TN 13 (11-11)

GN 01010.100 Subsequent Title II Claims and Field Office (FO) Adjudication

A. Definition of subsequent claim

A subsequent claim is an award of any type of benefit on a particular social security number (SSN) on which a Primary Insurance Amounts (PIA) was previously established. Awards after a T, M or Medicare-only (Hospital Insurance (HI)/Supplemental Medical Insurance (SMI)) claims are also examples of a subsequent claim.

In addition, in some situations the claimant can file a new claim while awaiting a final determination on a previously filed claim. (i.e., Disability (DIB) claim is pending an appeal decision at the hearing level when the claimant files a Retirement (RIB) claim).

B. Policy on adjudicating subsequent claims

The claims technician is responsible for fully developing and reviewing the subsequent claim to ensure that the claimant meets all factors of eligibility before adjudicating the claim. To complete adjudication of a subsequent claim, you must:

  • know the current status of the prior claim; or

  • have sufficient evidence for the current claim or be able to rely on the previously proven information of the prior claim (see GN 01010.038).

C. Procedure for adjudicating subsequent claims

1. Information Sources

Obtain information from prior claims using the following sources:

  • Cleared or archived Modernized Claims System (MCS) screens established for the prior claim. Reviewing these screens is comparable to reviewing the prior claims file in the paper process. Consider the information displayed on the MCS screens as proper documentation of prior activity in related subsequent claims. However, remember that neither an allegation by the claimant that evidence was previously submitted nor an entry on the development worksheet (DW01) is sufficient for the you to completely adjudicate a subsequent claim.

  • Full Master Beneficiary Record (MBR) or full account (FACT); do not use an abbreviated MBR (AACT) since it has limited information.

  • The Disability, Railroad, Alien and Military Service (DRAMS) query is a source of information about Military Service (MS), prior periods of disability, Japanese internment, railroad involvement, and non-citizen (alien) deportation actions from the Department of Homeland Security (DHS).

2. Reviewing prior claim sources

The technician is responsible for fully examining all prior records to determine the status of the prior claim before adjudicating the new claim. Also, examine the records for cross reference SSNs if current or potential beneficiaries are dually entitled.

Consider the following issues below when reviewing prior claims sources:

a. Identification of Issues:

  • MBR discrepancies;

  • Numident information (e.g., discrepancies in name, date of birth, and date of death);

  • MS or other data;

  • Underpayments, overpayments and uncollected annual earning test (AET) penalties;

  • Special Primary Insurance Amounts (PIA) computation factors (e.g., the Retirement limitation (RIBLIM), delayed retirement credits (DRCs) for survivor benefits or prior periods of disability);

  • Possible open applications;

  • Erroneous entitlements or terminations;

  • Adverse claims situations;

  • Multiple entitlement;

  • The effect of established work deductions or suspensions; or

  • Administrative finality and Res Judicata rule (e.g., technical denial code of 0S1 on the MBR).

b. Fully insured status

When the prior claim was a type of claim which could be paid based on currently insured status (i.e., benefit identification code “BIC” “E”, “C”, or “G” claimants) and the MBR does not contain sufficient data to determine fully insured status, request a certified earnings record (E/R).

3. Prior DIB claim filed

a. Current RIB claim

If the subsequent claim is a RIB claim filed after a prior denied DIB, treat the current claim as an initial claim and do not recall the prior folder information unless you need the material for information.

b. Pending appeal

In some situations, the claimant can file a new claim while awaiting final determination on a previously filed claim.

  • See DI 10105.900 DI 10105.907 for processing claims for other title II benefits when disability benefits have ceased and the beneficiary is receiving benefit continuation pending appeal.

  • See GN 03106.090 for processing subsequent disability claims when the individual has requested reinstatement while awaiting review of a prior termination.

4. Special adjudication considerations

Consider the unique issues below when adjudicating a subsequent claim.

a. PIA discrepancy

For all subsequent claims, obtain a certified E/R computation and compare the E/R PIA to the MBR PIA. If the PIAs are different, evaluate the E/R and the MBR to identify the reason of discrepancy (e.g. lag earnings missing on the initial award, duplicate postings) and take necessary actions as needed. If after resolving the discrepancy, you determine that:

  • The MBR PIA is correct, process the subsequent claim via automated 101 (A101).

  • The E/R PIA is correct, process the subsequent claim via MCS EC and document the claims file (e.g. RPOC) with the rationale of PIA discrepancy and the actions taken. Alert the processing center (PC) of any overpayment or underpayment resulting from the PIA correction by recording the proper information in the remarks (RMKS) screen.

    • If after all efforts, you cannot resolve the PIA discrepancy and immediate payment is due, document your efforts and partially adjudicate the award using the lower PIA. See GN 01010.110 for partial adjudication process.

b. Multiple entitlement

See GN 01010.050 for special considerations that apply in multiple entitlement situations (e.g. an Independently Entitled Divorced Spouse (IEDS) is already entitled RIB or DIB).

c. Child’s benefit reinstatements and adverse adjustments

Reinstatement of a child beneficiary's entitlement that begins with the same month that the prior entitlement ended is not a subsequent claim requiring a new award. Instead, it is a resumption of former benefits (see RS 00203.080 or RS 00205.400). Such reinstatements may adversely affect other entitled beneficiaries and you must treat them as adverse adjustments.

d. Survivor claims

If the only prior claim on an SSN was for the Lump Sum Death Payment (LSDP), treat the current claim as an initial claim. If a Number Holder (NH) dies before age 62 and she or he met all the other eligibility requirements in RS 00615.302, consider a WINDEX computation for the widow(er).

e. Deferred development claims

You are responsible for adjudicating subsequent auxiliaries in deferred development disability claims when the NH's claim is allowed. See DI 11010.030 for instructions for deferred title II disability claims.

Note: Do not attempt to trigger auxiliary claims until the system establishes the MBR for the NH.

f. MCS processing limitations

Some prior title II entitlements may cause an MCS processing limitation, see MSOM MCSEC 001.007 for information about processing claims with prior entitlement via MCS EC. See MSOM MCSEC 001.001 for a list of MCS processing limitations and messages.

g. District court case pending

Refer to GN 03106.090 for procedures on handling subsequent claims filed on an SSN in which a district court decision is pending.

D. References


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0201010100
GN 01010.100 - Subsequent Title II Claims and Field Office (FO) Adjudication - 02/10/2014
Batch run: 02/10/2014
Rev:02/10/2014