GN PHI03105.040 Reconstructing Lost/Missing Paper Claims Folders for ALJ Hearings (RTN 1 - 06/2007)

See GN 03105.040

A. Background

In the Philadelphia Region, field office management has authorized the reconstruction of lost or missing paper claims folders needed for ALJ hearings. The RO has maintained a role in this process by providing assistance as needed.

B. Scope

These folder reconstruction instructions apply to both disability and nondisability hearings, although they are most often used for disability cases. Now that all of the DDSs in our region have been IDA-certified and most disability folders for current claims are electronic, there should not be many paper disability folders that need to be reconstructed. However, there will always be some disability claims that are EDCS exclusion cases in which the paper folder is the official folder.

Regarding lost or missing disability folders needed for ALJ hearings which are EDCS exclusions there are three different categories of cases:

  1. The first group of cases consists of hearings for current claims in which the folder was a CEF at the initial (and reconsideration level if a non-Prototype disability claim), but the case is now excluded from electronic processing. Regarding this group of cases, in which all evidence is available electronically but an EDCS exclusion now applies at the hearing level, the FO

    1. Prints Sections A through Section D of the electronic folder (EF) and files the documents in the appropriate sections of the paper MDF.

    2. Forwards the MDF to the HO, which will review and print the Disability Related Development (Section E) and Medical Evidence of Record (MER) (Section F) of the EF.

    3. If the claimant submits new evidence that was not contained in the original claims folder, annotate it “New Evidence.”

  2. The second group of cases are those disability claims which were filed before the certification date of the DDS and which were processed as “hybrids,” i.e., the official folder was paper but an electronic folder was also created, and the claim was processed by DDS in Document Management Architecture (DMA). Regarding these cases, the FO

    1. Prints Sections A through Section D of the electronic folder (EF) and files the documents in the appropriate sections of the paper MDF.

    2. Forwards the MDF to the DDS, which will review and print the Disability Related Development (Section E) and Medical Evidence of Record (MER) (Section F) of the EF. The DDS needs to ascertain whether the electronic file contains all medical evidence used in the initial (and reconsideration when appropriate) determination(s). Any missing medical evidence needs to be redeveloped.

    3. If the claimant submits new evidence that was not contained in the original claims folder, annotate it “New Evidence.”

    4. Forward the folder to the hearing office.

  3. The third group of cases consists of hearings for current claims that were EDCS exclusion cases at the initial or reconsideration level and for which the official folder was paper. The regional folder reconstruction instructions shown below apply to this group of cases in which evidence from the initial and/or reconsideration level is not available electronically.

C. Timeframes

The timely processing of hearing requests requires that folder reconstruction, when needed, is performed in a timely manner. Shown below are timeframes for steps in the folder reconstructions process. These timeframes are based on national folder reconstruction procedure in GN 03105.040.

Folder Reconstruction Steps

Timeframe

Decision to reconstruct the lost or missing claims folder. The hearing office needs to be notified when this decision is made.

Within five business days after receipt of the hearing request unless the folder has been requested from a PSC, NRC/FRC, or another FO.

Reconstruction of nonmedical files or the nonmedical part of a DIB folder.

The FO has 15 business days.

Reconstruction of medical issues

The disability determination service (DDS) has 30 calendar days for reconstruction.

D. Communication with the Hearing Office

Timely communication with the hearing office is essential in folder reconstruction situations, as it is in all hearing situations. Communication with the hearing office should begin with the field office receipt of the hearing request. Per GN 03103.080, “When a request for hearing is filed, forwarding the HA-501-U5 and claims folder to the HO expeditiously has the highest priority.” This POMS reference provides specific instructions for forwarding a copy of the hearing request to the hearing office within one business day of the receipt of the request. If the claims folder is not readily available and is not being sent with the copy of the hearing request, GN 03103.080 also provides instructions for requesting the folder and providing the hearing office with documentation of the FO actions.

If the hearing office does not receive notification of the decision to reconstruct the folder or the requested development within the timeframes noted in GN PHI03105.040C, the hearing office will contact a manager in the servicing field office or a local FO/ODAR liaison if one has been designated. When necessary, the hearing office will contact the Office of the Regional Chief Judge for assistance.

