DI 11020.061 Routing Multiple Title II Claims
A. Disability Insurance Benefit (DIB) with Childhood Disability Benefit (CDB)
If a number holder (NH) files a DIB claim and lists a child who is a potential Childhood Disability Beneficiary (CDB), transmit the DIB claim to the appropriate Disability Determination Services (DDS) or Processing Center (PC). These include the Office of Disability Operations (ODO), Office of International Operations (OIO), or one of the six Program Service Center (PSC)/Disability Process Branches (DPBs).
Because entitlement to CDB depends upon an allowance of the DIB claim, do not take any action (development) on the CDB claim until a determination is made on the DIB claim. However, if the NH also filed for Retirement Insurance Benefit (RIB) and is insured, and the critical nonmedical requirements are met on the CDB claim, forward it to the appropriate DDS or PC based on where the child auxiliary is living at the time the case is forwarded. This may be a different place from the NH’s case if the child and NH are living in different States. Cross-refer each file by entering “(CDB or DIB) application for (name of NH or disabled child) forwarded to (DDS, ODO, OIO, or PSC/DPB) on (date)” in “Remarks” on the SSA-831-U3. Instructions for processing claims for DIB and CDB from, or on behalf of, the same individual are in DI 11020.055 “Routing Paper Childhood Disability Benefit (CDB) Cases to a Disability Determination Services (DDS) or Program Center (PC)”.
B. End Stage Renal Disease (ESRD) Claim Involved
Stand-alone claims for ESRD benefits are currently exclusions to EDCS processing. However, in situations where a Certified Electronic Folder (CEF) exists, or a CEF will be created for another disability claim (Title II and/or Title XVI), fax the ESRD information into the CEF. This eliminates the need to create and send a paper ESRD folder to Program Center (PC) -7.
1. ESRD-only case (No CEF exists)
Process ESRD-only cases according to current procedures. (See HI 00801.300 “District Office Final Authorization (DOFA) of ESRD Medicare Awards and Disallowances”).
REMINDER: Route the CMS-2728-U3 – End State Renal Disease Medical Evidence Report and brown folder to PC7. PC7 is the only PC that processes ESRD claims.
2. ESRD claim and existing certified electronic folder (CEF) case
If there is an existing CEF (pending or closed), the field office (FO) verifies ESRD entitlement and processes the claim according to current procedures. Additionally, the FO will:
Complete the End Stage Renal Disease (ESRD) Medicare Determination Form SSA-892-U2 per HI 00801.308 “Preparing the SSA-892-U2”.
Create a barcode coversheet for Form SSA-892-U2 using document type code 0113-ESRD Medicare Determination.
Create a barcode coversheet for Form CMS-2728-U3 using document type code 0114-ESRD Medical Evidence Report.
Fax both the SSA-892-U2 and the CMS-2728-U3 into the CEF using the barcode coversheets per DI 81010.090 “Faxing Documents into the Certified Electronic Folder (CEF) Using Barcodes”.
Prepare and fax Form SSA-3601 Claims Routing Form to PC7 via the Paperless Processing Center (PPC) system using FAX number 410-597-0939.
NOTE: This alerts the PC that there is an issue pending; the faxed Form SSA-3601 should display the proper TOEL – “CLAIM ESRDINT” and a remark “Manual Action Required”.
Input the adjudicative decision and PC7 jurisdiction on the Decision Input (DECI) screen.
NOTE: Use Non-Earnings Computation (EC) Clearance when transferring the MCS segment to PC7 for manual processing of the ESRD award.
In some cases, a CEF exists for a claimant in a terminated status (e.g., LAF-T8 or X7). If the FO can process the ESRD award action to completion (LAF change to “U”) via MCS EC, skip the 5th and 6th bullets shown above as no PC7 MACADE action is required.
3. Concurrent ESRD and Title II/Title XVI claims
A claim for CDB, which is within the jurisdiction of DDS, may be filed concurrently with an ESRD claim. In this situation, photocopy the medical evidence obtained in connection with the ESRD claim and include it in the file being forwarded to the DDS.
Route concurrently filed Retirement and Survivors Insurance (RSI) claims that do not require disability determinations separately to the appropriate PCs in the usual manner.
If an ESRD claim is taken concurrently with a Title II and/or Title XVI claim, the FO will:
Establish the disability claim(s) in Modernized Claims System (MCS) and/or Modernized SSI Claims System (MSSICS).
Establish the Title II and/or Title XVI cases in EDCS.
Transfer the MCS and/or MSSICS, and EDCS disability claim(s) for medical determination.
Verify ESRD entitlement, process the claim according to current procedures, and follow the additional steps outlined in this section at DI 11020.061B.2.
REMINDER: Process the ESRD award via MCS-EC once you secure all requirements and evidence. Do not delay the ESRD award action pending DDS determination of the disability claim.
NOTE: There is no requirement to create and send a paper folder to PC7 if you can input the ESRD documents to a CEF.
DI 11010.255 Sending Initial Disability Insurance Benefits (DIB), Freeze Claims to the Disability Determination Services (DDS)
HI 00801.233 Medical Evidence of ESRD - Form CMS-2728-U3