TN 21 (08-11)

GN 02610.055 Processing Administrative Law Judge (ALJ) Decisions in the Processing Center (PC) when Windfall Offset May be Involved

A. Background for processing of ALJ decisions in the PC

This section provides instructions for identifying and processing ALJ decisions so that the PC can release the Title II retroactive benefits without windfall offset development. The Claim Authorizer/Claims Technical Expert (CA/CTE) reviews the case to determine whether the beneficiary is eligible for Title XVI payments for any months covered by the Title II award. If the beneficiary is not eligible for Title XVI payments for any months covered by the Title II award, windfall offset development is not required and the Title II retroactive benefits should be released immediately.

B. PC process for CA/CTE to determine if windfall offset applies

Determine whether to release Title II retroactive benefits immediately or to refer the case to a Benefit Authorizer (BA) to initiate a windfall offset computation. Follow these steps to make the determination:

1. Review all case records

Review the Supplemental Security Record (SSR) to determine if the beneficiary is potentially eligible for Title XVI payments and whether windfall offset development is necessary. In addition, review the following sources as needed to resolve the issue of Title XVI eligibility:

  • Case folder to determine whether the ALJ decision includes awards for both Title II and Title XVI;

  • HA-501-U5 form (Request for Hearing by ALJ) to determine whether the beneficiary requested a hearing for Title II and Title XVI decision;

  • Online Retrieval System (ORS) for Title XVI initial claim or reconsideration denial notices. Their presence establishes that the beneficiary filed for Title XVI and that the ALJ may have issued a Title XVI decision;

  • MBR Supplemental Security Income (SID) data line to determine if the coding indicates that the beneficiary is potentially eligible for Title XVI benefits;

  • Case Processing and Management System (CPMS) to determine if Title XVI coding is present.

2. Request all SSRs

A beneficiary may have multiple SSRs. Review all established SSRs before determining that the beneficiary was not eligible for Title XVI. For more information on multiple SSRs see, GN 02610.055 C.1

3. Determine if windfall offset development is needed

After reviewing the case folder and queries, determine if windfall offset development is needed. If a review indicates the beneficiary is

  • eligible for Title XVI payments in any months covered by the Title II award, then withhold all retroactive Title II benefits until windfall offset development is completed.

  • not eligible for Title XVI payments for any of the months of Title II entitlement, then release the retroactive Title II benefits.

NOTE: If the Title XVI SSR is terminated or not in file (NIF) and the case requires windfall offset development, the CA/CTE should advise the Benefit Authorizer/Benefit Technical Examiner (BA/BTE) to send an e4345 ( Record of Manual Title II Offset Computation ) to alert the field office that offset development is necessary. The MBR/SSR interface does not occur with a terminated or NIF SSR.

C. CA/CTE Procedure for reviewing the SSR and MBR to determine if Title XVI eligibility is involved

Retrieve all SSRs using Query Master (QM) on the Office of Quality (OQA) toolbar. Check the block for retrieving all Title XVI records. The QM also links to POMS references by clicking on a specific field in the QM query.

Review the following fields on the SSR and MBR to determine if the Title II beneficiary is eligible for Title XVI payments for any months of Title II entitlement.

1. Message Line (MSG) at top of SSR

The Record Number (RN) field tells how many SSRs are present for a particular case. If the RN is other than 01X01, review all prior SSRs to determine if the beneficiary was eligible for Title XVI for any months covered by the Title II award. For information about the MSG line, see Online General Reply Format in SM 01601.040.

2. Case Control Data segment (CCTL)

The Payment Status (PSY) field indicates the payment status on the SSR. Review this field when determining whether to release or withhold retroactive Title II benefits. Look for the following PSY codes:

  • PSY Codes of T50 or T51 always indicate that we paid no Title XVI payments. If the record number is 01X01and the PSY is T50 or T51, Title XVI is not involved unless an APPE (appeals data) segment is present. For information on the appeal data segment, see GN 02610.055C.4 in this section.

  • PSY codes of T30, T31, T32, T33, and T01 indicate potential eligibility or that the claimant received Title XVI payments. The termination date for Title XVI payments is important when deciding whether to withhold retroactive Title II benefits. If the Title XVI termination month is

    • before the Title II month of entitlement, do not apply windfall offset.

