TN 43 (11-94)

DI 12594.020 FO Actions Prior to Final DDS Readjudication

A. Policy

The FO will contact the class member to update the medical sources and work activity information upon receipt of a DDS request for assistance. The FO may need to obtain folders from the DDS. The work development tolerances detailed in DI 12586.080 are applicable to State of New York case developments.

NOTE: Do not establish a systems record until after an allowance is made.

1. Development - Work Activity

Develop work activity as follows:

  1. The FO will fully develop SGA prior to final readjudication only if work activity, apparently at the SGA level, began within 12 months after onset and continues.

  2. In general, after the updating action is complete, the FO will send the folder(s) to the DDS or OHA for completion of the medical review.

  3. See DI 12594.025B.3. if class member is represented.

2. Obtaining Folders - General

The PC will ask the FO to obtain folder(s) if case control information indicates that a folder for the potential class member is located in the FO.

3. Lost Folders

  1. Definition - A folder is considered lost if it cannot be located within 120 days of the date the case is called up for screening (i.e., the date on which the alert is generated) to decide whether the individual is a class member.

  2. Case listed under code 170 - The individual is deemed to be a class member in the absence of evidence to the contrary.

  3. Case not listed under code 170 - If information available in the FO does not preclude class membership, the FO will obtain the information needed to make a class membership decision (see DI 12594.001) by contacting the potential class member and by using other sources, including:

    • Copies of prior SSA-831/832/833's that may have been retained in the FO (for diagnosis, date of determination, residency, basis for denial, listing code, type of claim, and level of denial);

    • Output from the MBR or SSR, for information leading to that found on the determination form (e.g., diagnosis code, basis code, level of denial code, type of claim, and date of determination);

    • SSA-250's, if retained by FO.

    The FO will not contact medical sources for this information.

B. Procedure

If the DDS requests an update via an SSA-883-U3, complete the requested actions (see DI 12594.010.4.):

1. Update Requested By DDS

  1. Obtain SEQY to determine if earnings are different from those of original certified earnings record. If date first insured or date last insured has changed since original determination, annotate route slip to that effect when transmitting development to DDS.

  2. Contact the class member or the representative (see DI 12594.025B.3.) for update of the claimant's medical condition and medical sources, as requested by the DDS.

  3. Use SSA-3441-F6 to obtain updated medical source and condition information. In terminated cases, use an SSA-454-BK to update the folder.

  4. Use SSA-3368-BK to obtain information in lost folder cases.

  5. Obtain SSA-827's for all medical sources, as necessary.

  6. Record work activity on an SSA-820 (SSA-821).

2. Class Member working At SGA Level - Original Determination Was a Denial

  1. If SGA began within 12 months after onset and continues to present, prepare SSA-831-U3/C3 to reopen and revise original determination to denial based on SGA. Forward copies of SSA-831-U3/C3 to the following addresses:

    Legal Services for the Elderly
    Attention: “SGA Decision”
    130 West 42nd Street
    17th Floor
    New York, NY 10036,

    and

    SSA
    State of New York Coordinator
    P.O. Box 17769
    Baltimore, MD 21235-7769.

    NOTE: If readjudication is ALJ jurisdiction, do not prepare SSA-831-U3/C3. Instead, advise ALJ of SGA determination.

  2. In all other situations involving work, forward folder to DDS/ALJ for readjudication.

3. Class Member Working At SGA Level - Original Determination Was a Cessation

  1. SGA began within 12 months after onset - consider revising to SGA denial under rules of administrative finality. If this SGA ended, forward to DDS/ ALJ so disability determination can be made for period after SGA ended.

  2. If SGA began later than 12 months after date of onset, notify DDS of work but take no further action on work until readjudication of entire period up to present is completed. Then, once completed SSA-832/833-U3/C3 is received, process trial work period, EPE, and Section 1619 eligibility as appropriate.

4. Obtaining Folders

Assist in locating folders upon request.

5. Lost Folders - Cases Not Listed Under Code 170

  1. For cases not listed under code 170, if the folder is lost review information available in FO to ascertain whether a determination was made, on or after June 1, 1980, denying or ceasing disability under title II or title XVI.

    • If information available in FO establishes that no denial or cessation determination was made on or after June 1, 1980, forward folder to DDS for screening. Advise DDS that folder is lost, and will not be reconstructed because class membership cannot be established.

    • If information available in FO establishes that disability was denied or ceased under title II or title XVI on or after June 1, 1980, or if information is inconclusive in this regard, obtain information needed to make class membership decision per b. below (also see DI 12594.005B.1.).

  2. Reconstruction - Use SSA-3368-BK to obtain only information that will be helpful to DDS in making class membership decision (see DI 12594.001 for requirements), for example:

    • query that includes DIG coding, or information about diagnoses;

    • statement from claimant as to whether he or she underwent a treadmill or other exercise testing;

    • statement from claimant as to whether he or she resided in State of New York at time of denial or cessation determination;

    • identity of treating medical sources during the one-year period preceding the date of application, plus the additional period ending with the date of the determination.

  3. After reconstruction pursuant to b. above is completed, forward all material to DDS for screening decision.

  4. If DDS decides that individual is class member:

    • Assist in reconstruction of folder per GN 03105.010. (This will include obtaining a replacement application.)

    • After FO reconstruction actions are completed, forward folder to DDS for completion of reconstruction and for readjudication.

6. Lost Folders - Case is Listed Under Code 170

  1. Assist in reconstruction of folder upon request. See GN 03105.010

  2. After FO reconstruction actions are completed, forward folder to DDS for final screening and for readjudication if appropriate.

7. Systems Input

  1. DDS controls via NDDSS.

  2. Title II - Use unit identifier “ZZZ” when establishing systems record.

  3. Title XVI - Use code “C” in AP field when establishing systems record.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0412594020
DI 12594.020 - FO Actions Prior to Final DDS Readjudication - 06/12/2015
Batch run: 06/12/2015
Rev:06/12/2015