TN 12 (10-17)

DI 13005.020 Field Office Actions for Processing and Screening Continuing Disability Review (CDR) Folders and Alerts

A. Processing a CDR referral

The field office (FO) should follow these guidelines when processing and screening a CDR referral.

1. CDR referrals for Title II and concurrent (Title II and Title XVI) cases

When a CDR selection for a Title II or concurrent (Title II and Title XVI) case occurs under the Automated Direct Release (ADR) system or after processing a Form SSA-455-OCR-SM (Disability Update Report), an alert generates to the folder location site. Some common folder location sites include:

  • the Social Security Administration’s National Record Center (SSANRC),

  • a program service center (PSC) module, or

  • the Disability Processing Branch (DPB).

The folder location site will forward the paper comparison point decision (CPD) folder(s) to the servicing FO using an alert flag or the Form SSA-5526-U3 (Request for Assistance - Disability).

If the paper CPD folder(s) is already in a FO, the PSC sends the alert flag or the Form SSA-5526-U3 to the FO. The alert flag or Form SSA-5526-U3 identifies the case and requests the FO to initiate a full medical CDR (commonly referred to as a “DO CDR” action). For a case requiring a “DO CDR” action in the PSC, see DI 40502.001. The PSC may forward additional documentation to the FO (for example, the CDR mailer form, attachments to the mailer form, work and earnings information, information that the disabled individual's whereabouts are unknown or that the disabled individual has refused to cooperate, etc.) using the Form SSA-5526-U3.

For a complete discussion of Title II and concurrent (Title II and Title XVI) CDR alerts and folder retrieval, see subchapter DI 40525.000.

NOTE: For instructions on processing electronic CDR cases, see DI 81010.000.

2. CDR case referrals for Title XVI-only

When a CDR selection for a Title XVI-only case occurs under the ADR or the mailer form process, the alert generates to the SSANRC or FO, depending on the CPD folder location shown in the Supplemental Security Income Case Control System (SSICCS). For a case requiring “DO CDR” actions in the PSC, see DI 40502.001. The PSC may forward additional documentation to the FO (for example, the CDR mailer form, attachments to the mailer form, work and earnings information, information that the disabled individual's whereabouts are unknown or that the disabled individual has refused to cooperate) using the Form SSA-5526-U3.

For a complete discussion of Title XVI folder retrieval, see sections DI 13015.035 and DI 13015.040.

3. FO screening procedures for a referred case

Upon receipt of the case folder(s), the FO must review the folder to make sure a CDR is appropriate. If a CDR is appropriate, the FO must initiate the CDR under the normal FO contact procedures in DI 13005.025 unless the medical improvement not expected (MINE) or MINE-equivalent procedures in DI 13005.022 apply.

If a CDR is not appropriate and the case meets the screen-out criteria, the FO should stop processing the CDR and update the Disability Control File (DCF). For additional information on updating the DCF, see DI 13010.500.

B. Querying or obtaining disability folders

The FO must follow these guidelines when querying or obtaining the disability folder(s):

1. Queries

Obtain the following:

  1. Master Beneficiary Record (MBR), DCF, New Date New Hire (NDNH), Detailed Earnings Query (DEQY), and Supplemental Security Record (SSR) queries in all cases to determine the service area jurisdiction and whether any dual or triple entitlement exists; and

  2. queries on any cross-reference Social Security Numbers (SSN) to identify all multiple entitlements.

2. CPD folders

Take the following actions:

  1. Associate the alert with the CPD folder(s) if it did not arrive with the alert.

  2. Review the CPD folder(s) to make sure it contains medical evidence and the CPD document(s), see DI 28010.105. The folder should contain the most recent of the following medical forms (when applicable):

    • Form SSA-831-U3 (Disability Determination and Transmittal),

    • Form SSA-832 (Cessation or Continuance of Disability or Blindness Determination and Transmittal – Title XVI),

    • Form SSA-833 (Cessation or Continuance of Disability or Blindness Determination and Transmittal – Title II), or

    • The disability decision from the Office of Hearings Operations (OHO).

  3. Obtain all related disability folders except the non-medical Title XVI portion of a concurrent (Title II and Title XVI) case.

  4. If the CPD folder is not located, follow the folder search instructions in DI 13015.055 through DI 13015.080. The FO should check EDCS to see if the case is electronic.

NOTE: For additional information on electronic CDR cases, see DI 81010.000.

C. What not to screen out

It is essential that the FOs only conduct timely CDRs on cases that cannot be screened out of the CDR process. Do not screen out the following types of cases:

1. A case based on the age of the disabled individual, except for certain Title II and concurrent (Title II and Title XVI) cases

Do not screen out a CDR based on the age of the disabled individual, except for certain Title II and concurrent (Title II and Title XVI) cases involving conversion to non-disability.

Do not stop a CDR because the disabled individual attained a specific age, because the agency refers certain age groups for CDRs under its CDR plan.