    • within the Title II entitlement period, withhold retroactive Title II benefits for windfall offset development.

  • If the PSY Code is blank, or in a held status (e.g., H80), non-pay (e.g., N04), M02, or suspended (e.g., S06), windfall offset may apply. Withhold retroactive Title II benefits pending offset development. The MBR/SSR interface will occur for these PSY codes, so there is no need for a BA/BTE to initiate an e4345. For information about PSY codes, see SM 01601.805 and SM 01305.001.

  • If the PSY Code is N12 (SSI claim withdrawal) or N17 (claimant does not want to pursue the Title XVI claim) do not apply windfall offset and release the Title II retroactive benefits. The Denial Code/Date (DS) field indicates the reason and date we denied the Title XVI claim. If the PSY is T50 or T51 and the DS code is N01 through N25, the Title XVI claim was a technical denial that the system terminated. Release the Title II retroactive benefits. For a list of payment status codes in computation history, see SM 01601.805.

  • In the Abbreviated Application (AB) field, an entry of “A” indicates that we denied the abbreviated Title XVI claim for non-medical reasons. If the “A” is present, the SSR record is 01X01, and no appeals data is on the SSR, then do not apply windfall offset and immediately release Title II retroactive benefits. For information about the AB field, see Standard Response Data SM 01601.430 and for the Abbreviated Application process see SI 00602.001.

3. SSR Record Identification Code (RIC) field in the case data segment

The RIC field indicates whether the SSR is active. RIC “T” indicates a terminated record. RIC “G” indicates an active record. If the CA/CTE determines that offset development is necessary, and the SSR shows:

  • RIC T, the MBR/SSR interface will not occur. Advise the BA/BTE to send an e4345 to the field office to obtain Title XVI computations;

  • RIC G, the MBR/SSR interface will occur, and do not refer cases to a BA/BTE to initiate an e4345. .

NOTE: The MBR/SSR interface does not occur on an Abbreviated Application, even if the RIC is G. If Title XVI is not involved and the SSR is active, then the SSR will automatically terminate. For information about the RIC codes, see SM 01601.445C.

4. SSR Appeals Data (APPE) segment

The presence of an APPE segment on a denied or terminated record indicates that offset may apply. Review the Appeals Decision Code and Date (DSN) field.

  • If the DSN date is equivalent to the ALJ decision date for the Title II claim, and the DSN code (e.g., FF-fully favorable, PF-partially favorable, etc.) matches the ALJ’s Title II decision, the case is a concurrent claim and develop windfall offset.

  • If the DSN code indicates that Title XVI payments are not payable (e.g., UF- unfavorable, WD – Dismissed Withdrawn, etc.), the beneficiary is not eligible for Title XVI and do not develop windfall offset.

For a complete list of the DSN codes, see SM 01601.685C.

5. Computation History Segment (CMPH)

For cases with multiple SSRs, the most recent record may be a terminated record, denied, and not appealed, but a prior record may indicate eligibility for Title XVI. Check the CMPH field for the month the prior record terminated. If the termination month of the prior record predates the Title II month of entitlement (MOE), do not apply windfall offset.

For information about the CMPH segment, see SM 01601.790.

NOTE: The CA/CTE may access the SSID Reader from Query Master, which provides detailed information about each of the fields shown on the SSR.

6. MBR Supplemental Security Income data (SID) line

Review the SID data line on the MBR. If this line is present with a Security Income Entitlement/Termination Date (SIED) date and a Security Income Status code (SISC) of “D” (denied), the Modernized Claims System (MCS) may not allow an Earnings Computation (EC) trigger due to a systems limitation. Input a “6” (Windfall Offset) in the “Select Miscellaneous Factor” field on the Benefit Continuity Factors (BECF) screen.

For information about the SID data line, see SM 00510.510.

D. CA/CTE procedure for determining if windfall offset applies

In the following situations, identify the type of case and determine if windfall offset applies.

1. Beneficiary does not appeal Title XVI denial

Many ALJ decisions are for cases where the individual initially filed a concurrent Title II/Title XVI claim. When the initial Title XVI claim was a denial, and the claimant did not appeal the decision, do not apply windfall offset. Process the case following the instructions in GN 02610.055E in this section.

