TN 15 (01-04)
RS 02801.001 Critical Case Criteria and Exclusions
A. Policy – critical case criteria
SSA's goal is to pay all benefits due on time. Processing critical cases has priority over all other workloads. Through routine processing, this goal is usually met. However, when a beneficiary is adversely affected because payment is not made timely, our goal is to resolve the problem and make payment as soon as possible. Some of these cases are considered “critical.”
Most critical cases are identified and processed in the FO and paid via the Critical Payment System (CPS) (SM 00635.001, MSOM INTRANETCPS 001.001). CPS is a method of payment designed for use primarily (but not exclusively) in critical case situations.
NOTE: The existence of a CPS exclusion does not also exclude the case from critical case processing. When a CPS exclusion exists, the FO will complete an MDW 2560HP Request (High Priority Payment Center Request) (MSOM MDW 001.003 MDW Worksheet (MMDW).
There are two methods of replacing payments which have not been received by an individual.
The critical payment--a check is issued by the Treasury Department and received by the individual in 5-7 days. The critical payment process is used for limited situations and the FO should be certain the problem cannot be resolved through routine processing.
The immediate payment (IP)--a check is issued immediately in the field office because of a dire need situation (see RS 02801.010). Both of these payment processes are recorded via CPS.
For all critical cases, there must be evidence of:
entitlement with the paper evidence submitted to SSA, and
payment is due (for terminal illness (TERI) cases, there are developmental tolerances).
1. A critical case exists when
the case is identified as a TERI case (DI 11005.601); or
a due payment has not been received and an urgent need exists and/or there is a public relations problem.
NOTE: For all garnishment situations, use COGS per GN 02410.210.
2. A critical case may be
An initial claim for retirement, survivors or disability benefits with all factors of entitlement met. All TERI cases are critical.
NOTE: An initial claim critical case may qualify for preliminary payment (RS 02807.005) or expedited payment (RS 02805.001).
A reinstatement of payment -- cases that have been suspended and evidence has been submitted showing the suspension no longer applies.
A delayed or interrupted payment for a beneficiary due to a processing error (e.g., failure to convert life benefits to survivors benefits, incorrect death termination).
With these cases
PC's may make payment in AC and ALJ reversals and RSI reconsideration cases. If an FO identifies such a case as a critical case, an MDW 2560HP Request (High Priority Payment Center Request) should be completed and sent to the PC.
NOTE: In concurrent Title II/XVI cases, the PC coordinates payment with the FO to avoid creating a windfall. See GN 02610.005.
The method of payment for a DIB reconsideration reversal identified as a critical case in an FO depends on the location of the file. In all cases CPS processing should be used. If there is a CPS exclusion, or the FO has not received a copy of an approved SSA-831-U5 or SSA-833-U5, the MDW 2560HP Request (High Priority Payment Center Request) should be completed and sent to the PC.
Nonreceipt of issued payment(s) - EFT or dire need
When nonreceipt is alleged involving EFT and the payment has been sent to the incorrect bank (e.g., wrong routing transmit number or RTN), a CPS payment may be issued. Refer to GN 02406.007 to determine appropriate action. When nonreceipt is reported for a nonrecurring paper check, see GN 02406.003 and GN 02406.200.
If the beneficiary reports nonreceipt and indicates dire need, SSA can issue an immediate payment if the criteria in RS 02801.010 are met. If there are any additional benefits due in excess of the immediate payment limitation, payment may be made through CPS. See GN 02406.125C and GN 02406.125D to determine what action to take for a missing paper check when dire need exists.
NOTE: If processing a CPS payment for nonreceipt of a check, DO NOT also do a nonreceipt input, as this would cause 2 replacement checks to be issued.
Cases identified in the PC
The following types of cases identified in the PC may need CPS processing.
Correspondence from the beneficiary, his/her representative payee, or someone writing on his/her behalf (e.g., a congressional inquiry) which indicates a payment problem that meets the criteria in RS 02801.001A.1., or
A delayed payment inquiry indicates a payment problem that meets the criteria in RS 02801.001A.1. or an inquiry that is not associated with the folder within 15 days of receipt in the PC, or
A disability to survivor conversion, not automatically processed by the Death Termination Program, that has subsequently failed two attempts to process the survivor award through MADCAP, or
A MADCAP adjustment action for nonpayment to payment status that has excepted three times.
B. Policy – critical payment exclusions
Listed below are exclusions from critical case processing.
1. Actions or issues where no payment is due:
A Medicare problem (no Title II payment problem);
NOTE: Refund of Medicare premium due to State Buy-In can be issued by CPS in situations where the State has already paid the premiums for that month(s).
SSN problems (see RM 10215.035) or;
Earnings discrepancies (see RM 03844.006).
Request for explanation of benefit or overpayment amounts.
2. Other exclusions
A request for recomputations, recalculations, and/or delayed retirement credits where only amount of payment is in question (RS 00605.401);
Nonreceipt that represents only: a retroactive cost-of-living increase payable to all beneficiaries; a LSDP, or an underpayment due a deceased beneficiary.
A conditionally adjudicated or unadjudicated claim.
The family maximum has been paid; a critical case payment may not exceed the family maximum
Tax Refund Offset (TRO) Refunds (GN 02201.030). The Critical Payment System should not be used for these refunds.
NOTE: SM 00635.001H.3. contains additional instructions for when CPS is not permitted.
C. Procedure – CPS processing
Evaluate cases other than TERI cases as follows.
Obtain evidence that entitlement exists and payment is due.
Ensure that the problem cannot be resolved through routine processing.
Consider the merits of each case when applying the critical case definition and criteria.
1. A Followup to priority payment request
If the FO has not received a reply from the PC to the MDW category 2560 or 2560HP within a few days indicating that
the requested action is being taken; or
the case is being treated as a critical case and payment is being (has been) made; or
the payment cannot be made and why.
Follow-up with the PC using the Manager-to-Manager process (see GN 01070.228).
2. Benefit Payment Offset (BPO) cases
Title II benefit payments are subject to the Treasury Offset Program (TOP). BPO reduces an individual's Title II benefit to recover non-tax debts owed to other Federal agencies. Therefore, make the CPS for the amount the individual is due minus any BPO amount. Do not include the BPO amount in the CPS payment because SSA cannot be reimbursed for the BPO amount. DO NOT use CPS to pay back excess BPO payments (see GN 02410.300A.8.) See GN 02201.029.