SSA - POMS: DI 13004.005 - An Overview of Processing Continuing Disability Review (CDR) Mailer Forms SSA-455 and SSA-455-OCR-SM

A. Policy for conducting continuing disability reviews

Section 221(i) of the Social Security Act (Act), as amended, requires a periodic continuing eligibility review for disabled beneficiaries at least every three years except where we determined that the disability is permanent. The Commissioner determines the appropriate times for case reviews involving a permanent disability. We call this review 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. Description of mailer form SSA-455 Disability Update Report

Form SSA-455 (Disability Update Report) is a self-help mailer form designed to solicit key information from a disabled beneficiary about his or her medical conditions and recent treatment for it. “Recent” usually means within the last two years. The mailer form also asks for information about recent education or training, and recent attempts to return to work.

C. Who to send a mailer form

We usually send the mailer form to beneficiaries who, based on statistical analysis called profiling, would have a low probability of medical improvement if we conducted a full CDR. We sometimes describe this group of beneficiaries simply as “LOWs.” In some instances, we may send mailers to other groups of beneficiaries. We refer to these groups as “HIGHs” or “MEDIUMs,” based on a profiling score that reflects the probability of a productive CDR or as a combined group, we may refer to them as “non-LOWs” or “not-LOWs”.

D. Mailer form processing outcomes

Depending on the information received with the completed mailer, we may initiate a referral for a full CDR (commonly referred to as a “DO CDR” action). A full CDR referral occurs in a small percentage of the mailer forms received for processing. Much more frequently, a deferral action is made to defer doing a full CDR. A new medical reexamination diary (MRED/MR) resets for up to seven years for deferred cases. The medical diary reason (MDR) at the time of the case selection for mailer form processing determines how long the new MRED/MR should be. If there is no MDR value, we establish a default value of “3” for the MDR and the MRED/MR resets for 36 months or 3 years.

E. 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. For an explanation of CPD, see DI 13005.022C.1.

F. The scannable mailer form

We use an optically scannable variation of the mailer form, the SSA-455-OCR-SM, most frequently. Mailer recipients return the scannable mailer forms to the Wilkes-Barre Direct Operations Center (WBDOC). (For the WBDOC process, see DI 13004.005E. (in this section)). Since October 1995, we use the scannable mailer form SSA-455-OCR-SM most of the time, although the processing centers (PCs) or field offices (FOs) may use the standard “hard paper” form.

G. Question sequencing on the mailer forms

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

1. Questions on the SSA-455 hard paper mailer form

The hard paper form has a fixed report period format (the last two years). We took the questions from the version of form SSA-454-BK, Report of Continuing Disability Interview, then in use, and modified the questions to fit a self-mailer form design. The following table provides the list of questions on the SSA-455 hard paper mailer form.

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?

2. Questions on the SSA-455-OCR-SM scannable mailer form

Each question on the scannable mailer is a specific period unique to that mailer. This “report period” usually begins with the 24^th month prior to the month we send the mailer and continues to the present, but may be a longer or shorter period. The following table provides the list of questions on the SSA-455-OCR-SM scannable mailer form.

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.

3. 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. We modified the sequence and wording of questions on form SSA-455-OCR-SM 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.

H. Procedure for sending out the mailer form and establishing systems controls

1. Sending out the mailer form

We send the mailer form -- a generic cover notice and instruction insert, and a reply envelope to the beneficiary or representative payee as the initial mailer form or “1^st-request” form. If it is not returned and receipted within a specific time frame, we send a “2^nd-request” mailer form. (If the second mailer is not 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 includes:

•

an explanation of the mailer process,
•

an explanation of the possible results of the mailer process,
•

the importance of returning the form(s),
•

the time frames for responding,
•

the telephone numbers for contacting us, and
•

the instructions for completing the form.

2. When we send mailer forms

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.

We send scannable mailer forms SSA-455-OCR-SM to title II-only and concurrently entitled beneficiaries or their representative payees in October, February, and June of the FY.

