TN 8 (06-04)

GN 04440.207 Correcting Group I Medical Documentation Deficiencies Involving Onset – Concurrent Title II/Title XVI Cases

A. Procedure – corrective action

1. Post–Effectuation Correction

If payment can be made on the Title XVI portion of the concurrent claim, but additional development regarding onset date is needed in the Title II claim, corrective action is taken after effectuation of the Title XVI determination. See GN 04440.206A. for an explanation of when a medical documentation deficiency involving onset exists.

EXCEPTION: If the claimant dies before the review is completed, the corrective action will be taken pre-effectuation. Follow GN 04440.206 in these situations.

2. Routing – initial claims

In concurrent Title II/Title XVI initial claims with a medical documentation deficiency involving onset, the folder and deficiency return are sent to the adjudicating component, and the Title XVI SSA-831-C3/U3 is faxed to the FO.

EXCEPTION: Cases involving unresolved capability issues or cases in which the beneficiary has a drug addiction and/or alcoholism (DAA) condition and is incapable of managing his/her benefits follow the same routing procedure as concurrent reconsideration claims as discussed in GN 04440.207A.3.

3. Routing – reconsideration//nitial exception cases

In concurrent Title II/Title XVI reconsideration claims and concurrent Title II/Title XVI initial claims that are an exception to the initial claims routing procedure, both claims folders are sent to the FO for effectuation of the Title XVI determination and any other necessary action. The review component faxes an SSA-1774-U5 deficiency return and supporting documentation to the adjudicating component for corrective action.

B. Procedure-review component- initial cases

Take the following action in an initial claim unless the case involves an unresolved capability issue, or the beneficiary has a DAA condition and is incapable of managing his/her benefits (in which case, follow GN 04440.207C.).

1. Title XVI SSA-831-C3/U3 Action

For Title XVI SSA-831-C3/U3 action:

  • Annotate block 34 of the Title XVI SSA-831-C3/U3

    Documentation involving onset being developed in the Title II claim. Effectuate payment on the Title XVI claim. Do not effectuate payment on the Title II claim at this time. DQB will send folders after development is completed.

  • Approve the Title XVI SSA-831-C3/U3.

  • Place a copy of the annotated Title XVI SSA-831-C3/U3 in the claims folders.

2. Deficiency return

Prepare an SSA-1774-U5 to the adjudicating component and:

  • Request medical documentation of onset;

  • Instruct the adjudicating component to return the case to the review component;

  • Tell the adjudicating component that they are not being charged with a deficiency if the Title II claim is not the sample case.

Release copies of the SSA-1774-U5 in accordance with GN 04440.501.

3. DICARS action

For DICARS action:

  • Code the appropriate group I medical documentation deficiency when the Title II claim is the QR sample case (See GN 04440.125), and enter the review findings into DICARS.

  • Control the return.

  • Ensure results data input when the case is returned.

4. Additional actions

For additional actions:

  • Prepare and/or release the Title XVI notice.

  • Effectuate the Title XVI determination if possible.

  • Attach the special payment effectuation flag (see exhibit in GN 04440.940) to the annotated Title XVI SSA-831-C3/U3 and fax the Title XVI SSA-831-C3/U3 to the appropriate FO. (The FO will effectuate payment.)

  • Document the file with the fax action taken.

  • Send both claims folders with the covering SSA-1774-U5 to the adjudicating component for corrective action in the Title II claim.

C. Procedure-review component – reconsideration/initial exception cases

Take the following action when the case is a concurrent reconsideration claim or a concurrent initial claim that involves either an unresolved capability issue or a beneficiary who has a DAA condition and is incapable of managing his/her benefits:

1. Title XVI SSA-831-C3/U3 action

For Title XVI SSA-831-C3/U3 action:

  • Annotate block 34 of the Title XVI SSA-831-C3/U3:

    Return folders to (name of adjudicating component) after award payment - Documentation i