When the DDS makes an unfavorable medical determination on an EXR request, the determination will appear on the Electronic Disability Collect System (EDCS) Action Items list. The electronic folder will contain a denial notice with a Personalized Decision Notice, and an SSA-832 Title XVI Cessation or Continuance of Disability Determination and Transmittal, or SSA-833 Title II Cessation or Continuance of Disability Determination and Transmittal. If the EXR is an EDCS exclusion, the DDS will send the paper folder to the FO. The determination will not appear on the EDCS Action Items List. Determine the basis for the medical determination by reviewing the following items on SSA-832 or SSA-833:

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  Item 10 will have block D indicated, which shows “other”.

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  Item 11 will show code 28 for Title II not same as or related denial, 61 for Title XVI not same as or related denial, or normal CDR codes for MIRS denials-see DI 28084.015.

The DDS prepares and sends a denial notice with a Personalized Explanation to the claimant and any appropriate third party. The notice informs the claimant that they may file a new application for disability benefits, request a reconsideration of the EXR decision, or file a new EXR application. For information about appropriate Medicare language in denial notices, see DI 13050.070.

NOTE: The request for reinstatement can be used as protective filing for a new application if the claimant chooses to file a new application.

Terminate provisional benefits (if currently being paid). The last month provisional benefits are payable is the month the DDS mails the EXR denial notice, provided the benefit is not subject to earlier termination for another reason. For termination reasons, see DI 13050.025A.2 and DI 13050.030A.2.

Refer to HI 00801.165C and DI 13050.070 for the effect an unfavorable medical decision has on Medicare entitlement and SI 01730.010 for the effect on Medicaid.

NOTE: If the DDS medically denies an EXR request on a concurrent claimant under the MIRS, initiate a medical CDR for the other title, per DI 13001.005A.8

Document the reason the claimant decided to file a new initial claim instead of an EXR request on the Report of Contact (RPOC) screen in MCS. Close out the existing EXR protective writing by including a closeout statement in the remarks on the initial claim application.

If the claimant is not eligible, but chooses to file for EXR, take the following steps:

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  Obtain a form SSA-371 - Request for Reinstatement for Title II;

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  Establish the EXR event in the DCF, per DI 13010.610;

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  Establish the EXR case in EDCS;

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    Select “Claims Action” on the EDCS tool bar at the top of the screen and then select “Add FO Determination”;

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    Select “No Determination” and reason "Misc Clearance";

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    Add the reason for denial in remarks. Example: EXR Tech Denial-SGA; and

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    Select “OK” at the bottom of the screen;

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  Document the reason the claimant is ineligible for EXR on an SSA-553-Special Determination, or an SSA-5002 - Report of Contact and store in eView or Evidence Portal (EP) along with any supporting documentation;

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  Terminate provisional benefits, if started. For termination instructions see, DI 13050.025;

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  If there is Medicare entitlement, refer to DI 13050.070;

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  Close the EXR event on the DCF. On the IFOA screen, select 5=SSR/MBR/STOP CDR for the clearance reason.

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  Send an EXR denial notice to the claimant and any appropriate third party and store a copy in ORS. Title II EXR denial notices are available in DPS. Include Medicare information as appropriate.

Document the reason the claimant decided to file a new initial claim instead of an EXR request on the Report of Contact page. Close out the existing EXR protective writing by including a closeout statement in the remarks on the initial claim application.

If the claimant is not eligible for, but chooses to file for EXR, take the following steps:

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  Obtain a form SSA-372, Request for Reinstatement for Title XVI;

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  Establish the EXR event in the DCF, per DI 13010.610;

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  Establish the EXR case in EDCS;

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    Select “Claims Action” on the EDCS tool bar at the top of the screen and then select “Add FO determination and”;

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    Select “ No Determination” and the reason "Misc Clearance";

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    Add the reason for denial in remarks. Example: EXR Tech Denial-SGA; and

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    Select “OK” at the bottom of the screen;

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  Document the reason the claimant is ineligible for EXR on an SSA-553-Special Determination, or an SSA-5002 - Report of Contact and store in eView or Evidence Portal (EP) along with any supporting documentation;

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  Process the denial. Post payment status code N07 to the SSR, per SM 01701.080 and SM 01305.001O.6;

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  Terminate provisional benefits, if started. For termination instructions, see SM 01701.080;

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  Close the EXR event on the DCF. On the IFOA screen, select 5=SSR/MBR/STOP CDR for the clearance reason; and

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  Send a manual EXR denial notice to the claimant and any appropriate third party. Retain a copy of the notice in the file and fax into eView or Evidence Portal(EP).