We send scannable mailer forms SSA-455-OCR-SM 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, we have not used the hard paper form for the large scheduled mailings. The PCs and FOs use these forms on an as-needed basis.

3. Establishing systems controls for receipt of the CDR mailer form

This table contains DCDRS actions for updating the Disability Control File (DCF) for after the CDR mailer forms process.

When…	Then…
we send a title II-only, concurrent or title XVI-only initial or “1^st-request” mailer	we update the DCF to show event code of 001: • “T2 INITIAL MAILER SENT,” or • “T2/16 INITIAL MAILER SENT,” or • “T16 INITIAL MAILER SENT”
We complete • the next title II/concurrent mailer selection (currently, every 4 months), or • the title XVI-only mailer selection (currently, every 6 months) select cases	under the following conditions, the system selects to receive a 2nd-request mailer: • any case with “001 INITIAL MAILER REVIEW” as the most recent event, and • mailer not returned by next mailing. We post to the DCF an event code of 002: • “T2 SECOND MAILER SENT,” or • “T2/16 SECOND MAILER SENT,” or • “T16 SECOND MAILER SENT.” with the most recent posted event code of • “002/T16 SECOND MAILER SENT” and that event is more than 150 days old a nonresponder alert sent to the PCs post to the DCF an event code of 003: • “T2 NONRESPONDER REVIEW,” or • “T2/16 NONRESPONDER REVIEW,” or • “T16 NONRESPONDER REVIEW.”
DCDRS decides which receipted mailer for PC review PC review pending more than 45 days	post to the DCF an event code of 006: • “T2 PC MAILER REVIEW,” or • “T2/T16 PC MAILER REVIEW,” or • “T16 PC MAILER REVIEW” post to the DCF event code of 007: • “T2 PC REVIEW FOLLOW-UP,” or • “T2/T16 PC REVIEW FOLLOW-UP,” or • “T16 PC REVIEW FOLLOW-UP.”

When…

Then…

we send a title II-only, concurrent or title XVI-only initial or “1^st-request” mailer

we update the DCF to show event code of 001:

•

“T2 INITIAL MAILER SENT,” or
•

“T2/16 INITIAL MAILER SENT,” or
•

“T16 INITIAL MAILER SENT”

We complete

•

the next title II/concurrent mailer selection (currently, every 4 months), or
•

the title XVI-only mailer selection (currently, every 6 months)

select cases

under the following conditions, the system selects to receive a 2nd-request mailer:

•

any case with “001 INITIAL MAILER REVIEW” as the most recent event, and
•

mailer not returned by next mailing.

We post to the DCF an event code of 002:

•

“T2 SECOND MAILER SENT,” or
•

“T2/16 SECOND MAILER SENT,” or
•
“T16 SECOND MAILER SENT.”

with the most recent posted event code of

•

“002/T16 SECOND MAILER SENT” and that event is more than 150 days old a nonresponder alert sent to the PCs

post to the DCF an event code of 003:

•

“T2 NONRESPONDER REVIEW,” or
•

“T2/16 NONRESPONDER REVIEW,” or
•

“T16 NONRESPONDER REVIEW.”

DCDRS decides which receipted mailer for PC review

PC review pending more than 45 days

post to the DCF an event code of 006:

•

“T2 PC MAILER REVIEW,” or
•

“T2/T16 PC MAILER REVIEW,” or
•

“T16 PC MAILER REVIEW”

post to the DCF event code of 007:

•

“T2 PC REVIEW FOLLOW-UP,” or
•

“T2/T16 PC REVIEW FOLLOW-UP,” or
•

“T16 PC REVIEW FOLLOW-UP.”

4. Responding to the mailer form

The beneficiary or representative payee completes the mailer form and returns form SSA-455-OCR-SM to the WBDOC or the PC, and returns form SSA-455 to the FO. Printed on the reply envelope provided with the mailer form is the address of the Social Security Administration (SSA) component where he or she should return the mailer form .

