TN 43 (11-94)
DI 12594.025 FO Actions After Final Readjudication
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.
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
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.
Complete SSA-820-F4 or SSA-821-F4 covering all periods of work.
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:
Conduct all development through representative unless either:
class member appoints different representative;
class member states that he or she is no longer represented;
representative provides written approval of direct contact.
Send SSA-1696-U4 to class member to complete if one is not in file.
4. Class Member Deceased
If underpayment is payable:
Locate survivor(s), qualified substitute party, representative payee, and /or legal representative, if any. Obtain death certificate.
Obtain necessary information (see 1. - 3. above).
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.
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:
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.
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:
Forward folder to PC under cover of SSA-3601.
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.
Clear awards as APO processing exclusions (RV-14).
2. Readjudication Resulted in Denial or Cessation
If readjudication resulted in a denial or cessation:
Retain folder for appeals period.
Take no notice action.
In denial cases, do not input determination to MBR or SSR.
Route folders as usual, with following exceptions in certain cases involving affirmations of denials:
D. Procedure - Payment of Title II Benefits in Allowance Cases
For the payment of title II benefits in allowance cases:
Prepare SSA-101-U3 for PC processing of cases reversed to allowance. Show “State of New York Case” in item 11.
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:
Claimant is represented by attorney other than legal services, or
File contains fee petition filed due to previous attorney representation and no fee payment has been released.
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
If an initial denial is posted, process routine reconsideration reversal input with SSA-1719/SSA-4648-U3, using SODO, DO, MD, etc.
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.
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:
Process SSA-450-SI per SM 01801.001 ff.
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:
Process A-OTP to pay retroactive amount back to DOE in accordance with SM 01901.150.
IAR involved - reimburse State even if IAR was paid on later application if:
To send retroactive check to State via A-OTP, designate State agency as payee.
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:
Process A-OTP to pay retroactive amount based in accordance with SM 01901.150.
IAR involved - Do not reimburse State if only DOE is being redetermined.
Issue any retroactive payment due to individual.
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:
IAR involved - refer to B.3. above.
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.