SSA - POMS: DI 11055.055 - Multiple Claims with Supplemental Security Income (SSI) Involved

A. Claim types

A Title XVI disability claim may occur in combination with one or more Title II disability or non-disability claims.

1. Title II disability categories

The Title II disability claim types include:

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Disability insurance benefits (DIB) or DIB Freeze (see sections in DI 10105.000)
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Disabled widow(er) benefits (DWB) (see DI 10110.001)
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Childhood disability benefits (CDB), also known as disabled adult child (DAC) benefits (see RS 00203.080 and sections in DI 10115.000)

NOTE: Medicare-only entitlement may also be based on disability. For Medicare qualified government employment (MQGE) and other types of Medicare claims, see GN 00203.025.

2. Title II non-disability categories

The Title II non-disability claim types include:

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Retirement insurance benefits (RIB) (see RS 00201.001)
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Widow(er) insurance benefits (WIB) (see RS 00207.001)
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Child benefits (see RS 00203.001), including student benefits (see RS 00205.001)
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Spouse benefits (see RS 00202.001), including divorced spouse benefits (see RS 00202.005)
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Parent benefits (see RS 00209.001)
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Child-in-care benefits, also known as mother/father benefits (see RS 00208.001)

3. Developing Title XVI claimant’s potential entitlement to Title II benefits

To be eligible for SSI, an individual must file for certain other benefit payments if the individual is likely to be eligible for such payments (see Social Security Act, Section 1611 [42 USC 1382](e)(2)). For that reason, a Title XVI application is also an application for Title II benefits.

When a Title XVI application is filed, the field office (FO) (or equivalent claims-taking unit, e.g., workload support unit (WSU)) will:

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explore potential eligibility for all classes of Title II benefits (see GN 00204.022 and SI 00510.001);
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develop the allegations, and other related evidence in the claim, that may indicate potential entitlement to Title II benefits (see SI 00601.100);
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provide help with filing for Title II benefits (when the individual asks for or needs help), including help to complete required forms or obtain required evidence (see GN 00301.180); and
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ensure proper adjudication of any Title II application that results from the filing of the Title XVI application (see GN 00204.027 and SI 00601.035).

NOTE: There is no requirement for an SSI eligible individual to file a Medicare-only claim. Medicare (Title XVIII) entitlement itself produces no source of income that reduces SSI payments.

4. Claims requiring a medical determination

Send only the claim type(s) requiring a medical determination to the Disability Determination Services (DDS).

NOTE: The FO processes required nonmedical determinations. Do not send a claim to the DDS (or equivalent disability determination unit) unless the claim requires a medical determination.

B. Processing concurrent Title II and Title XVI claims

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For certified electronic folders (CEF), use the Electronic Disability Collect System (EDCS) to process concurrent cases that require a medical determination. For instructions on how to establish and transfer a case in EDCS/eView, see sections in DI 81010.000.
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If the case is a CEF exclusion (i.e., EDCS/eView cannot store the case folder), establish the folder following the instructions in DI 81010.030E.

NOTE: The same disability forms (e.g., the SSA-3368 (Disability Report - Adult), the SSA-3367 (Disability Report – Field Office), and SSA-827 (Authorization to Disclose Information to SSA)) serve their purpose under both titles for the concurrent disability claim. In general, only one set of disability forms is necessary for the concurrent case.

1. Medical determination is unnecessary

a. Technical denial based on substantial work activity

Follow instructions in DI 11055.095 to prepare the substantial gainful activity (SGA) technical denial when:

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the claimant is engaging in SGA,
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none of the alleged impairments indicate statutory blindness, and
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the period of SGA precludes establishing disability in the pending claim.

Document the work activity using the SSA-820/SSA-821 (Work Activity Report) and SSA-823 (Report of SGA Determination).

For more information on SGA determinations, see the appropriate instructions in DI 10500.000. For EDCS instructions on using the FO denial function in SGA determinations, see DI 81010.140C.