I. Procedure for FO involvement in the mailer process

1. FO assistance in completing mailer forms

a. Obtain responses to all questions and an acceptable signature

If the beneficiary requests help or the PC requests assistance, you may assist in the completion of this form. When assisting in the completion of the form, attempt to obtain a response to each question, and to obtain an acceptable signature. For signature requirements, see GN 00201.010. When providing assistance by telephone, ask the beneficiary or representative to use the reply envelope provided with the mailer form. Use of the reply envelope ensures the return of the mailer form to the correct SSA component. If the beneficiary or representative completes the mailer form in the FO, forward it to the appropriate component per DI 13004.005I.2. (in this section).

b. Individual questions the mailer form and is reluctant to respond

•

Refer the individual to the generic insert that he or she received with the mailer form and encourage him or her to read it, if they have not already done so.
•

Explain that the Act requires that we periodically review disability cases.
•

Explain that we send the CDR mailer form to determine if the agency needs to do a full medical review of whether the disabled beneficiary continues to be disabled, and that in most cases the responses provided show that a CDR is not necessary.
•

Explain that it is very important that the individual respond.
•

Explain in a non-threatening tone that answering the form is voluntary, but if the individual declines to respond to the mailer form that, a full medical CDR will be necessary.

c. Individual reports receiving a 2^nd-request CDR mailer form after responding to the 1^st -request CDR mailer form

The beneficiary or representative payee may contact the FO and report receipt of a 2^nd-request mailer after they have responded to the 1^st-request mailer. If there was some delay in responding to the first mailer, or if the agency experienced a delay in receiving or processing the mailer form, he or she may receive a second mailer. In this situation, ask the individual to complete and return the 2^nd-request mailer form. This action will help ensure that at least one mailer form will process. There is no harm if we process both forms. If he or she requests help completing the forms, assist the individual. For instructions, see DI 13004.005I.1.a. (in this section).

2. Forwarding mailer forms (and any attachments)

a. Forward scannable mailer Forms SSA-455-OCR-SM to the WBDOC

Forward all scannable mailer forms SSA-455-OCR-SM (and any attachments) to the WBDOC for processing. It is important to forward the mailer form as soon as possible. The mailing address for the WBDOC is at the top of the front side of every form SSA-455-OCR-SM.

NOTE: The SSA-455-OCR-SMs that we send 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 is:

SOCIAL SECURITY ADMINISTRATION

WILKES BARRE DIRECT OPERATIONS CENTER

PO BOX 4550

WILKES BARRE PA 18767-4550

NOTE: One way to identify the SSA-455-OCR-SM mailer forms that we sent to title II-only or concurrently entitled beneficiaries is the five numbers in the red box at the top of the front of the form are 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., 999-00-9999A, or 888-00-8888C2, or 777-00-7777W).

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

SOCIAL SECURITY ADMINISTRATION

WILKES BARRE DATA OPERATIONS CENTER

PO BOX 4556

WILKES BARRE PA 18767-4556

NOTE: One way to identify SSA-455-OCR-SM mailer forms that we sent to title XVI-only recipients is the 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 Recipient Identification Code (ID) (e.g., 999-00-9999DI, or 888-00-8888BI, or 777-00-7777DC).

b. Forward hard paper mailer forms SSA-455 to the servicing PCs

•

Forward the “hard paper” SSA-455s (and any attachments) to the servicing PC for processing.
•

Send Title XVI-only hard paper SSA-455 mailer forms to PC-1 though PC-6 only,
•

Send title II-only and title II/concurrent hard paper forms to PC-1 through PC-7.

To determine the type of entitlement and the servicing PC, it may be necessary to query the DCF, Master Beneficiary Record (MBR), or Supplemental Security Record (SSR).

