not necessarily the DIB onset date); and

   • Provide the name of the worker’s employer at the time of the injury or illness.

If you need to verify excludable medical expenses, include the:

• nature of WC/PDB injury or illness, and

• names and addresses of the sources of medical treatment.

Take the following actions to strictly control these cases by diaries and avoid costly delays in development:

1. Establish a PCACS diary for 60 days and send the ACR to DHF.

2. Follow-up to the FO only once and set another PCACS diary for an additional 30 days sending the ACR to DHF.

3. If you do not receive a response or evidence after a reasonable effort to secure proof of WC/PDB, the PC should fully document the record of all unsuccessful attempts and send a due process notice informing the individual that we will impose offset at the State maximum unless we receive the requested evidence per GN 03001.015.

4. Establish a 30-day diary from the date the due process notice was sent; if you do not receive a response, take action to adjust the record using the State maximum.

C. Systems processing of cases with WC/PDB offset

There are three ways to process and annotate WC/PDB information to the MBR:

1. Modernized Claims System/Earnings Computation (MCS/EC). For instructions on systems processing of initial claims involving WC/PDB, see DI 52155.000.

2. Title 2 Redesign (T2R) Interactive Computation Facility (ICF). For instructions, see DI 52165.000, and

3. ICF calculations processed via Online Records Entry Operation (OREO) and transmitted through the Manual Adjustment Credit and Award Process (MADCAP). For processing instructions, see DI 52165.020.

NOTE: For instructions regarding obtaining proofs prior to adjudication, see DI 52145.000.

1. MCS/EC processing

The FO processes most initial and reconsideration level claims via MCS/EC. MCS/EC is able to process most disability claims involving WC/PDB.

The PCs are responsible for MCS processing of all ALJ-level awards and some subsequent claims.

To do so through MCS, follow these steps:

1. Review all MCS/EC WC/PDB screens input by the FO.

2. Check the electronic folder or NDRed for proofs (if a paper folder is involved, review for any missing information).

3. Attempt to adjudicate the ALJ claim through MCS/EC. The MCS/EC trigger adjusts WC data on the Shared Process screens and codes offset to the MBR.

4. Finally, prepare notices to advise the beneficiaries of our decisions. For notice instructions, see Initial Determination Workers’ Compensation/Public Disability Benefit (WC/PDB) Notices in DI 52155.035.

2. Processing claims by T2R ICF and MADCAP

If you encounter an MCS/EC limitation:

1. Input the WC/PDB information into ICF to compute offset and adjudicate the claim. For WC/PDB Data Computation Results Screens, see MSOM ICFT2 032.001 through MSOM ICFT2 032.008.

2. Prepare an A101 or EF101. For A101 processing, see DI 52155.025 and for EF101 processing, see DI 52155.030.

Both T2R and MADCAP utilize a Datasheet produced from the ICF computation action. For Datasheet information, see MSOM ICFT2 035.001 and MSOM ICFT2 035.002.

The BTE/BA can key only limited WC data into MADCAP. WC data propagates into MADCAP from the data that the CS adjudicated.

The CS does the following:

1. Completes the WRAC screen with a “Y” in “USE THE RESULTS IN ICF?”

2. Provides all pertinent WC/PDB paragraphs for a complete award notice.

   NOTE: In MADCAP, the BTE/BAs input determines the type of notice that goes to the NH. Providing the BTE/BA with the correct paragraphs is crucial in getting your message across and creating a complete, accurate notice.

3. Routes the case to the BTE/BA for MADCAP processing.

You may partially adjudicate the award based on the NH’s allegations and secure proof on a post-adjudicative basis. For partial adjudication, see procedures in GN 01010.110.

If an attorney represents the NH and the case involves a fee agreement, refer to instructions in GN 03940.036.

3. WC/PDB verification is received and differs from the alleged WC/PDB

Adjust all offset through ICF if a new proven rate differs from the allegation.

For partially adjudicated ALJ cases with attorney involvement:

• Recalculate the attorney fee based on the proven rate (if necessary).

• Add a special message on the MBR explaining that the attorney fee is ready for calculation since WC/PDB rates are now proven.

NOTE: Provide appropriate language regarding the established fee amount. ICF Function 32 input will except because of the attorney fee coding on the MBR. Therefore, use Function 34 of Online Record Entry Operation (OREO) and send the case to the BTE/BA to recalculate the attorney fee. The BTE/BA will then pay the correct amount to the attorney using the Single Payment System (SPS).

IMPORTANT: If we obtained the WC/PDB information through a third party resource, follow due process procedures in Processing Third Party Reports GN 03001.025.

D. Establishing a diary control in the PC

Create a diary for a future WC/PDB action when no system output or alert will generate to notify the PC of the future action.

Take the following steps, as appropriate, to establish a diary control in the PC:

1. MCS - When processing an approved hearing decision, establish the diary using the DECI and DIAR clearance screens. The MCS diary establishes a diary control in PCACS. For instructions on establishing diary control for WC/PDB, see DI 52155.005.

2. Non-MCS - Control the ACR by sending it to the DHF and establish the diary through PCACS. For PCACS instructions, see Diaries and Development Overview in MSOM PCACS 009.001 through MSOM PCACS 009.013.

E. Post-entitlement (PE) action when the case involves WC/PDB offset

Post-adjudicative receipt of information from beneficiaries, insurance carriers, etc., indicating a change in the WC/PDB rate, dates, or LS settlement requires a review of the MBR offset data and possibly a recomputation of the offset.

1. Use the following ICF functions for post-adjudicative offset calculations and updates to the WC/PDB MBR data:

• ICF Function 32 (WC/PDB: Adjudicate Claim) propagates certain data from the MBR, propagates data from one ICF screen to another, and computes offset. T2R processes the offset unless there is an exception, which would then go to a BTE/BA for MADCAP processing.

