TN 43 (11-94)

DI 12594.025 FO Actions After Final Readjudication

A. Policy

1. Development of Cases Reversed to Allowances or Continuances

After DDS readjudication is complete, the FO will thoroughly develop work activity and all matters relating to payment and benefit amount (e.g., payee, auxiliary applications, earnings discrepancy, WC/PDB amount), for the period from the denial or cessation date to the present.

2. Awards

Cases reversed to allowances are District Office Final Authorization (DOFA).

3. Processing Title II Payment

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

4. Title XVI Payment

For title XVI payment with IAR involved - The retroactive check should be sent to the State when appropriate.

B. Procedure - Development

1. Work Activity

  1. Develop any work activity that was not previously investigated as set out in DI 12594.020A and DI 12594.020B.2. and DI 12594.020B.3.

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

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

2. Representative Payee

Develop representative payee as appropriate, and make payee determination.

3. Class Member Has a Representative

Whenever class member has representative of record:

  1. Conduct all development through representative unless either:

    • class member appoints different representative;

      or

    • class member states that he or she is no longer represented;

      or

    • representative provides written approval of direct contact.

  2. Send SSA-1696-U4 to class member to complete if one is not in file.

4. Class Member Deceased

If underpayment is payable:

  1. Locate survivor(s), qualified substitute party, representative payee, and /or legal representative, if any. Obtain death certificate.

  2. Obtain necessary information (see 1. - 3. above).

  3. Title II:

    • Forward death certificate and other development to DDS or OHA if substitute party located.

    • If no substitute party located, forward all material to PC and advise DDS to forward folder to PC.

  4. Title XVI - If disability determination is not necessary (i.e., none of the situations in the following bullets exists), forward all material to PC and advise DDS to forward folder to PC. Advise DDS that disability determination is necessary if any of the following situations exists:

    • surviving spouse (eligible or ineligible) was living in same household at time of death or any time in preceding 6 months; or

    • deceased was disabled or blind child in month of death, living with parent(s) at time of death or any time in preceding 6 months; or

    • determination is needed for Medicaid eligibility purposes (see DI 23510.001C); or

    • IAR payments have been advanced by State under agreement.

5. Other Non-Disability Matters

For other non-disability matters:

  1. Title II - Develop all matters relating to payment and benefit amount (e.g., auxiliary applications, earnings discrepancy, WC/PDB events) for period from denial or cessation date to present.

  2. Title XVI - Conduct PERC.

6. Readjudication Established Closed Period

If readjudication established close period, develop only through ending date of period of disability.

C. Procedure - General

1. Clearance - Title II Case Reversed to Allowance, Continuance, or Closed Period

If title II case was reversed to an allowance, continuance, or closed period:

  1. Forward folder to PC under cover of SSA-3601.

  2. Check “Other” block on SSA-3601 and indicate in “Remarks” that notice language prepared by DDS is in folder and that case should be processed per DI 42594.025.

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

2. Readjudication Resulted in Denial or Cessation

If readjudication resulted in a denial or cessation:

  1. Retain folder for appeals period.

  2. Take no notice action.

  3. In denial cases, do not input determination to MBR or SSR.

  4. Route folders as usual, with 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 in Allowance Cases

For the payment of title II benefits in allowance cases:

1. Award

Prepare SSA-101-U3 for PC processing of cases reversed to allowance. Show “State of New York Case” in item 11.

2. Entitlement

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

3. Compute Benefit

Consider Medicare premiums, offsets, overpayments, and attorney's fees. If attorney's fees are involved, withhold 25% of past due benefits when:

  1. Claimant is represented by attorney other than legal services, or

  2. File contains fee petition filed due to previous attorney representation and no fee payment has been released.

4. Routing

Send folder(s) to PC for payment and notice.

E. Procedure - Payment of Title XVI Payments

For title XVI payments:

1. Compute Payments

Consider overpayments and offsets (see GN 02610.010B).

2. Initial Denial Posted

  1. If an initial denial is posted, process routine reconsideration reversal input with SSA-1719/SSA-4648-U3, using SODO, DO, MD, etc.

  2. IAR involved - Reimburse State if initial application was denied and is now being reopened and revised, and if:

    • grant reimbursement (GR) code is on record, or

    • valid IAR authorization exists.

      NOTE: If no IAR authorization is in file, see SI 02003.010D.2.

  3. If GR code is not on record, but IAR authorization is in file, post GR code to record via SSA-450-SI (PR-9) process.

3. Record in T-50 or T-51 status

If record is in T-50 or T-51 status:

  1. Process SSA-450-SI per SM 01801.001 ff.

  2. IAR involved:

    • Automated or non-automated case with GR on prior record - carry over to new record;

    • Non-automated case with no GR on prior record, but IAR authorization is in file - input GR code on new record. Complete manual SSA-8125 and mail to appropriate State agency.

    NOTE: See SI 02003.020D.2. if no IAR authorization is in file.

4. Initial Denial-Record in Pay Based on Subsequent Application

If an initial denial with record in pay based on subsequent application:

  1. Process A-OTP to pay retroactive amount back to DOE in accordance with SM 01901.150.

  2. IAR involved - reimburse State even if IAR was paid on later application if:

    • GR code is on prior record; or

    • IAR authorization is in file from prior claim.

  3. To send retroactive check to State via A-OTP, designate State agency as payee.

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

5. Record in Pay - Reopening Results in Earlier DOE On Same Application

If a record is in pay and reopening results in earlier DOE on same application:

  1. Process A-OTP to pay retroactive amount based in accordance with SM 01901.150.

  2. IAR involved - Do not reimburse State if only DOE is being redetermined.

  3. Issue any retroactive payment due to individual.

  4. Apply title II and title XVI offset per GN 02610.018.

6. Current Initial Denial Posted; Reopening Results in Earlier DOE on Earlier Application

If a current initial denial is posted and reopening results in an earlier DOE on an earlier application:

Prepare SSA-450-SI with correct DOE. (Input will create new record unless exceptions exist.) If exception exists:

  • T-30 or T-50 record, and

  • establish new record reflecting earlier DOE. (Do not duplicate any PD/PB payments made on prior record.)

IAR involved - refer to B.3. above.

7. Notice

Prepare and release appropriate notice. Send copy to representative if claimant is represented, and, if the determination was less than fully favorable, also send a copy to class counsel:

Legal Services for the Elderly
Attention: “Reconsideration Decision”
130 W. 42nd St. 17th Floor
New York, NY 10036.

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0412594025
DI 12594.025 - FO Actions After Final Readjudication - 06/29/2012
Batch run: 06/29/2012
Rev:06/29/2012