When sending hard paper mailer forms (SSA-455) to the PCs, use the Non-PC Paperless Barcoding Application; select CDR Mailer T2 or CDR Mailer T16 Doc/Type from the dropdown Menu.

c. Send mailer forms and any related materials only to the WBDOC or a PC

It is important to forward as soon as possible, completed mailer forms, and any information that the beneficiary or representative may submit with the form only to the WBDOC (all scannable mailer forms SSA-455-OCR-SM) or the servicing PC (all hard paper forms SSA-455). Misrouted or late-forwarded forms can cause substantial delays in processing the form, resulting in the generation of a 2^nd-request mailer, see DI 13004.005I.1.c. (in this section), and may cause a nonresponder alert to be generated on a case.

Do not send mailer forms to:

•

Central Office;
•

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

Any folder storage facility or federal record center, including but not limited to the Wilkes-Barre Folder Servicing Operation (WBFSO), the National Records Center (the Caves), the Rolling Heights Building (the Megasite), or the Office of Disability Adjudication and Review Megasite.

J. WBDOC processing for CDR mailer forms

1. Handling of undeliverables

The WBDOC reviews and processes most scannable CDR mailer forms, including forms returned by the United States Postal Service (USPS) as undeliverable. When this happens, the WBDOC has procedures to attempt redelivery.

2. Preliminary screening for signatures, damaged forms, name or address changes, reports of death, or allegations of fraudulent activity

a.

Some received mailer forms are not signed, in which case the WBDOC sets up controls to obtain a signature.
b.

Signed mailers sometimes have unanswered questions; the WBDOC uses the agency's Direct Contact (DIRCON) procedures and the mail to secure missing responses.
c.

Some returned mailer forms contain a report of death, name change, change of address to a foreign country, and information regarding fraudulent activity, and may not be optically scannable because of damage. When this happens, the WBDOC refers the CDR mailer form to the servicing PC for necessary action.
d.

The WBDOC makes MBR update inputs for name corrections (but not name changes), 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.

3. WBDOC mailer form analysis, coding, scanning and keying

Upon completion of the preliminary actions, the WBDOC does a detailed analysis of the mailer responses, including remarks and any attachments sent with the mailer forms. We summarize the results of the analysis as codes for use by the Division of Continuing Disability Reviews Support (DCDRS) decision logic program. For DCDRS decision logic, see DI 13004.005K.1. (in this section). The WBDOC enters a code in each of three “ANY CODES?” boxes provided on the back of the form.

A scanning and keying operation then creates an electronic data file of each mailer form.

4. Sorting and shipping mailer forms in the WBDOC

Some “actionable” paper mailer forms need to be sent to the PCs for translation or further review, see DI 13004.005L.4. (in this section). We determine, what mailers needs referring to the PC, then the WBDOC sorts the processed mailer forms by title (title II/concurrent or title XVI-only) and by PC jurisdiction, and mails them to the PCs. The WBDOC sends Title XVI-only mailer forms to PC-1 though PC-6 only and send title II-only and title II/concurrent forms to PC-1 through PC-7.

5. Transmission of the mailer form electronic data files and confirmation files to the National Computer Center (NCC)

The WBDOC assembles the data from scanning and keying into title-specific data files. The WBDOC also creates title-specific confirmation files consisting of the SSN and BIC/ID. WBDOC transmits all files to the agency's NCC.

The NCC receives, prepares and routes the confirmation file data to the appropriate program for updating the DCF. Receipt of the confirmation data clears the control that if not cleared will cause the case to be selected for a 2^nd-mailer or nonresponder alert. Upon receiving receipt notification, the DCF shows EVENT 005 “T2 MAILER RETURNED-DECISION PENDING,” “T2/T16 MAILER RETURNED-DECISION PENDING”or“T16 MAILER RETURNED-DECISION PENDING.”

The NCC receives and prepares the data files for DCDRS to retrieve and process through DCDRS's decision logic program.

K. Procedure for DCDRS decision logic and CDR Mailer PC Review alerts

1. DCDRS decision logic

DCDRS retrieves the data files prepared by the NCC based on receipt of data files from the WBDOC. DCDRS processes the data through a decision logic program. The logic provides front-end screening of all returned mailers and results in one of three actions (deferral, DO CDR, or PC Review). DCDRS process to completion clear decision mailer forms to do a full CDR or to defer a CDR. DCDRS processes approximately 80 percent of mailer form electronic data files received directly to a deferral or DO CDR action, the rest require PC review.

