TN 13 (08-97)

DI 12015.003 The FPM Disability Claims Process

A. Process - The Full Process Model Test

The FPM is the testing of the combined SDM, PDI, RE, AO and Appeals Council review elimination processes.

Under the FPM tests:

  • The SDM adjudicates the disability issue at the initial claims level;

    NOTE: Before the initial determination is made, the cases in which MC input is required by statute, i.e., initial denials that involve mental impairments and title XVI childhood disability claims, are reviewed and the disability determination form(s) signed by an MC.

  • The SDM offers the claimant an opportunity for a predecision interview and/or submission of additional evidence prior to making an initial determination that is less than fully favorable;

  • The reconsideration step of the appeals process is eliminated for disability issues, i.e., whether or not the claimant is disabled, the onset date, and whether the period of disability is continuing or closed;

  • Appeals on the disability issue are sent for a hearing decision as the first step in the appeals process. If the AO does not make a fully favorable decision, the AO sends the case to an ALJ. SGA denials are processed as usual; reconsideration is the first step in the administrative appeals process. Reconsideration also applies to other non-disability issues such as the benefit amount, date of birth, etc.; and

  • Appeals Council review elimination, for some claims, eliminates the right to request Appeals Council review of the ALJ decision. In those cases, the ALJ's decision will be the final decision that may be appealed by filing an action in Federal District Court.

On 4/07/97, DDSs participating in the test began random selection of FPM test cases. Selection of 30,000 test cases will occur over a nine-month period. The participating DDSs are:

  • Albany, NY;

  • Brooklyn, NY;

  • Buffalo, NY;

  • Harrisburg, PA;

  • West Columbia, SC;

  • Nashville, TN;

  • Decatur, GA;

  • Salt Lake City, UT;

  • Madison, WI; and

  • Denver, CO.

NOTE: The Adjudication Officer unit in the Wilkes Barre, PA DDS handles some of the hearings requested by claimants selected by the Harrisburg DDS.

B. Process - The Federal Full Process Model (FFPM) Test

An alternative claims processing test that incorporates the processes in the first four bullets in A. above is also being conducted by a special unit known as the Disability Teleclaim Unit (DTU) in the Western Program Service Center (WNPSC). The DTU includes personnel who take and process teleclaims and perform the DDS disability adjudication function on those claims. Test cases for the WNPSC DTU are selected from residents of the State of Arizona.

On 8/11/97, ODIO also began taking claims under a test similar to the WNPSC DTU from claimants serviced by the Richmond and Lexington, Kentucky Field Offices. That test will incorporate the processes in the first four bullets in A. above.


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