TN 5 (03-13)

GN 02615.185 Supplemental Security Income (SSI) Clark Relief Appeals

A. Cases selected for potential Clark relief

Cases selected for potential Clark relief may have an appeal pending or posted on October 24, 2006, or later. We identified these cases with a Court Case Identifier (CCID) of C5 on the Civil Action Tracking System (CATS). The appeal may be on an initial determination for a medical issue that involves a parole or probation violation (PPV) period, solely a PPV issue, or on some other non-medical issue. The appeal may be pending at the Field Office (FO), the Disability Determination Services (DDS), the Office of Disability Adjudication and Review (ODAR) either with an administrative law judge (ALJ) at the hearing office (HO), or the Appeals Council (AC) in the Office of Appellate Operations (OAO). The type of appeal will determine the action required prior to providing Clark relief.

B. Determining the type of appeal

To determine the type of appeal that exists on the Supplemental Security Record (SSR), review the following:

1. Medical appeal exists and involves a PPV suspension period

A medical appeal exists if the Appeals Segment Identifier (APPE) field on the latest SSR shows a Reason (RSN) code of DI. If a medical appeal exists on the latest SSR, and there is a PPV suspension period on that or any earlier SSR, see the chart for the action required to resolve the appeal in GN 02615.185C in this section. If a case does not have a medical appeal pending, but has a PPV suspension period that meets the class definition, we identified these cases as C3 or C4 in CATS. Process the case following instructions in GN 02615.180.

2. Non-medical appeal exists that may involve a PPV issue

A non-medical appeal exists if the RSN code is other than DI. If the APPE field on the SSR shows RSN = OT, OP, or blank, determine if the appeal is on a PPV issue by checking the Claims File Records Management System (CFRMS) for reconsideration appeals, the Case Processing and Management System (CPMS) for hearing level appeals, or the Appeals Review Processing System (ARPS) for Appeals Council cases. The Clark case characteristic in CPMS or ARPS is CALC. If the PPV issue has a pending appeal or has a posted appeal decision in the DSN field on the SSR, follow instructions in GN 02615.185D in this section. For a list of DSN codes, see SM 01601.685.

C. Resolve pending medical appeals

A pending medical appeal requires action prior to providing relief. Resolve the pending medical appeals using the following charts as guidance.

1. Types of medical appeal issues

The following are different types of medical appeal issues that require action prior to providing relief.

Issue

Field Office (FO) Action

DDS, HO, AC Action

a.  Concurrent – A medical appeal pending on the title II (T2) but title XVI (T16) was a technical denial based on a PPV with no medical determination

  • Secure a T16 application and medical evidence for the PPV N25 record (use protective filing date of original N25 application);

  • Unless pending at the AC, escalate the T16 claim following instructions in DI 11055.025;

  • Add a remark to the SSR, “If favorable medical determination, develop for possible Clark relief per GN 02615.180”;

  • Mark the case complete on the Clark SSTNG Exception Cases website.

  • If at the AC, notify the AC of pending T16 Clark case via the SSA-5002 (Report of Contact) with a follow up email that you sent the case to DDS for a disability determination, for the earlier Clark relief period. For HO email, use the Detailed Office/Organization Resource System (DOORS). For the AC, send the email to |||ODAR OAO. Enter “Clark Case” in the subject line

Case stays at DDS or the HO for a medical evaluation. The AC will hold the case pending DDS determination. If unfavorable, the AC will consider the appropriate course of action. If favorable, the AC will dismiss and send the case to the FO for Clark processing.

b. SSI Only - Latest SSR contains both the PPV N25 suspension period and a medical appeal

  • Add a remark to the SSR, “If favorable medical determination, develop for possible Clark relief per GN 02615.180”;

  • Do not mark the case complete until you provide Clark relief.