2. DCDRS decision logic inputs

DCDRS makes the appropriate input to update the DCF to reflect the results of decision logic processing. This table contains the DCDRS decision logic actions and the corresponding DCF results.

When…	Then…
the DCDRS decision logic action input is a deferral action,	the DCF shows EVENT 018 • “T2 CDR DEFERRED BY AUTOMATED REVIEW,” or • “T2/T16 CDR DEFERRED BY AUTOMATED REVIEW,” or • “T16 CDR DEFERRED BY AUTOMATED REVIEW.” The input also causes a printed deferral notice (see NL 00705.355) and sends it to the beneficiary (or representative payee).
the DCDRS decision logic action input is a DO CDR action,	the DCF shows EVENT 014 • “T2 CDR INITIATED BY AUTOMATED REVIEW,” or • “T2/T16 CDR INITIATED BY AUTOMATED REVIEW,” or • “T16 CDR INITIATED BY AUTOMATED REVIEW.”
the DCDRS Decision logic action input is that PC Review is required,	the DCF shows EVENT 006 • “T2 PC REVIEW,” or • “T2/T16 PC REVIEW,” or • “T16 PC REVIEW.”

When…

Then…

the DCDRS decision logic action input is a deferral action,

the DCF shows EVENT 018

•

“T2 CDR DEFERRED BY AUTOMATED REVIEW,” or
•

“T2/T16 CDR DEFERRED BY AUTOMATED REVIEW,” or
•

“T16 CDR DEFERRED BY AUTOMATED REVIEW.”

The input also causes a printed deferral notice (see NL 00705.355) and sends it to the beneficiary (or representative payee).

the DCDRS decision logic action input is a DO CDR action,

the DCF shows EVENT 014

•

“T2 CDR INITIATED BY AUTOMATED REVIEW,” or
•

“T2/T16 CDR INITIATED BY AUTOMATED REVIEW,” or
•

“T16 CDR INITIATED BY AUTOMATED REVIEW.”

the DCDRS Decision logic action input is that PC Review is required,

the DCF shows EVENT 006

•

“T2 PC REVIEW,” or
•

“T2/T16 PC REVIEW,” or
•

“T16 PC REVIEW.”

3. CDR mailer PSC review alerts, facsimiles and profile sheets

For each case requiring PC Review, DCDRS provides electronic files containing:

a.

an output CDR MAILER PSC REVIEW ALERT sheet,
b.

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

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

For detailed descriptions of these documents, see DI 13004.005L.6. and DI 13004.005L.7. (in this section).

L. Procedure - PC processing of the CDR mailer form

1. Hard paper mailer forms

A significant additional PC workload consists of hard paper forms initiated by and returned to the PC. WBDOC cannot scan and process these forms to a data file. DCDRS decision logic cannot process these forms because no electronic data file exists for these mailers and the PCs must manually review them. We do not generate CDR MAILER PSC review alerts, facsimiles or profile sheets for these cases.

In addition, processing of undeliverable hard paper forms may be required.

2. Processing nonresponder alerts

PC personnel receive systems notification (a nonresponder alert) when a response (a confirmation file) is not received to the 1^st-request and 2^nd-request mailer forms within a specified time frame, see DI 13004.005H.3. (in this section). The PC processes the nonresponder alert as follows.

a. DIRCON

WBDOC use the telephone for DIRCON to complete form SSA-455. The PC follows the PC DIRCON procedures in GN 01070.305 and GN 01070.315. We make two DIRCON attempts; do not count busy signals as attempts. WBDOC use the form SSA-5002 to record the results of DIRCON.

b. DIRCON is successful

If DIRCON is successful, the PC processes the mailer to a deferral action, as described in DI 13004.005L.9.a. (in this section), or DI 40502.001J.4; or a DO CDR action, as described DI 13004.005L.9.b. (in this section), or DI 40502.001J.4.

c. DIRCON is unsuccessful

If DIRCON is unsuccessful because the individual cannot be located or is located but refuses to cooperate, the servicing FO process the case as a “DO CDR” to, see DI 13004.005L.9.b. (in this section), or DI 40502.001J.4.

