TN 22 (09-24)

DI 13050.090 Expedited Reinstatement (EXR) and Initial Claim Filed for the Same Benefit

A. Background

Most individuals who meet the requirements for EXR also meet the requirements to file a new initial claim. The field office (FO) technician should discuss the filing considerations of filing a new initial claim versus and EXR request per DI 13050.020. The individual must decide which claim they wish to pursue. While an individual may insist on filing for both a new initial claim and EXR at the same time, we can only process one claim allowance.

B. FO procedure for sending an initial claim and EXR case to Disability Determination Services (DDS)

Due to systems limitation, an EXR and an initial claim with the same claim type are multiple pending cases (MPC) electronic disability collect system (EDCS) exclusions. For example, an EXR request with an initial disability claim on the same SSN is an EDCS exclusion and you must revert to paper processing. Take the following actions to process the case:

  • Establish initial claim in EDCS.

  • Add message to EDCS indicating that a paper EXR exists.

  • Upload any documents that apply to both the electronic and paper claim in eView.

  • Create a modular disability folder (MDF) for the EXR claim.

  • File the documents that pertains solely to the EXR claim in the paper folder.

  • Update the paper folder indicator (PFI) in EDCS stating that a paper folder has been created for this filing, see DI 81010.085;

  • Transfer EDCS to DDS.

  • Print an EDCS routing form for the MDF and the add remarks "EDCS exclusion-associate with EDCS case transferred on MM/DD/YYYY".

  • Mail the paper MDF to DDS.

NOTE: EXRs and initial claims with different claim types can be loaded as an MPC in EDCS. For example, an EXR Childhood Disability Benefit (CDB) claim and an initial disability (DIB) claim, can be loaded into EDCS as an MPC.

C. Procedure for an EXR and initial claim approval

If DDS makes a favorable medical determination on both the EXR request and initial claim, the FO will explain to the individual that we cannot process both actions. The individual must withdraw the claim they do not wish to pursue. Discuss the advantages and disadvantages of both actions per DI 13050.020. If the claimant does not respond, use failure to cooperate and whereabouts unknown processing, per GN 01010.300, GN 01010.410, DI 11018.005, DI 13015.001 through DI 13015.025, and SI 00601.110. Repayment of benefits is determined under normal withdrawal processing, per GN 00206.005 and SI 00601.050.

NOTE: Although Medicare is withdrawn on either the EXR or initial claim, Medicare or Medicaid will be available on the other action when it is processed. When an individual previously had Medicare and entitlement ended within 5 years, the individual does not serve another qualifying period for Medicare.

 

If the individual chooses EXR:

  • Process a withdrawal of the initial claim per GN 00206.011, GN 00206.014 and SI 00601.050.

  • Process the EXR allowance per DI 13050.060 for title II and DI 13050.061 for Title XVI.

    Take these additional steps for Title II:

  • If current entitlement exists on the initial claim, do not stop current initial claim benefits. This will avoid interruption of benefits and Medicare coverage. OCO/PC will take necessary termination, recovery and entitlement actions when it processes the EXR award.

  • Alert OCO/PC to the withdrawal via a remark on the EFBCRN screen of the EF-101 to remind it of action needed in relation to the initial claim withdrawal, if appropriate.

If the individual chooses an initial claim:

  • Process a withdrawal of the EXR request per, GN 00206.011, GN 00206.014 and SI 00601.050.

  • Add a statement to the withdrawal request that the individual understands that the withdrawal will end provisional benefits (and provisional Medicare/Medicaid if applicable), and that the individual understands that they will have Medicare/Medicaid on the initial claim and a new Initial Enrollment Period (IEP) will also apply.

a. Title II initial claim award

  • Do not stop provisional benefits, if still being paid. This will avoid interruption of benefits and Medicare coverage. OCO/PC will take necessary termination, recovery and entitlement actions when it processes the award.

  • Adjudicate the initial claim.

  • Annotate a remark on the EFBCRN screen of the EF-101, stating “EXR filed mm/dd/yy withdrawn mm/dd/yy”, if appropriate. Also annotate remarks about the need to offset appropriate provisional or reinstated payments made against initial claim benefits due.

  • Forward the claim to the PC of jurisdiction.

b. Title XVI initial claim awards

If necessary, terminate provisional payments in accordance with SM 01701.080. Process the initial claim provisional payments and reinstated payments that have been made.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0413050090
DI 13050.090 - Expedited Reinstatement (EXR) and Initial Claim Filed for the Same Benefit - 09/04/2024
Batch run: 10/22/2024
Rev:09/04/2024