Case stays at DDS, HO, or the AC for a medical evaluation.

c. SSI Only - Latest SSR contains a medical appeal, but the N25 suspension period is on a prior SSR and that prior SSR has a favorable medical determination or decision

  • Case is a subsequent medical denial case; refer to instructions in DI 52522.001;

  • Complete the RZ to determine if Clark relief is due. Fully develop eligibility from the earliest point of Clark relief forward. If development reveals 12 consecutive months of ineligibility for reasons other than N25, conduct an RZ only for the applicable closed period and take no action on the pending appeal. If development reveals continuing eligibility, request that the ALJ or OAO dismiss or vacate the appeal;

  • Recall the pending medical appeal following SM 01201.225;

  • Complete the SSA-5002, advising the appeal level that no medical determination is required based on the Clark court order.

DDS, HO, or the AC will vacate the appealed determination or decision and refer the case back to the FO to determine Clark relief. For additional instructions, see HALLEX I-5-4-70.

d. SSI Only - Latest SSR contains a medical appeal, but the PPV N25 suspension period is on a prior SSR and there is no medical determination or decision on that prior SSR

Medical appeal pending at the DDS:
  • Secure an application and medical evidence for the PPV N25 record (use protective filing date of original N25 application);

  • Route the claim to DDS and inform them that they need to make a medical determination on the entire Clark relief period following procedures in DI 52522.001;

  • Add a remark on the SSR stating: “If favorable medical allowance, develop for possible Clark relief per GN 02615.180”;

  • Mark the case complete on the Clark SSTNG Exception Cases website.

    

Medical appeal is pending at HO or the AC:

  • Secure an application and medical evidence for the PPV N25 record (use protective filing date of original N25 application) and route to DDS following procedures in DI 52522.001;

  • Add a remark on the SSR stating: “If favorable medical allowance, develop for possible Clark relief per GN 02615.180”;

  • Mark the case complete on the Clark SSTNG Exception Cases website;

  • Notify the HO or the AC via the SSA-5002, with a follow up email that you sent the case to DDS for a disability determination, for the earlier Clark relief period. For HO email, use the Detailed Office/Organization Resource System (DOORS). For the AC, send the email to |||ODAR OAO. Enter “Clark Case” in the subject line;

For additional actions required for this specific type of appeal issue, see chart in GN 02615.185C.2. in this section.

Case stays at the DDS, HO, or AC for a medical evaluation.

2. Additional actions required for specific type of appeal issue

The following are additional actions required when the case contains the specific type of appeal identified in the chart in GN 02615.185C.1. in this section.

Issue

Field Office (FO) Action

DDS, HO, AC Action

SSI Only - Latest SSR contains a medical appeal, but the PPV N25 suspension period is on a prior SSR and there is no medical determination or decision on that prior SSR

Medical appeal at DDS

No action required. The DDS will process the medical determination following normal procedures.

Medical appeal at the HO

  1. If the DDS determination for the PPV N25 period is unfavorable and the medical appeal is still pending at the HO, route the PPV N25 claim to the HO to associate with the pending appeal.

  2. If the DDS determination for the PPV N25 period is favorable and the HO appeal is still pending:

    • send an SSA-5002 with a follow up email with the subject line “Clark Case” requesting that the HO dismiss the pending medical appeal citing Clark and send the case back to the FO. Use DOORS for HO email;

    • provide Clark relief; or

  3. If the HO made a favorable decision on the pending medical appeal prior to receiving the DDS determination for the PPV N25 period, process the period covered by the HO medical appeal decision following normal procedures. Once you receive the DDS determination for the PPV N25 period for:

    • a favorable DDS medical determination, provide relief for the Clark period and continuing; or

    • an unfavorable DDS medical determination, follow normal appeal procedures.

  4. The HO made an unfavorable decision on the pending medical appeal prior to receiving the DDS determination for the PPV N25 period. Once you receive the DDS determination on the PPV N25 period for:

    • a favorable DDS medical determination, send an SSA-5002 with a follow up email with the subject line “Clark Case” requesting that the HO vacate the medical appeal decision citing Clark and send the case back to the FO. Use DOORS for HO email;

    • an unfavorable DDS medical determination, follow normal appeal procedures.

Medical appeal pending at the AC

  1. If the DDS determination for the PPV N25 period is unfavorable:

    Notify the AC via an SSA-5002 with a follow up email to |||ODAR OAO with a subject line of “Clark Case” that an unfavorable medical decision was issued on a prior Clark claim and that there is pending appeal at the AC.