In addition to the DCF input described in DI 13004.005L.9.b. (in this section) and DI 40502.001J.4., 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 MS 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. We annotate the DCF by entering a “Y” after REMARKS on the PC Input Screen (IPCB). This takes the user to the CDR Remarks Input (IRMK) screen see MS CDR 001.009. The user then enters the nonresponder information on the IRMK screen.

REMEMBER: 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. We may apply the FOs' WU or an FTC procedure in DI 13015.001 through DI 13015.025 to an initiated CDR.

3. DIRCON to resolve unanswered questions or conflicting responses

DIRCON may also be required to obtain answers to questions, or to resolve conflicting responses.

4. Folderless processing of completed forms

The review performed in the PC is usually a folderless process. The PC reviewer considers the beneficiary's responses on the mailer, any other documents that may have been submitted (e.g., a medical report), the contents of the profile sheet, see DI 40502.095, Exhibit 1, and any on-line information to determine if a CDR is appropriate.

Rarely, it may be necessary to obtain the claim folder to complete the PC review.

5. Sorting mailers received from the WBDOC

The PCs sorts the actionable mailers received from the WBDOC in anticipation of receipt of the decision logic alert/facsimile/profile sheet output.

6. Receipt of the alert, mailer form facsimile and profile sheet

For each mailer received for PC Review through DCDRS decision logic, an alert, a facsimile of the mailer, and a profile sheet (see DI 40502.095, Exhibit 1) are generated.

The facsimile of the mailer form includes questions, answers, and any relevant remarks of less than 30 words or 200 characters. However, a portion of the mailers received at the WBDOC has lengthy relevant remarks, work information, relevant attachments or require translation. The WBDOC identifies these mailers as “actionable” forms and WBDOC ships these mailers to the PCs in specially labeled containers. We cannot generate a useful facsimile for these cases. Instead, actionable mailers require association with the profile sheet and paper alert before processing.

The profile sheet contains much of the data used by DCDRS to identify and profile the case. The profile sheet includes the disabled individual's name, account number, application date, date of entitlement, date of onset of disability, diagnoses codes, impairment data, medical diary type as calculated by DCDRS (the OD-CALC MDR: field), profile category (Low, Medium, or High), recent earnings information, and initial claim and prior CDR data.

7. Review of the alert

a. The purpose of the alert

The next action is determined by reviewing the alert. Each alert includes a message that specifies whether translation is needed, and whether review by a Benefit Earnings Technician (BET) (PC-7)/Disability Technician (DT) (PCs 1-6), or by a Disability Examiner (DE), Disability Examiner Consultant (DEC) or Disability Consultant (DC) is needed. Each message also includes a recommended final action.

b. Actionable mailer alert

Receipt of an alert may tell the Development and Support Examiner (DSE) (PC-7)/Folder Location Clerk (FLC) that before the next action they need to associate an actionable mailer with the electronically generated output. The DSE and FLC put the documents in a holder and refer them for review based on the specific alert message.

c. Work activity alert

Some alerts will state that BET/DT/Earnings Reviewer (ER) review is needed if the response to question 1 (work activity) is “Yes,” if earnings information is provided, or if a code of “1” (or, in certain cases, “3”) was input by the WBDOC in either of the first two “ANY CODES?” boxes.

d. Translation is needed

On the alerts that state, a need for review because translation is required. The WBDOC identifies the need for translation and passes that information through the DCDRS decision logic by entering the appropriate code in the ANY CODES? boxes. The BET/DT/ER refers the holder to the appropriate translator.

e. When no work activity is reported and no translation is needed

DE/DEC/DC/Disability Processing Specialist (DPS) review is required for all other PC review mailers.

f. The automated recommended final action

The alert message includes an “automated recommended final action.” It reflects the action the DCDRS decision logic would have made (to defer and rediary, or refer the case for a CDR) without consideration of what is in the untranslated remarks, other remarks, or in the attachments.