NOTE: If earned income is above the break-even point after considering all income exclusions, use denial code "N01" (excess income) to deny the SSI claim without developing SGA under Title XVI. For more information on income affecting SSI eligibility, see SI 00810.001.

b. Technical denial on only one of the claim types

If a concurrent case involves a nonmedical/technical denial under one title, transfer only the claim(s) needing a medical determination to the DDS. The FO has jurisdiction of the technical denial.

2. Medical determination is necessary

After required nonmedical development, send the case to the DDS for a medical determination.

REMINDER: Develop and resolve all potential SGA issues prior to transfer of the case to the DDS. For guidelines on when to defer certain other nonmedical development until after a favorable medical determination, see DI 11010.025 and SI 00603.002.

a. Nonmedical requirements met, claims already pending for medical determination

In general, after the FO completes required actions to establish potential eligibility and sends the case to the DDS, the FO's decision whether to defer further development has no effect on the disability determination.

The FO does not need to document decisions on deferred or simultaneous development unless the DDS contacts the FO to develop an aspect of a deferred claim. If necessary, use the EDCS Update-After-Transfer (UAT) Utility to send a report of contact to the DDS to notify them of the resolution of all critical nonmedical requirements on the claim (i.e., nonmedical issues affecting whether the claim is allowed or denied) and that a concurrent medical determination is still needed.

NOTE: In a Quick Disability Determination (QDD) or Compassionate Allowance (CAL), an EDCS onscreen message will prompt the FO to complete simultaneous full development (i.e., continue additional nonmedical development after EDCS transfer). Upon completing full nonmedical development, if the SSI claim remains pending for only medical development at the DDS, use the Consolidated Claims Experience (CCE) to build the Supplemental Security Record (SSR) in blank payment status (PSY blank). In general, when the DDS makes a favorable disability determination within 120 days of the CCE input and no additional FO action (e.g., capability or payee development) is necessary, the SSI allowance will automatically effectuate on the SSR.

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For instructions on FO-DDS communication and exchange of information, see DI 10005.010.
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For when the QDD predictive model or CAL selection software determines that a case qualifies for priority processing, see DI 23022.030.
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For requirements and systems inputs for simultaneous development in SSI claims, see SI 00603.004.

b. Nonmedical requirements met, one claim not yet sent for medical determination

If only one claim type in a concurrent case was sent to the DDS but, after additional development, the FO determines a concurrent medical determination is necessary for another claim type, use EDCS UAT to:

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add the additional claim type to the case pending at the DDS, and
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create a report of contact to explain why the claim type was added to the CEF.

NOTE: For information on updates to CEF cases, see DI 81010.095. For instructions on CEF exclusions, see DI 81010.030.

C. When a new Title XVI claim is filed after a prior Title II denial or cessation

When processing a new disability claim after a prior disability denial or cessation, the EDCS/SSA-3367 for the new claim must include the applicable prior claim information. For prior filing information required in Item 7 of the EDCS/SSA-3367, see DI 11005.045A.3.

NOTE: On the EDCS/SSA-3367, enter remarks to alert the DDS when a prior period of disability (PPD) ended in benefit termination due to failure to cooperate (FTC). Never assign a potential onset date (POD) within a PPD that ended in cessation or termination. For more information about recording the POD on the EDCS/SSA-3367, see DI 25501.220.

REMINDER: If the prior denial or cessation adjudicated the Title II claim through the date the nonmedical requirements for entitlement are last met (i.e., the DIB date last insured (DLI), CDB attainment of age 22, or end of the DWB prescribed period) and the FO may apply res judicata to the current Title II claim, transfer only the new Title XVI claim to the DDS. For instructions on when the FO may apply res judicata, see DI 27516.001B.

