TN 57 (02-97)

DI 12521.030 FO Actions After Final DDS Readjudication

A. Policy

1. Development of Reversals

After DDS readjudication is complete, reversed cases will be returned to the FO for review and development of non-medical entitlement factors. This also applies to ODIO/NEPSC presumptive disability cases.

  1. The FO must develop work activity and all matters relating to payment and benefit amount (e.g., payee, auxiliary applications, earnings discrepancy, WC/PDB amount, income and resources, Medicare, overpayments, attorney fees, Windfall Elimination Provision (WEP), institutionalization, drug addiction and alcoholism (DI 90070.000.), etc.), for the period from the denial or cessation date to the present.

  2. Full development of all nonmedical issues must be done beginning with January 1 of the year before the year in which the medical decision is made. Tolerances will be used in developing earlier periods per DI 12521.030B.4.

  3. If the whereabouts of the individual are unknown or the individual fails to cooperate, see DI 13015.001.

2. Awards

Cases reversed to allowances are District Office Final Authorization (DOFA). For OHA cases, normal procedures will be followed for processing awards based on ALJ or AC decisions.

3. Paying Title II

Title II payment cases are Award Processing Operation (APO) exclusions. Manual Adjustment Credit and Award Processing (MADCAP) action is required.

4. Paying Title XVI

If IAR is involved, the retroactive title XVI check should be sent to the state when appropriate.

B. Procedure - Development

1. Work Activity

  1. See DI 12521.030B.4. Develop any work activity that was not previously investigated per DI 12521.025B.2.

    See DI 12586.070 for determining the applicability of tolerances and the applicable tolerance period.

  2. Complete an SSA-820-F4 or SSA-821-F4 covering all periods of work.

  3. Make an SGA determination if the trial work period is completed or not appropriate. (See 4. below.)

2. Representative Payee

Develop representative payee as appropriate, and make a determination.

3. Class Member Represented

If a class member has a current representative of record, conduct development through the current representative unless otherwise indicated. (See GN 03910.001 ff.).

4. Non-Medical Issues

Develop title II and title XVI non-medical issues as follows.

a. Title II

  • Develop all issues relating to payment and benefit amount (e.g., auxiliary applications, earnings discrepancy, WC/PDB (DI 52101.001, Medicare, overpayments, attorney fees, Windfall Elimination Provision (WEP) (GN 02610.005 - GN 02610.022), institutionalization, etc.) for the period from the denial or cessation date to the present.

    If auxiliaries are present, protect their filing date(s) as of the date of the earliest Form SSA-16 within the Dixon period on which the auxiliary was mentioned.

    NOTE: In lost/destroyed cases where ODIO and/or NEPSC has determined that a class member is disabled based on the presumptions in DI 12521.015B.5., the MBR will not show the application date of the Dixon claim. Since the FO will need this information to prepare the award form, determine the earliest filing date of the Dixon claim when contacting the claimant for the non-medical development.

  • Develop work activity using the instructions in DI 12586.070.

  • Beneficiaries who are currently entitled based on subsequent claims may be adversely affected as a result of counting trial work months from the new Dixon period of entitlement.

    If the EPE is completed and termination occurs for an individual entitled to disability subsequent to the Dixon claim, obtain a new application (using the date of the individual's Dixon response as the protective filing date) if the SGA stopped.

    Prepare a Form SSA-833-U3 cessation determination and return the case to the DDS to establish a new period of disability. When the folder is returned from the DDS, effectuate payments for the proper periods.

b. Title XVI

Develop in accordance with DI 12586.080E.2.b.

5. Closed Period

If the readjudication establishes a closed period, develop only through the ending date of the period of disability.

C. Procedure -- General

1. Systems Input

a. Title II

Use unit identifier “ZZZ” when establishing systems record.

b. Title XVI

Use code “C” in AP field when establishing systems record.

2. Allowance

  1. Forward the folder to the PC under cover of Form SSA-3601 (Non-CAPS Routing).

  2. Check “Other” block on the SSA-3601 and indicate in “Remarks” that the PC should include the notice language shown on the Form SSA-865 (Disability Instruction Notice) which was prepared by the DDS and which is in the folder. Also, enter in “Remarks” that “Case Should be Processed per DI 42521.035.”

  3. If the DDS has made a favorable decision and there are no additional benefits due, annotate the “Remarks” section of the Form SSA-3601 “No Additional Benefits Due. Prepare a Notice Per DI 42521.035B.1.d.

  4. Clear awards as APO processing exclusions (RV-14).

3. Continuance

Forward reversals of cessations to the PC for processing under cover of a Form SSA-408 (Route Slip) annotated “ Dixon Class Action Cases - Process per DI 42521.035.”

