TN 50 (02-11)

DI 11010.025 Guidelines for Deferral of Non-Medical Development

These instructions contain both non-medical and medical guidelines

  • To help interviewers decide whether non-medical development deferral is appropriate, and

  • For situations when simultaneous development is mandatory.

A. Policy for deferral of non-medical development

This policy applies to all field office (FO) employees conducting Title II or concurrent Title II and Title XVI disability claims interviews.

The general rule is to defer non-medical development at all levels of adjudication (initial, reconsideration, hearing, etc.) in Title II and concurrent Title II and Title XVI disability or blindness claims until the Disability Determination Services (DDS) or the administrative law judge (ALJ) makes a favorable medical determination. With the exception of mandated situations, exercise discretion when choosing whether to defer development. Generally, if you are unsure about whether to defer or simultaneously develop a claim, defer the development.

NOTE: For an explanation of deferring and simultaneously developing Title XVI claims, see SI 00603.002.

B. Tell the claimant recontact may be necessary prior to adjudicating the claim

Tell the claimant during the initial disability interview that recontact may be necessary, e.g., to provide additional evidence before adjudicating the claim.

FOs must ask the claimant about work activity or incarceration since the alleged onset date if recontact is necessary for another reason.

Document the claimant’s response on any of the following:

  • SSA-5002 (Report of Contact) (RPOC)

  • RPOC screen in MCS or MSSICS.

If the claimant answers “yes” to returning to work after the alleged onset date, go to DI 11010.025E.4. in this section.

IMPORTANT: Do not tell the claimant that recontact is made only if the claim is allowed. Do not indicate to the claimant in subsequent contacts that the DDS or ALJ allowed the claim. Wait until case processing is complete since a reversal is possible. DDS determinations and ALJ decisions are not final until all quality reviews are complete.

If there are other pending issues, e.g., workers compensation or public disability benefits (WC/PDB) with a particular case, consider asking or following up with the claimant at the time of recontact. WC/PDB payments may start, stop, or change in the time it takes to develop or process a claim.

C. Reminders about deferring development

The decision to defer or simultaneously develop non-medical factors does not affect the disability or blindness determination, and you do not have to document the decision to defer or simultaneously develop.

NOTE: Do not defer non-medical factors in claims situations identified in DI 11010.025D and DI 11010.025E in this section and SI 00603.002, Explanation of Deferred and Simultaneous Development.

1. Protective filing dates

It is important to protect the filing dates of potential auxiliaries in deferred development cases. Therefore, list the potential auxiliaries on the Modernized Claim Systems (MCS) disability application, paper Form SSA-16-F6 (Application for Disability Insurance Benefits), or other protective writing.

2. DDS contacts FO

If the DDS contacts the FO to develop one aspect of a deferred claim, it is not necessary to develop the other non-medical aspects unless an allowance is probable.

3. DDS jurisdiction

The instructions in this section for deferring development apply only to disability claims in DDS jurisdiction.

EXCEPTIONS:

  • Use simultaneous development procedures for claims that are not (or not expected to be) in DDS jurisdiction, see the procedures in DI 20101.001.

  • For exceptions involving auxiliary claims development in border FOs, see the NOTE in DI 11010.030B.

D. Mandatory development of all non-medical issues

Develop all non-medical issues immediately in the following claims situations; do not defer development.

1. Terminal illness cases

Follow the instructions in DI 11005.601 to identify and process terminal illness (TERI) cases. Initiate all development to expedite DDS processing if the claimant suffers from a terminal condition.

CAUTION: The claimant (or the claimant's family) may not be aware the condition is terminal, therefore, do not reveal information that the family or claimant’s medical source(s) requests withheld.

Annotate the official folder using the following procedures:

  1. For Electronic Disability Collect System (EDCS) claims that are Certified Electronic Folder (CEFs), flag the case as potentially TERI, see DI 81010.080, Alerts, Flags, and Messages in the Electronic Disability Collect System (EDCS).

  2. For paper folders, complete Form SSA-2200 (TERI Flag) and place it on the outside cover of the disability folder before sending it to the DDS.

2. Military casualty/wounded warrior cases

For instructions on identifying, processing, and tracking Military Casualty/Wounded Warrior (MC/WW) cases, see DI 11005.003 and DI 11005.006.

Initiate all development to expedite DDS processing. Annotate the official folder using the following procedures:

  1. For EDCS claims that are CEFs, add the MC/WW flag. Annotate the EDCS Remarks section “Military Casualty/Wounded Warrior Case” on the routing cover sheet.

  2. For paper folders, attach the MC/WW flag shown in DI 11005.006I. Place it on the outside cover of the disability folder before sending it to the DDS.

