BASIC (09-07)

DI 11011.005 FO Adoption Decision

A. Procedure — FO Adoption

FOs should read the collateral estoppel instructions in DI 11011.001 before using the chart below to determine when FO adoption of the previous disability decision applies.

See DI 81010.142 for related instructions for processing FO adoption cases in the Electronic Disability Collect System (EDCS).

If Existing Claim Is

And the New Claim Is

Then

HA and/or Title XVI (Adult)

CDB

Adopt the previous decision unless HA/DI onset date is after age 22. For Exceptions see DI 11011.005B.1.

HA and/or Title XVI (Adult) or MQGE

DWB

Adopt the previous decision (if onset is before the end of the prescribed period). For onset prior to 01/01/91, if Regulation Basis Code begins with “A” or “B” (meets or equals the Listing) use that onset. For exception to onset prior to 01/01/91, see DI 11011.005B.2.

HA and/or Black Lung DAC

Title XVI (Adult)

Adopt the decision.

DWB

HA/Title XVI (Adult)

Adopt the DWB decision. See exception in DI 11011.005B.4.

Title XVI (Adult)

HA or MQGE

Adopt the DI decision. For exceptions see DI 11011.005B.3.

Title XVI (Child)

CDB

Send claim to DDS.

Title XVI (Child)

HA

Send claim to DDS.

Title II (HA, DWB, CDB)

Title XVI Blindness

Send claim to DDS unless statutory blindness is already established.

Black Lung (LM)

Title XVI

Send claim to DDS.

MQGE

HA/Title XVI (Adult)

Adopt the MQGE decision.

Title II (CDB)

HA, CDB, and/or Title XVI (Adult)

Adopt the CDB decision. For exception see DI 11011.005B.4. When adopting a CDB to a new CDB filing on another SSN see POMS DI 11020.020 When Childhood Disability Development is Not Required.

Title XVI (BI)

Title II Blindness

Send claim to DDS.

B. Procedure — Exceptions

1. Existing HA and/or Title XVI DI Claim, New HA and/or CDB Claim

If established onset is after age 22 in a CDB claim and is not based on a traumatic onset, but is based on date of filing under Title XVI, or insured status on Title II (i.e., a possible earlier onset exists), forward the claim to the DDS for a disability determination.

When deciding to adopt a Title XVI (DI) determination, be sure to check the age of the claimant at time of Title XVI onset. If the claimant was awarded as a “DC” and converted to “DI” at age 18, and a medical determination, using adult criteria, was never made, the Title XVI determination cannot be adopted. Forward the claim to the DDS.

NOTE: If the SSIDC attained age 18 before 08/22/96, different rules for determining disability apply. See DI 11070.001, Title XVI Childhood and Age 18 Disability Redetermination Cases (Public Law (P.L.) 104-193 As Modified by P.L. 105-33) - FO.

If the claimant was awarded as a “DC” and converted to “DI” at age 18, and a medical determination, using the adult criteria, was made, the Title XVI determination can be adopted, as long as the claimant attained age 18 on or before the alleged onset date (AOD)/date first insured for Title II DIB or AOD/age 22 for the Title II CDB.

In addition, be alert to situations in which the FO can not adopt a prior favorable Title XVI determination when there is substantial gainful activity (SGA) after the established Title XVI onset date.

2. Existing HA and/or Title XVI DI Claim New DWB Claim

If established onset is after the end of the prescribed period and is based on the date of filing under Title XVI or insured status on Title II (i.e., a possible earlier onset exists), forward the claim to the DDS for a disability determination.

If the disability onset date of the existing claim is after the “controlling date” for the DWB claim, but is within the “prescribed period” (see DI 11005.050), adopt the determination using the existing onset date and forward the claim to the DDS on a post adjudicative basis to determine if an earlier onset is possible.

If the Regulation Basis Code begins with a “C” or “A63,” or the FO cannot determine the Regulation Basis Code and possible DWB entitlement exists prior to 01/91, prepare a partial award with entitlement beginning 01/91, and refer the claim to the DDS on a post-adjudicative basis for a determination based on pre-01/91 rules.

3. Existing Title XVI DI Claim New HA, MQGE or CDB Claim

If possible earlier onset exists; send the claim to the DDS on a post-adjudicative basis. If the Title XVI claim was originally awarded as a DC and converted to DI at age 18, and a medical determination under the adult criteria has not been made, do not adopt the Title XVI decision; forward the claim to the DDS for a disability determination. See also DI 11011.005B.1.

4. Existing CDB or DWB Claim, New HA and/or Title XVI DI Claim

If possible earlier onset exists based on insured status in the HA claim, send claim to DDS on a post-adjudicative basis.

C. Procedure — Possible CDR

CDRs will not be initiated on any adopted claim unless there is evidence of current SGA or an indication of medical improvement. In any adoption situation, if a diary was never established on the existing claim, if a current diary is due, or the diary is past due or will be due within 3 months, adopt the prior favorable determination and establish a MIE diary on the current claim to mature in 1 year, unless the diary was a MIP or MINE. If the diary on the existing claim is a MIP or a MINE, and no medical issue is raised with the new claim, set a MIP on the new claim to mature in 3 years or a MINE on the new claim to mature in 7 years (whichever applies). Forward the claim, after processing, to the PSC of jurisdiction for filing.

IMPORTANT: Title XVI claims should not be sent to the PSC.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0411011005
DI 11011.005 - FO Adoption Decision - 02/23/2015
Batch run: 02/23/2015
Rev:02/23/2015