• Use ICF Function 34 (OREO) screens to input manual WC/PDB computations to create an electronic version of the offset computation. For additional information on ICF WC/PDB Computations, see DI 52165.000.

ICF creates a Datasheet that is available for view/print via ICF - “WCPDB: DATASHEET/QUERY MENU” Function #33 or through the Online Retrieval System (ORS) or Master File Query Menu (MFQM) Function #25. The Datasheet contains all WC/PDB information from the ICF action, including offset computation results, special instructions, and notice information.

2. Reviewing for proof as a PE action

Search all available internal resources to determine if WC/PDB verification has been previously secured (e.g., paper file, paperless completed side of the folder, EF folder, NDRed, MBR special message field, Shared Process evidence screens, Online Retrieval System (ORS) for prior WC datasheets, and MCS development screens). Take note of the following reminders:

• In Paperless, use the “Get Folder” feature on every case and review the entire list of active and archived action control records (ACRs) before taking your action. The necessary WC/PDB proof may already be available in Paperless.

• We consider WC/PDB evidence of periodic payments as current if it is no more than 2 years old. Therefore, if proof in file is more than 2 years old, you must obtain updated proof. See DI 52145.001G. for the re-verification rule and two exceptions to the rule.

• If you find no proof, initiate the direct contact procedures previously mentioned in DI 52140.010B.1.

• Retain the oldest active ACR until the action is complete. When initiating direct mail development, be sure to keep the oldest ACR in DHF, document what you are requesting, and keep the ACR open until you receive WC/PDB proof. Close any other WC/PDB-related ACRs, adding a comment that the ACR is cross-referred to the oldest ACR.

3. Re-imposing offset after reverse offset ends

To re-impose offset after reverse offset ends, use the most recent periodic payment rate to adjust the benefits and develop on a post-adjudicative basis for current proof of WC/PDB payments. Carefully review reverse offset instructions and examples in:

• DI 52105.001G. - Reverse Offset Plans

• DI 52150.020E. - WC/PDB Offset First Considered Date and Offset Effective Date

4. Taking non-WC/PDB-related PE actions

When non-WC/PDB-related PE actions (such as Automatic Earnings Reappraisal Operation (AERO) or earnings enforcements) are involved, we do not require re-verification of proof of the WC/PDB periodic payments unless there is knowledge that a WC/PDB event occurred and is material to current processing of the action. Use the quickest means available (online access, DIRCON, etc.) to obtain WC/PDB verification/proof, if needed.

5. Deleting the WC/PDB data from the MBR

It may be necessary to delete WC/PDB data previously established on the MBR. This situation can occur if all the WC/PDB payments are repaid; as the result of a third-party settlement or if a pending WC claim is subsequently denied; and there is no request for appeal. T2R release 3 and the expansion of the MBR make the deletion process more complicated, but you can still delete WC/PDB data using ICF. Annotate the special message field on the MBR of the deletion of previous WC/PDB data and state the reason.

Be sure to review the MBR the next day to verify that all WC/PDB data fields were removed and to check that any process to correct payment is complete. For deleting WC/PDB data through ICF, see DI 52165.015. Specific instructions on how to delete the data are also available using the following link:

Interactive Computations Facility (ICF) Resource Page for WC/PDB Offset Computations.

F. Handling WC/PDB-related alert and exception output received in the PC

1. Output from inputs made in the FO

Some FO actions using ICF #32 (Adjudicate Claim) create a system exception that requires final processing in the PC. Other FO actions process, but produce an alert in the PC if T2 identifies an MBR inconsistency or other issue that requires attention. An FO input using Function 34 (OREO) produces output in the PC for processing to completion via MADCAP.

In most instances, T2R exceptions and alerts initially go to the BTE/BA for processing via MADCAP. The BTE/BA may forward the output to a CS if they believe there is a problem with the input data or the ICF result is something that the BTE/BA is unable to resolve.

If the BTE/BA forwards the case to the CS, the CS must then review the alert or exception and make the correction needed to complete processing. The CS should review the EF, NDRed, or the completed side of the Paperless folder for prior WC/PDB information or proof that might be available to resolve the alert or exception before returning the case to the BTE/BA for final processing.

2. Triennial redetermination alerts

Triennial redetermination alerts are a PC workload responsibility. For information regarding the triennial redetermination of the average current earnings (ACE), alerts received in the PC each year, and re-verifying WC/PDB, refer to DI 52150.080.

G. Regular Transcript Attainment and Selection Pass (RETAP) alerts for WC/PDB events

The BTE/BA or CS process the following RETAP alerts in the PC. See the following applicable references for complete processing instructions:

H. References

• DI 52101.005 - Social Security Amendments with Workers’ Compensation/Public Disability Benefit (WC/PDB) Offset Provisions

• DI 52145.001 - Verification of Proof of Workers' Compensation/Public Disability Benefits (WC/PDB)

• DI 52150.080 - Triennial Redetermination (Redet) of the Average Current Earnings (ACE)

• DI 52155.005 - Initial Claims and Appeals Requiring Diary Control for Workers’ Compensation/Public Disability Benefit (WC/PDB)

• DI 81010.090 - Faxing Documents into the Certified Electronic Folder (CEF) Using Barcodes

• GN 00301.322 - Retention of Paper Material After Faxing into Either the eDIB Folder or Claims Folder using NDRed

• GN 03001.015 - Notices Required Before and After Taking A Title II Adverse Action

• GN 03001.025 - Processing Third Party Reports in Title II Adverse Action Situations

• NL 00720.395 - WCP Workers’ Compensation