E. Folder Search

Systems queries should be reviewed to ascertain possible locations for the missing folder. The Seattle Region's Automated Folder Location Web Site can assist in the folder location process by doing most of the “leg work” behind the scenes. Simply enter the claimant's SSN and this system will access a series of systems records in a logical order and provide a list of locations that can be eliminated and a list of locations that are potential leads to the whereabouts of a specific file. Regional office can also provide assistance in locating folders when needed.

F. Reconstruction - Management Approval

If the current claims folder under appeal cannot be found after all reasonable efforts have been made to locate the file per GN 03105.020, and the missing folder contains documents that are not available electronically per GN 03105.010 (certified electronic folder for a disability claim) or GN 03105.010 (other records available electronically), a field office manager should authorize reconstruction of the folder. In the Philadelphia Region it is not necessary to contact the regional office for authorization to reconstruct. Other regions should follow the instructions in GN 03105.040 or, when appropriate, their own regions instructions.

G. Hearing Office Notification

When the FO manager authorizes reconstruction, the Hearing Office (HO) must be notified immediately and given an anticipated completion date. The FO should complete all necessary development within the timeframe shown in the chart in GN PHI03105.040C. Tight control of this development is essential to minimize further delay and hardship for the claimant.

Hearing offices in our region report that claimant representatives have, on many occasions, been able to supply portions of missing folders. When the FO notifies the HO that folder reconstruction is being initiated, the FO should request information concerning the claimant's representative (in some cases the hearing office may have new or updated information concerning the representative) and any evidence the representative may have submitted to the hearing office.

If the current claim under appeal at the hearing level is located, but a prior file cannot be located, advise the hearing office (HO) of any pertinent information you have about the prior file. Do not attempt to reconstruct the prior file unless the ALJ has requested it.

H. Reconstruction Involving Nonmedical Issues

Follow GN 03105.010 for reconstructing nonmedical claims. The reconstructed material should be forwarded directly to the HO under cover of the Reconstruction Folder Flag (Exhibit 1).

I. Reconstruction Involving Medical Issues

The FO will initiate reconstruction of the medical issue disability claims. The field office will obtain the appropriate medical history forms, medical release forms and any other evidence that will assist the DDS with medical reconstruction. Send these forms immediately to the DDS under cover of the Request for Medical Reconstruction Flag (Exhibit 2). Do not hold medical forms until the nonmedical evidence is reconstructed.

Set a 30-day tickle, and followup with the DDS if the medical portion of the reconstructed folder isn't received in the field office by then. Local arrangements may be made between the field office and the DDS to further expedite the medical reconstruction.

Hold the completed nonmedical portion of the reconstructed folder in the field office pending receipt of the medical portion from the DDS. When both parts (medical and nonmedical) are completed, forward the entire file to the HO. Annotate "Reconstructed" in bold red letters across the front of the folder jacket, and mark each piece of evidence in the folder "reconstructed." If the claimant submits new evidence that was not contained in the original claims folder, annotate it “New Evidence.”

J. Failure to Cooperate

When a claimant fails to respond to the field office's efforts to reconstruct the folder (initial contact and follow-up at 7 days), the field office should advise the HO.

NOTE: If the claimant has appointed a representative, per GN 03910.025.1.a, the representative should “be informed of all additional evidence needed to support the claim.”

Unless special instructions are provided by the HO, if the claimant fails to respond to requests for information needed for the reconstruction, the hearing can be cleared to ODAR by sending what information the field office has been able to reconstruct from the office records. All efforts to contact the claimant must be properly documented in the file.

K. Change of Address

If the claimant no longer resides in the service area of the field office handling the reconstruction request, transfer the reconstruction to the appropriate servicing field office after advising the new office of the transfer by telephone. Record the name, title, and phone number of the individual who will handle the reconstruction in the new office and send this information to the HO.

EXHIBIT 1

G-GN_03105.040-1

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EXHIBIT 2

G-GN_03105.040-2

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GN PHI03105.040 - Reconstructing Lost/Missing Paper Claims Folders for ALJ Hearings (RTN 1 - 06/2007) - 0