D. Medical determination on only one claim type in a concurrent case and the other claim type remains pending

If the DDS returns a medical determination to the FO and then the FO discovers a concurrent medical determination was necessary for another claim type already pending in the FO:

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Enter remarks on the EDCS 3367, or in a report of contact in the case folder, to explain why all claim types requiring medical development were not previously sent together for a concurrent determination, and
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send the additional claim type to the DDS.

If the FO receives new and material evidence or discovers a processing error that may affect the disability determination under both titles in the concurrent case, determine whether medical reactivation of the DDS’s initial determination is appropriate, following instructions in DI 81010.143. If an appeal is already pending, follow instructions in DI 11055.055F in this section.

NOTE: In a past relevant work (PRW) determination for DIB when the DLI is prior to the date of adjudication, the relevant period generally covers the 5 years prior to the DLI. In a PRW determination for SSI, the relevant period generally covers the 5 years prior to the date of adjudication. Consequently, under rare circumstances involving a DLI that is after the concurrent application filing date and before the date of adjudication, the disability determination may result in a denial under Title II with PRW in only the DIB relevant period and an allowance under Title XVI in which the SSI established onset date (EOD) precedes the DIB DLI.

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For the DIB denial adjudicated after the DLI, the eView Case Status/History tab and Item 22 of the SSA-831 (Disability Determination and Transmittal) will display the regulation basis code (RBC) "H2" (capacity for SGA - any PRW) or "J2" (when transferable skills from PRW resulted in capacity to perform other SGA).
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To avoid any potential misunderstanding or unnecessary redevelopment in future reviews of insured status (KZ) diaries, add remarks on the SSI record to explain the nonroutine or special circumstances. For example, when processing the Title XVI disability allowance in the concurrent claim, use the “SSR Special Message” page in CCE to post the special message “DIB denial dated [MM/DD/YYYY] based on PRW. Although SSI EOD is prior to DIB DLI in the concurrent claim, there is no PRW within 5 years prior to SSI allowance and no conflict to resolve between the determinations.”
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For more information on the FO’s and DDS’s responsibilities in PRW issue development, see DI 25005.015.

E. Current disability beneficiary alleges new visual impairment when statutory blindness is not yet established under one or both titles

Determine whether a medical determination of statutory blindness is necessary, following instructions in DI 26001.015.

When sending a statutory blindness case to the DDS:

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obtain the necessary completed forms (e.g., EDCS/SSA-3368, SSA-827), and
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use on the EDCS/SSA-3367 to document relevant technical information (e.g., the insured status and POD for statutory blindness ).

Additionally, when a current SSI Disabled Individual (DI) requests a multicategory determination on statutory blindness:

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explain multicategory eligibility to the individual (following instructions in SI 00501.300),
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obtain a signed statement documenting the individual’s request (for example, “I request a blindness determination with any retroactivity to which I may be eligible. I want the determination to apply to my federal payment and state supplement.”), and
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on the EDCS/SSA-3367, enter remarks “SSI multicategory case - blindness [MM/DD/YYYY]” to identify the earliest onset date for which the Blind Individual (BI) category will affect the SSI (following instructions in DI 26005.005E).

F. When a Title XVI claim is filed while an appeal is pending on a prior Title II disability claim

When the Title II claim is pending at the reconsideration or hearing level and the subsequent claim is filed under Title XVI, determine whether the claims share a common issue (as described in DI 12045.005).

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When a common issue exists, the subsequent claim may escalate to the same level as the current appeal. For instructions on common issue cases, see DI 12045.010.
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Escalate a subsequent claim to the hearing level only if the administrative law judge (ALJ) agrees to join the claim with the pending appeal. For instructions on contacting the hearing office to request to consolidate claims, see DI 12045.015.

NOTE: If there is no common issue, the claims remain separate. Process the Title XVI initial claim as appropriate. The appeals process for single claims under the respective titles will apply.

Social Security

Program Operations Manual System (POMS)

DI 11055.055 Multiple Claims with Supplemental Security Income (SSI) Involved