TN 13 (11-11)

GN 01010.028 Processing center (PC) adjudicative responsibilities

A. Policy on PC responsibilities

PC adjudicators and other technicians involved with the effectuation process (e.g., benefit authorizers (BAs)) perform important functions to ensure high quality standards in the claims process. These functions include full adjudicative and authorization responsibilities for the categories of claims not adjudicated by the field office (FO) (see GN 01010.027B) as well as effectuation of the adjudicative determinations made in FOs but processed outside the Modernized Claims System (MCS).

You must identify non-DOFA claims by reviewing:

  • the code shown on decision (DECI) screen;

  • the special instructions recorded in the report of contact (RPOC);

  • the remarks in the benefit continuity remarks and notice (BCRN) screen;

  • the instructions in the printed routing form attached to the file (for paper cases) or in the PC paperless file for electronic cases.

PC adjudicators prepare many amended awards. PC adjudicators and other technicians also help resolve systems alerts and exceptions performed in-line screening of selected claims. You can provide the FOs with feedback on missing material and repetitive errors detected. You may also use similar feedback procedures for manually processed claims (e.g., after properly processing the claim, fax a copy of an automated 101 (A101) to the originating FO with corrections, instructions or explanation of changes).

The policy is not to transfer unadjudicated claims back to the FOs for correction or adjudication (except for claims described in DI 11050.000. To avoid unnecessary claims processing delays, the PC adjudicator is responsible for completely adjudicating and effectuating any misrouted claim received before forwarding it to the proper component, see GN 01050.075. This mandate includes A101 actions with erroneous “in-transit” destinations.

B. References

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GN 01010.028 - Processing center (PC) adjudicative responsibilities - 11/10/2011
Batch run: 05/08/2020