4. Denial/Cessation

  1. If the readjudication results in an affirmation of a prior denial or cessation, retain the folder(s) for the appeals period.

  2. Take no notice action.

  3. Do not input the determination to the MBR or SSR in denial cases.

  4. Route the folder(s) as usual, with the following exceptions in certain cases involving affirmations of denials:

    • ODIO jurisdiction case in which subsequent application resulted in allowance - route to:

      SSA

      Office of Disability Operations

      1500 Woodlawn Dr.

      Baltimore, MD 21241-1500

    • ODIO jurisdiction case in which class member has never been entitled to benefits - route to:

      SSA/ODO/FRC Screening Group

      Gwynn Oak Bldg.

      Box 17253

      Baltimore, MD 21235

D. Procedure -- Payment of Title II Benefits

Process payment as expeditiously as possible, applying all appropriate deductions, offsets, and fees.

1. Award

Prepare an SSA-101-U3 (Determination of Award) for PC processing of cases reversed to allowance or closed period. Show “ Dixon Case” in item 11.

2. Entitlement

Review entitlement factors. (See GN 02602.025 for suspension, deduction, and termination events.)

3. Compute Benefits

  1. Consider Medicare premiums, offsets, Windfall Elimination Provision (WEP), overpayments, and attorney's fees in computing benefit. If an attorney is involved, attorney fee withholding is applicable. (See GN 02610.010D. and SI 02006.001 ff.).

  2. If it appears that the claimant will be liable for over 6 months' retroactive Medicare premiums, initiate equitable relief development. Do not delay adjudication pending resolution of the equitable relief issue. If the issue is still pending when the claim is forwarded to the processing center, indicate that fact on the Form SSA-3601.

  3. If any of the tolerance rules in DI 12586.080 was used, annotate the Special Message field of the MBR to show “Allowance Processed Under Special Dixon Rules” via the CIPM screen.

4. Routing

Send folder(s) to the PC for payment and notice (see C. above).

E. Procedure -- Payment of Title XVI Payments

Process payment as expeditiously as possible, applying all appropriate deductions, offsets, and fees.

1. Compute Payments

Consider overpayments and offsets in computing benefits (see GN 02610.010B.).

2. Initial Denial Posted (e.g., N-30)

a. Initial Denial Posted

  • T-30 prior record (if needed) - (see SM 01801.001 ff.)

  • Process a start date record with Form SSA-450-SI.

b. No Record Online

  • Follow routine procedures for establishing a record.

  • Process a Form SSA-450-SI (SSI Data Input) per SM 01005.002.

  • Show Dixon in the CG field.

c. IAR Involved

  • If grant reimbursement (GR) code is on the record, or a valid IAR authorization exists, reimburse the State.

  • Post GR code to record if not already on record.

  • If no IAR authorization is in the file, but the file indicates that the claimant received reimbursable assistance, and there is no evidence that SSA told the State of the absence of an IAR authorization, contact the State to determine if their files contain a signed statement.

  • If the State indicates that there is an agreement, withhold payment for 2 work days to give the State a chance to provide a copy of the agreement. Do not delay payment if there is no authorization or the State chooses not to send a copy.

3. Record In T-50 or T-51 Status

  1. If the record is in T-50 or T-51 status, prepare a Form SSA-450-SI per SM 01005.001 ff. to establish a new record.

  2. If IAR is involved and the case is:

    • automated or non-automated with GR on prior record, carry over to a new record;

    • non-automated with no GR on prior record, but IAR authorization is in file, input GR code on new record. Complete a manual Form SSA-8125 (SSI Notice of Interim Assistance) and mail to the appropriate State agency.

      NOTE: See SI 02003.020 for action required when an authorization is received by the FO. An award made under the Dixon court order is a revised determination, therefore, an earlier IAR authorization may still be applicable. If no IAR authorization is in file, but the file indicates that the claimant received reimbursable assistance, follow E.2. above.

4. Record in T-30 or T-31 Status

Refer to SM 01005.020D. if the record is in T-30 or T-31 status.

5. Initial Denial -- In Pay Based On a Later Claim

  1. First, T-30 the C01 record and re-establish an SD record with the Dixon case filing date. Then, process A-OTP to pay retroactive amount back to Dixon DOE in accordance with SM 01901.150.

  2. Reimburse the State if IAR is involved, even if the IAR was paid on a later application if:

    • there is a GR code on the prior record; or

    • there is an IAR authorization in the file from the prior claim.

  3. Designate State agency as payee to send retroactive check to the State via A-OTP.

  4. Complete and mail a Form SSA-8125 to the appropriate State agency.

6. Notice

  1. Prepare and release the appropriate SSI notice.