  2. If the DDS determination for the PPV N25 period is favorable and the AC appeal is still pending:

    • send an SSA-5002 with a follow up email to |||ODAR OAO with subject line of “Clark Case” requesting that the AC dismiss the pending appeal under Clark and send the case back to the FO;

    • provide Clark relief.

  3. If the AC acted on the pending medical appeal with a favorable decision prior to receiving the DDS determination for the PPV N25 period, process the period covered by the AC medical appeal action following normal procedures. Once you receive the DDS determination for the PPV N25 period for:

    • a favorable DDS medical determination, provide relief for the Clark period and continuing; or

    • an unfavorable DDS medical determination, follow normal appeal procedures.

  4. The AC acted on the pending medical appeal with an unfavorable action prior to receiving the DDS determination for the PPV N25 period. Once you receive the DDS determination on the PPV N25 period for:

    • a favorable DDS medical determination, send an SSA-5002 with a follow up email to |||ODAR OAO with subject line of “Clark Case” requesting that the AC vacate the action and send the case back to the FO;

    • unfavorable DDS medical determination, follow normal appeal procedures.

Medical appeal at DDS

The DDS will send the medical determination to the FO following normal procedures.

    

Medical appeal at the HO

    

  1. If DDS makes an unfavorable determination, the HO will consolidate the claims with the pending appeal.

  2. If DDS makes a favorable determination on the Clark period, the HO will dismiss the pending medical appeal and send the case back to the FO.

  3. The HO makes a decision on the pending medical appeal prior to receiving the DDS determination for the Clark period, the HO will route the case to the FO following normal procedures.

     

Medical appeal at the AC

  1. DDS makes an unfavorable determination; the AC takes into consideration the prior application in determining appropriate action.

  2. DDS makes a favorable determination on the Clark relief period; the AC will dismiss the pending medical appeal citing Clark and send the case back to the FO.

  3. The AC acts on the pending medical appeal prior to receiving the DDS determination for the Clark period, the AC will route the case to the FO following normal procedures.

D. Resolve claims with PPV related non-medical appeals

If a PPV non-medical appeal is pending or has a posted decision in the DSN field on the SSR, review the following actions required in order to provide Clark relief.

1. PPV pending non-medical appeal level actions

The FO, HO, or AC will take the following actions to resolve the pending appeal before the FO provides relief. Once the appeal level action is complete, the FO will provide relief following instructions in GN 02615.180 and close out the appeal following instructions in GN 02615.185D.2. in this section.

Appeal Type

Appeal Level Action

Reconsideration

FO stops development of the appeal and develops for Clark relief.

Hearing with the ALJ

  • Remand the appeal back to the FO via form HA-L48 (Transmittal by Office of Disability Adjudication and Review);

  • Identify as “Clark Court Case”; and

  • Place an alert in the Alert and Message section in eView to notify the FO of Clark involvement.

For additional instructions, see HALLEX I-5-4-70.

AC Review

  • Issue an order vacating the hearing decision;

  • Return the case to the local FO via form HA-505 (Transmittal by Office of Disability Adjudication and Review, Office of Appellate Operations);

  • Identify as “Clark Court Case”; and

  • Include a red “Special” label with form HA-505.

For additional instructions, see HALLEX I-5-4-70.

2. FO closes out the pending appeal on the SSR

Take the following action to close out the pending appeal on the SSR:

a. MSSICS

  • From the MSSI menu, select “2” (Update) and “9” (Appeals).

  • On the ADIS screen, input the Decision Type as the “Other Disposition Type” and select “3” (Closed for Other Reason).

b. Non-MSSICS

  • From the MSSI menu, select “2” (Update) and “19” (Direct SSR Update).

  • On the UAPD screen, input the Decision Type as “Other Disposition Type” and select “8” (Closed for Other Reason).

3. PPV non-medical appeals with posted decisions

If a case has an unfavorable decision on the SSR for a PPV related issue and there has been no request for a further appeal review, provide Clark relief following instructions in GN 02615.180. There is no need to vacate the appeal decision.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0202615185
GN 02615.185 - Supplemental Security Income (SSI) Clark Relief Appeals - 06/18/2013
Batch run: 06/18/2013
Rev:06/18/2013