3. End stage renal disease Medicare claims

Do not defer non-medical development if a claimant with end stage renal disease (ESRD) is undergoing a regular course of dialysis or has undergone a kidney transplant within the last 12 months. We deem ESRD beneficiaries disabled for Medicare purposes.

4. Presumptive disability or presumptive blindness provisions

A claimant (including a child) applying for Supplemental Security Income (SSI) based on disability or blindness, may receive up to 6 months payments prior to the final determination if the FO determines the claimant is presumptively disabled or blind and meets all other eligibility requirements. Follow the procedures in DI 11055.240, Field Office (FO) Procedures for Processing Presumptive Disability (PD) and Presumptive Blindness (PB) Cases and complete all necessary non-medical development, e.g., income or resources as appropriate.

NOTE: For an explanation of deferring and simultaneously developing Title XVI claims, see SI 00603.002.

5. Quick disability determination and compassionate allowance cases

Do not defer development for claims electronically identified as a quick disability determination (QDD) or a compassionate allowance (CAL) case.

See Also:

  • DI 11005.603, Processing Quick Disability Determinations (QDD) Cases - Field Office (FO) Instructions

  • DI 11005.604, Processing Compassionate Allowance (CAL) in the Field Office (FO)

6. Amyotrophic lateral sclerosis cases

Do not defer development of cases with allegations of ALS. Complete all information carefully to avoid unnecessary recontact with the claimant. For further instructions, see DI 11036.001, Amyotrophic Lateral Sclerosis (ALS) – Medicare Waiting Period Waived – Field Office (FO).

For EDCS claims that are CEF, add the electronic ALS Case flag before transferring the claims to the DDS.

For paper folders, annotate the case as ALS and place the flag on the front of the paper disability folder to the DDS.

E. Mandatory development of some non-medical issues

Do not defer specific development essential in determining DDS jurisdiction or in recalling a case from the DDS, i.e., determining whether to process as a technical denial or obtain a medical determination. Develop issues critical to basic eligibility; deferral of other issues is subject to FO discretion. The following non-medical issues may require simultaneous development.

1. Technical denials

When it is clear that non-medical factors of entitlement are not met, deferral of development does not apply. The FO must deny these cases and ensure that technical denials do not go to the DDS for a medical determination as explained in DI 11010.075. Usually, Title II technical denials do not involve the DDS, however, if unsuccessful work attempt (UWA) may be an issue in technical denial cases, see DI 11010.145, Unsuccessful Work Attempt (UWA).

For CEF cases involving technical denials, see DI 81010.140, Processing Field Office (FO) Determinations.

For paper cases involving technical denials, see DI 70010.001, Modular Disability Folder (MDF) – Field Office Procedures.

NOTE: For SSI technical denial situations and the development required in these cases, see SI 00602.001, The Abbreviated Application Process.

2. Proof of age required

Request proof of age (POA) in all disability cases at the initial interview unless the streamlined POA development tolerance applies.

If the Numident meets the POA and citizenship criteria, do not develop any further, see GN 00302.030, Tolerances for Developing Evidence of Age. Code the APPL and CITZ screens in MCS and annotate the DW01 to show the Numident was used for POA and citizenship. If the claimant is a non-citizen, develop lawful presence in the U.S. per RS 00204.020.

Delay disability claims adjudication until you obtain POA only in the following situations:

  • Any date of birth (DOB) discrepancy that affects insured status

  • Doubt exists that the claimant is within 6 months of age 55 or older and they are filing under the special blindness provisions

  • Special insured status for disability benefits before age 31 applies

  • The DDS determines the DOB is material to the determination and requests the FO develop POA.

    Age is a material factor in the evaluation of disability claims on medical-vocational grounds and may be a decisive factor in the determination. The DDS bases the determination on the DOB shown on the SSA-831 (Disability Determination and Transmittal). Therefore, when the DOB shown on the SSA-831 is not the established date of birth (discrepancy with the month or year), contact the DDS (excluding disabled widow(er)’s (DWB) and SSI childhood claims). Include an SSA-5002 in the official electronic or paper folder transmitted to the DDS.

    If there are situations where the DDS asks the FO to undertake POA development when the FO was not aware of a discrepancy, follow the procedures above.

    If the Office of Central Operations (OCO)/Office of Disability Operations (ODO), Disability Processing Branch (DPB), or OCO/Office of International Operations (OIO) must make a disability determination, the FO prepares an SSA-5002 advising them of any age discrepancy.

    NOTE: If a DOB discrepancy arises during DDS’s development of medical evidence, the DDS cannot complete its determination until the DOB discrepancy is resolved. Therefore, expedite the age development and determination. If the FO recontacts the claimant to develop POA, ask the claimant about work activity or incarceration since the alleged onset date and document the claim.

See Also:

3. DWB and childhood disability benefits critical eligibility factors

Critical eligibility factors in DWB and childhood disability benefit (CDB) claims are not subject to deferred development.