2. Title II-only ALJ decision

Do not apply windfall offset if the ALJ makes a Title II-only decision and no months of Title XVI eligibility on any prior SSRs coincide with months of entitlement for the current Title II claim. In this situation, process the case following the instructions in GN 02610.055 F in this section to release the retroactive Title II benefits.

3. Title II-only ALJ decision and prior record(s) show SSI eligibility

When the ALJ made a Title II-only decision and the individual is eligible for Title XVI on prior terminated SSRs, withhold the retroactive Title II benefits and develop for windfall offset. Process the case following the instructions in GN 02610.055G.

4. ALJ decision applies to the Title II and Title XVI claims

When the ALJ decision applies to the Title II and Title XVI claims, withhold the retroactive Title II benefits pending development of windfall offset. Process the case following the instructions in GN 02610.055 G in this section.

NOTE: The instructions in GN 02610.055 focus on identifying when Title II retroactive benefits can be released immediately without windfall offset development. Some of the PCs have established local instructions for processing the release of the Title II retroactive benefits. These local instructions might be slightly different from the instructions in GN 02610.055E through GN 02610.055G, but can be used if they achieve the correct result.

E. CA/CTE procedure for processing Title II-only ALJ decisions when Title XVI claim is denied and not appealed

If the claimant received a denial notice for the Title XVI claim, and did not file a timely appeal, no Title XVI payment is due. If the ALJ made a Title II-only decision, release the retroactive benefits without holding for windfall offset development. Before releasing the retroactive benefits, determine that no months of Title XVI eligibility on any prior record coincide with months of entitlement for the current Title II claim. Process the case as follows.

1. MCS input screens

If MCS does not generate an exception or processing limitation, take the following actions on MCS.

  • BECF Screen - Do not enter the “6” (Windfall Offset) in the “Select Miscellaneous Factor” field on the BECF screen. Remove the “6” if it propagates from a prior MCS segment.

  • Adjudicate the claim with no Title XVI coding and release the past-due benefits through MCS-EC.

For information about the IDEN screen, see MSOM MCS 005.059. For information about the BECF screen, see MSOM MCS 009.003.

2. MCS Earnings Computation (MCS-EC) trigger

For the MCS exception “SSI RECIPIENT; NO WINDFAL OFFSET ON BECF”, take the following actions:

  • BECF Screen - Enter a “6” (Windfall Offset) in the “Select Miscellaneous Factor” field on the BECF screen to bypass the exception.

  • Worksheet Remarks (DW03) Screen – Add a comment “SSI does not apply. “6” used on BECF screen to bypass MCS exception. Benefits will be released immediately through MACADE.”

  • Notice 3 (NOT3) Screen - Input a “Y” for an incomplete notice on the NOT3 screen. The next day, remove the WFO002 paragraph from the notice in Aurora. Do not release the notice.

  • Adjudicate the claim through MCS-EC.

  • Route the APPEAL/DHEAR Action Control Record (ACR) to BA/PROC.

  • Inform the BA/BTE that Title XVI offset does not apply.

  • The BA/BTE must remove the Windfall Offset data (WOD) field from the MBR, release the past-due benefits immediately. After processing the MACADE action, add prior month accrual (PMA) and current month accrual (CMA) information to the incomplete award notice in Aurora.

For information about:

  • MCS-EC trigger, see MSOM MCSEC 001.001 and MSOM MCS 004.004;

  • MSC-EC exception messages, see MSOM MCSEC 001.036;

  • NOT3 screen, see MSOM MCS 009.010

NOTE: An alternative process to posting the windfall offset code of “6” on the BECF screen can be followed. If the SSI claim was recently withdrawn and N12 is posted to the SSR, the Title II claim will process thru EC without generating the edit for the CA/CR. If the CA/CTE holds the case for a day or two, the entire Title II retroactive benefit will be released immediately.

3. A101 needed

For MCS processing limitations or exceptions generated for reasons other than windfall offset, process the case as follows:

  • Remove the Title XVI windfall offset code “6” from the BECF screen on MCS and adjudicate the award with an A101.

  • Route the “APPEAL/DHEAR ACR” to the benefit authorizer/benefits technical examiner (BA/BTE).

  • Inform the BA/BTE that Title XVI offset does not apply and to release the past-due benefits immediately.

  • MACADE may require the input of the WOD field if the SISC field in the SID line of the MBR is other than “I” or “Y.” In this situation, complete the WOD screen with a Windfall Indicator (WIN) code of “D” without Non-countable (NCI) to avoid the115 MACADE exception.