NOTE: Review of the mailer form, remarks on the form, and any attachments may warrant an action different from the “automated recommended final action”.

8. PC review decisionmaking

Following translation -- the BET/DT/ER make decisions on referred cases with reports of work and earnings, see DI 40502.001I.2.c.

The DE/DEC/DC/DPS conduct a review of the responses to the 6 questions, any remarks and attachments to most of the mailers and all other mailer forms not requiring BET/DT review that are referred.

Note that the reviewers do not consider the response (or no response) to question “5” on the hard paper mailer form SSA-455 regarding interest in a referral for rehabilitation services; the reviewers only considered the responses (or missing responses) to the other questions.

The reviewers uses the following to decide whether a deferral action or a referral for a full medical CDR is appropriate: the responses and the documentation with the mailer form; online data (e.g., MBR query response; Supplemental Security Record (SSR) query responses; Summary Earnings Query (SEQY); and Detailed Earnings Query (DEQY) query responses) the beneficiary may submit, and the information contained on the profile sheet.

For a thorough description of PC decisionmaking, see DI 40502.001I. and DI 40502.001J.

9. PC input and related actions to reflect deferral or DO CDR action

The DE/DEC/DC/DPS updates the DCF to reflect the result of the completed review.

a. Deferral action

The DE/DEC/DS/DPS makes the appropriate input to the DCF (see DI 40502.001J.3.), which generates an automated notice (Continuing Disability Review (CDR) Deferral Notice, see NL 00705.355) which is mailed to the beneficiary (or representative payee), and sets a new medical reexamination diary date for full medical CDR deferrals.

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

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

When we obtain the claims folder, in the unusual situation, to do the PC review, we return the claims folder to the appropriate folder storage facility (the Caves, Megasite, WBFSO, etc.). A Processing Center Action Control System (PCACS) input (for title II claims folders) or Supplemental Security Income Case Control System (SSICCS) folder transfer input (for title XVI claims folders) is done to reflect the movement of the claims folder.

b. DO CDR/full medical CDR referral action

If we do a DO CDR action, as is more fully described in DI 40502.001J.4., we refer the case to the FO to notify the beneficiary and the representative payee, if any, that we have initiated a CDR.

Title II cases - 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.

Title XVI cases - 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.”

c. CDT coding on the SSA-5526-U2-OP2

The current version of the SSA-5526-U2-OP2 (Request for Assistance Disability) initiated after FY 1999 does not have pre-printed Continuing Disability Review Type (CDT) codes for mailer form cases. 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, and it is equally important that the FO use the correct CDT code when the FO refers the CDR to the DDS.

M. Procedure for FO action upon receipt of the DO CDR referral

1. Obtain any paper claims folder if not forwarded by the PC

Follow the procedures for obtaining the claims folder in DI 13015.030 through DI 13015.080.

2. Screen out review

Upon receipt of the claims folder, review the folder to determine if we should screen out the case and the CDR discontinued for one of the reasons described in DI 13005.020.

3. Medical improvement not expected (MINE) or MINE-equivalent review

If you do not screen out the case from further processing, determine if the case can process under the MINE or MINE-equivalent procedures in DI 13005.022. If the case can process under the MINE or MINE-equivalent procedures, refer the case to the servicing DDS for processing under DI 28040.000.

4. FO contact to initiate CDR

If the case cannot process under the MINE or MINE-equivalent procedures, notify the beneficiary and representative payee, if any, that SSA is initiating CDR and conduct a CDR interview in accordance with DI 13005.025 through DI 13005.040.

Program Operations Manual System (POMS)

DI 13004.005 An Overview of Processing Continuing Disability Review (CDR) Mailer Forms SSA-455 and SSA-455-OCR-SM