TN 3 (02-95)

GN 01703.240 Processing Initial U.S. Claims in OIO Modules

A. Process

After the initial RSDI denial has been processed, FOs and IBO route claims for U.S. benefits to the OIO modules where the possibility of paying totalization benefits exists.

After the initial CA review, if a claim for foreign benefits is also present, the folder is routed to the BET for preparation and forwarding of the claims package.

If the claims are CAPS cases, they are filed in the Segment I holding file until CAPS output is associated. The CA action depends upon the status of the foreign coverage record.

B. Procedure - CAPS

Follow the instructions concerning foreign coverage records shown below.

1. Foreign coverage record requested by border DO or FSP

If the foreign coverage record has been requested by the FSP or border DO:

  1. Review the CAPS output to be sure a proper notice was released which included paragraph MX02.

  2. Complete e4962 via TDCP.

  3. Diary for receipt of the foreign coverage record.

  4. Develop for any missing evidence.

  5. Route the claim to files to await receipt of the foreign coverage record.

2. Foreign coverage record not requested

If the foreign coverage record has not been requested:

  1. Review the CAPS output to be sure a proper notice was released which included paragraph MX02.

  2. Complete e4962 via TDCP.

  3. Develop for any missing evidence.

  4. Route the claim to the BET for completion of e2960 via TDCP requesting the foreign coverage record and any other needed information as specified in each agreement's specific subchapter.

For Italian and German agreement cases, provide the BET with the dates; i.e., 37 to date or number of weeks, for which coverage information should be requested.

3. Foreign coverage record I file

If the foreign coverage record is in file:

  1. Draw an “X” through the computer generated notice, mark it “not released” and file it on the right side of the RSI folder.

  2. Adjudicate the U.S. totalization retirement or survivor claim. (See GN 01703.245 for instructions on adjudicating U.S. totalization claims.)

  3. Since the initial insured status denial notice has not been released, designate the appropriate nontotalization RSI denial paragraph to be included on the totalization award or denial notice.

  4. For disability claims, determine if disability status is met and follow the instructions in GN 01703.245.B for processing the claim.

  5. Complete e4962 via TDCP.

C. Procedure - CAPS exclusion

If a CAPS exclusion applies, adjudicate the claim via MACADE. (The CA action depends on the status of the foreign coverage record.)

1. Foreign coverage record has been requested by FSP or Border DO

If the foreign coverage record has been requested by the FSP or border DO:

  1. If the FO or IBO prepared Form SSA-3428-U2 (Determination of Disallowance Coding Sheet), review the form to ensure that paragraph MX02 is present.

  2. If the FO or IBO neglected to prepare Form SSA-3428-U2, process the denial via MACADE and designate the appropriate notice and paragraphs.

  3. Input the SSA-3428-U2 via MACADE

  4. Complete e4962 via TDCP.

  5. Diary for receipt of the foreign coverage record.

  6. Develop for any missing evidence.

  7. Send the folder to typing.

2. Foreign coverage record requested

If the foreign coverage record has not been requested:

  1. If the FO or IBO prepared Form SSA-3428-U2 (Determination of Disallowance Coding Sheet), review the form to ensure that paragraph MX02 is present.

  2. If the FO or IBO neglected to prepare Form SSA-3428-U2, process the denials via MACADE and designate the appropriate notice and paragraphs.

  3. Input the Form SSA-3428-U2 via MACADE

  4. Complete e4962 via TDCP.

  5. Develop for any missing evidence.

  6. Send the folder to typing.

  7. After typing, subsequently route the claim to the BET for completion of e2960 via TDCP requesting the foreign coverage record and any other needed information as specified in each country's specific subchapter.

  8. For Italian and German agreement cases, provide the BET with the dates or number of weeks for which coverage information should be requested.