Resolve the eligibility factors when:

  1. If there is an unresolved material discrepancy involving the insured status of the number holder (NH) or the relationship of the claimant to the NH, hold the DWB or CDB claim until you resolve the issue.

  2. Develop POA if a DOB discrepancy is material.

  3. Check the prescribed period on the EDCS 3367 or in item 6 on the SSA-3367 (Disability Report – Field Office), as explained in DI 11005.050, Prescribed Period and Controlling Date. The prescribed period is necessary for a DWB disability determination. For more information about the prescribed period and disability requirements, see DI 10110.001, Requirements for Disabled Widow(er)’s Benefits (DWB).

4. Substantial gainful activity

Develop and resolve all work issues at the time of filing and during the application process. If the claimant returned to work after their alleged onset date, evaluate the work, complete the appropriate Form SSA-820 (Work Activity Report for Self Employed Person) or Form SSA-821 (Work Activity Report – Employee), and document the substantial gainful activity (SGA) determination.

References:

DI 10501.025 Field Office (FO) and Disability Determination Services (DDS) Responsibilities and Procedures for Work Issue Cases

DI 10505.003 Evaluating and Developing Earnings that Clearly are or are not Substantial Gainful Activity (SGA) for Field Office (FO) and Disability Determination Services (DDS)

DI 10505.035 Documenting Employment Cases Using the SSA-821-BK (Work Activity Report-Employee) and the SSA-823 (Report of SGA Determination-For SSA Use Only)

DI 10510.025 Documenting Self-Employment Cases Using the SSA-820-BK (Work Activity Report-Self-Employment) and the SSA-823 (Report of SGA Determination-For SSA Use Only)

DI 81010.140 Processing Field Office (FO) Determinations

5. Insured status

Resolve any questionable issue involving disability insurance benefits (DIB), Medicare Qualified Government Employee (MQGE), or freeze insured status before sending a case to the DDS. Develop the case if it is not evident in the initial interview that the insured status requirements are met at or before the earliest onset date or after the most recent substantive denial.

Document lag earnings allegations on the MCS “WORK” and “EARN” screens or in the applicable sections of the SSA-16, and initiate development if alleged lag earnings indicate insured status.

NOTE: The DDS is only involved in cases where the claimant is not insured for U.S. coverage if the OIO requests medical development. See DI 23550.001, Totalization Case Processing.

6. Claimant dies while claim is pending

Follow the procedures outlined in DI 11010.330, Developing Cause of Death on a Pending Disability Claim.

See Also:

DI 11010.255, Sending Initial Disability Insurance Benefits (DIB), Freeze Claims to the Disability Determination Services (DDS)

7. Exclusion of felony-related impairments in prisoner cases

NOTE: This exclusion only applies if the claimant was convicted of a felony committed after October 19, 1980.

If the claimant is convicted and confined for committing a felony:

  • Establish when the claimant committed the felony, and

  • Determine if impairments or aggravation of pre-existing impairments relate to the commission of a felony or relate to confinement for conviction of a felony.

This development is necessary so the DDS can exclude any applicable felony or confinement-related impairments from the medical determination.

References:

  • DI 10105.094 Field Offices Identifying and Documenting Prisoner Status for Title II Disability Benefits

  • DI 10105.100 Permanent Disregard of Impairments Incurred or Conditions Aggravated in the Commission of a Felony

  • DI 23501.010, Evaluating Impairment(s) in Prisoner Cases

F. Optional deferral situations

Although simultaneous development is not always mandatory, use discretion to defer non-medical development in the following situations.

1. Geographical or physical problems

Simultaneously develop the claim if the initial interview is face-to-face and the claimant's impairments or geographical considerations would make recontact difficult.

2. Time-consuming development

If you expect pre-adjudicative development to take a long time, e.g., requesting a foreign birth certificate and developing lawful presence, you may partially develop time-consuming factors or develop all non-medical aspects of the claim.

3. Auxiliaries present at the interview

If auxiliaries are present, you may choose to take the applications and any available proofs, particularly if recontacting the auxiliaries may be difficult. Enter the proofs the NH submitted during the interview into the shared process evidence screens.

NOTE: Take the auxiliary applications regardless of the deferral policy if the NH or the claimant insists the FO take the applications.

4. Dire need and possible PD payments

If the claimant alleges an extreme financial emergency or hardship and meets the requirements for PD payments, conduct simultaneous development in order to expedite processing.

5. Other situations

If there are special considerations involved, simultaneous development or partial non-medical development is appropriate. In addition, local offices and Regional Offices generate guidelines for this optional category of exclusions from deferral.


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DI 11010.025 - Guidelines for Deferral of Non-Medical Development - 04/05/2017
Batch run: 04/05/2017
Rev:04/05/2017