  • Inform the BA/BTE that a second day MACADE input is required to delete the WOD data from the MBR.

For information on completing the A101, see SM 00880.252 and MSOM MCS 014.001.

F. CA/CTE procedure for processing Title II-only ALJ decisions and withholding retroactive benefits due to Title XVI eligibility on prior record or current SSR

If the ALJ made a Title II only decision, but the individual was eligible for Title XVI payments on a prior terminated or current SSR for any month of Title II entitlement, withhold retroactive Title II benefits pending windfall offset development. Process the case as follows.

1. MCS input

  • IDEN screen - Enter “1” (Yes) to the question “Filed or Intends to File for SSI” on the IDEN screen.

  • BECF screen - Enter “6” (Windfall Offset) in the “Select Miscellaneous Factors” field on the BECF screen.

2. MCS-EC trigger

  • Do a pre-adjudicative EC to determine if adjudication can occur through MCS-EC. Clear any alerts, processing limitations, and exceptions. For information about the pre-adjudicative EC, see MSOM MCSEC 001.004.

  • If no processing limitations or exceptions prevent processing the case, adjudicate the case through MCS-EC with the past-due benefits in suspense LAFS9/WINFAL.

  • If the PSY on the SSR shows a termination code, route the APPEAL/DHEAR ACR to the BA/BTE.

  • Advise the BA/BTE to send an e4345 to the field office (FO) for an offset determination with the comment “SSR terminated, possible Title XVI Offset.”

3. A101 needed

If there is an MCS processing limitation or exception, process the case as follows.

  • Adjudicate the case with an A101 and route the A101 to the BA/BTE using the APPEAL/DHEAR ACR.

  • Request the BA/BTE to suspend the past-due benefits (LAF S9/WINFAL).

  • If the SSR is a terminated record, the BA/BTE must initiate an e4345 to the FO for an offset determination because the MBR/SSR interface will not occur. Include a comment on the e4345, “SSR terminated, possible Title XVI Offset.”

  • If the SSR is not a terminated record, the MBR/SSR interface will occur and the e4345 is not necessary.

G. CA/CTE procedure for processing concurrent ALJ decisions and withholding retroactive benefits pending windfall offset development

For cases with concurrent Title II/Title XVI ALJ decisions, always withhold the retroactive Title II benefits pending windfall offset development. Process the case as follows.

1. Review all SSRs

Check the (PSY) field on all SSRs for the presence of a termination code (i.e., T30, T31, T32, T33, T50, T51, or T01).

  • A terminated or NIF SSR will always require a PC to send an e4345 to alert the FO of the possibility of offset because the MBR/SSR interface will not occur. The FO will establish the SSR and provide Title XVI payment information as a response to the e4345.

  • If the PSY code on the SSR is blank or other than "T", the MBR/SSR interface will occur and an e4345 is not necessary.

  • In concurrent claims, the (APPE) data segment will be present on the SSR. Check to see if the appeal decision code and date (DSN) is equivalent to the ALJ decision date to prevent an incorrect offset determination.

2. Complete the MCS inputs

The PC will process as follows:

  • IDEN Screen - Enter “1” (Yes) for the question “Filed or Intends to File or SSI” on the IDEN screen.

  • BECF Screen - Enter “6” (Windfall Offset) in the “Select Miscellaneous Factor” field on the BECF screen.

  • MCS-EC Trigger - Do a pre-adjudicative EC to determine if adjudication can occur through EC. Resolve alerts, processing limitations, and exceptions.

  • If a processing limitation or exception does not prohibit EC processing, adjudicate the case through MCS-EC with the past-due benefits in suspense (LAF S9/WINFAL).

  • If the PSY on the SSR shows a termination code, route the APPEAL/DHEAR ACR to the BA PROC and advise the BA/BTE to send an e4345 to the FO for an offset determination and include a comment in remarks “SSR terminated, possible SSI Offset”.

3. A101 needed

If there is an MCS processing limitation or exception, process as follows.

  • Adjudicate the case with an A101 and route the A101 to the BA/BTE using the APPEAL/DHEAR ACR.

  • Request that the BA/BTE suspend the past-due benefits (LAFS9/WINFAL).<