TN 13 (11-11)

GN 01010.325 Processing Center (PC) Procedures for Handling Adverse Claims

A. PC actions

1. Senior Claims Processing Specialist (SCPS) actions

You must review, further develop (if necessary) and effectuate the award for the adverse claimant that indicates a reopening and non-entitlement decision for a currently entitled or previously entitled beneficiary (i.e., voids or totally defeats all entitlement).

If you determine that, the adverse claimant is not due benefits, process under normal disallowance procedures and send the appropriate notice.

If your determination affirms the award for the adverse claimant, then take the following actions:

  • Ensure the 30-day advance due process notice described in GN 01010.325B. is sent to the adversely affected beneficiary;

  • Respond to any timely protest received (e.g., initiate additional development based on the beneficiary's protest);

  • Verify the adjudicative determination if necessary, considering any evidence submitted or obtained with a timely protest;

  • Provide the benefit authorizer (BA) with non-entitlement and benefit termination notice language for the adversely affected beneficiary, including the reconsideration paragraph; and

  • Advise the BA that you sent the advance due process notice and she or he needs to process the award determination and effectuation of benefits termination.

2. Claims Authorizer (CA) actions

You must review, further develop (if necessary) and effectuate the initial determination for the adverse claimant that indicates:

  • A disallowance of the adverse claimant; or

  • An award of the adverse claimant indicating the termination of a currently entitled or previously entitled beneficiary

If you determine that, the claimant should not be entitled, process under normal disallowance procedures and send the appropriate notice.

If your determination affirms that the adverse claimant should be awarded, take the following actions:

  • Ensure the 30-day advance due process notice described in GN 01010.325B. is sent to the adversely affected beneficiary;

  • Respond to any timely protest received (e.g., initiate additional development based on the beneficiary's protest);

  • Verify the adjudicative determination if necessary, considering any evidence submitted or obtained with a timely protest;

  • Provide the BA with benefit termination notice language for the adversely affected claimant, including the reconsideration paragraph; and

  • Advise the BA that you sent the advance due process notice.

B. Content of due process notice

Because an adverse claim award either voids or terminates the entitlement of an earlier entitled beneficiary, make sure to mail the due process notice before you effectuate the adverse action. Include the following information in the advance due process notice:

  • The new claimant's name, type of benefit and relationship to the number holder (NH);

  • A summary of the evidence supporting the claim;

  • The non-entitlement determination and the effect on the current beneficiary, including the month benefits will cease;

  • An explanation that the current beneficiary will be given 30 days from the date of written notice (additional time in foreign cases) to protest and submit evidence to support their claim;

  • Explanation about the beneficiary’s choice to elect continuance of benefits while we make a formal determination in regards to the protest;

  • An explanation that if the adverse claim is sustained, the continued benefits will be subject to Overpayment (O/P) recovery provisions including waiver, reconsideration, etc.; and

  • That if we do receive the protest within the allowed time period, we will send another notice with more information about our action.

  • See NL 00703.121 for the advance due process exhibit notice for Adverse Claims.

C. Benefit Authorizer (BA) actions

1. No protest received

If we not receive a written protest within the 30-day protest period, process the action against the adversely affected beneficiary and ensure that a reconsideration paragraph is included in the adjustment notice. Include applicable O/P paragraphs and any other language supplied by the SCPS or CA if necessary.

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