Exception: Do not screen out a CDR based on age except when the:

  • disabled workers within three months of attaining full retirement age (FRA) see RS 00615.003A; and

  • disabled surviving spouses who are within three months of a potential conversion to a benefits based solely on age or relationship qualifications solely on age and relationship, see RS 00615.003B.

NOTE: Screening out a case based on age of the disabled individual does not apply to Childhood Disability Benefits (CDB)-only cases.

2. A case based on an individual who is involved in a court case or who is a member of a class action

Do not screen out a CDR because the individual has a civil action pending in Federal court or is a member of an active class action. There are no exceptions for individuals involved in individual or class action court cases. The fact that a case(s) may be involved in an active individual or class action is not a valid reason for delaying a scheduled CDR. Once the CDR is completed, we will process the case under the individual or class action order.

Example scenarios:

A CDR alert generates and an individual civil action or class action member claim:

  1. is pending in the disability determination services (DDS). The FO will forward the CDR alert to the DDS which will process the CDR alert and the individual civil action or class action simultaneously;

  2. is pending a folder reconstruction in the FO. The claim folder(s) cannot be located and needs reconstruction. Once folder reconstruction is complete, process the CDR alert and individual civil action or class action simultaneously;

  3. is pending in the Office of Hearings Operations (OHO), the Office of the Inspector General (OIG), or the Office of the General Counsel (OGC). If the CDR is completed and the case is still pending due to a court case or a class action, follow the instructions in DI 13015.040F;

  4. has not received an class action member alert. Process the CDR and if the class action member alert generates before the CDR is complete, the DDS will not release the folder for class action member screening as long as a pending action is taking place. Continue processing the CDR and the Office of Central Operations (OCO) will get the folder after completion of the CDR; or

  5. receives a denial and the folder(s) are waiting because of the class counsel review process. Pull the folder(s) and process the CDR. Central Office will make sure that the class action membership review process is complete after completion of the CDR.

3. A Title XVI child case on the basis of a future medical reexamination diary date (and the exception to this rule)

Public Law 104–193 (the Personal Responsibility and Work Opportunity Reconciliation Act of 1996) amended Section 1614(a)(3) of the Social Security Act. The law requires the agency to do CDRs on all non-permanently disabled children under age 18 at least once every three years. The Commissioner may review Title XVI child cases involving a permanent impairment at such times that the Commissioner deems appropriate. The law also directs when a CDR is required for cases in which low birth weight is a contributing factor material to the disability determination.

In addition, the law requires that an eligible Supplemental Security Income (SSI) disabled individual before age 18 must be subject to a review upon attaining age 18. In these cases, the medical improvement review standard (MIRS) does not apply. Instead, the age-18 medical redetermination applies the disability evaluation process used for an initial Title XVI adult claim, see DI 13005.020D in this section. A “future” medical reexamination date may warrant that a CDR be screened out and discontinued at this time, pending maturation of the medical reexamination review date, see DI 13005.020D in this section.

Do not screen out a CDR based on the future medical diary date on the Supplemental Security Record (SSR). If the medical diary on the current SSR displays a future diary date based on a system limitation (such as a start date record), review the medical diary date established on the last favorable medical determination. If the medical diary date has expired, complete the CDR.

Do not screen out a case that involves the following:

  • a Title XVI age-18 medical redetermination case with a future medical reexamination diary,

  • a Title XVI low birth weight (LBW) case with a future medical reexamination diary, or

  • a Title XVI disabled child case with a future medical reexamination diary.

Exception:

Screen out a Title XVI disabled child (not LBW) case if the case meets both of the following conditions:

  1. A fully developed DDS or OHO decision (initial claim, CDR, or childhood redetermination, but not a modified decision) was made within the last 12 months; and

  2. The medical diary has not matured and will not mature in the next 3 months.

4. A case on the basis of a human immunodeficiency virus (HIV) infection

Do not screen out a case from the CDR process solely because it involves an allegation or diagnosis of HIV infection.

NOTE: A diagnosis of HIV infection by itself is not a reason to screen out a CDR; however, other screen-out criteria may apply to an HIV case. For additional information on CDR screen-out criteria, see DI 13005.020D in this section.

D. Screen-out criteria by the case type

Use these charts to determine whether there is a reason to screen out a case by the case type:

1. Title II and concurrent (Title II and Title XVI) cases (except for concurrent age-18 medical redeterminations)

The FO will screen out Title II and concurrent (Title II and Title XVI) CDRs (except for a concurrent Title II and age-18 medical redeterminations) for the following reasons:

Reason

There is a prior uneffectuated medical cessation (UMC) or overdue medical cessation (OMC) case. For additional information on processing OMC and UMC cases, see DI 13015.265.

The medical review diary is not mature and will not mature in the next three months and there is no other reason (for example, a report of medical improvement) to process a CDR. To determine the medical reexamination diary date, use the most recent medical CPD document(s) when applicable:

  1. Form SSA-831-U3,

  2. Form SSA-832,

  3. Form SSA-833, or

  4. The highest disability decision from OHO.

The case has been withdrawn or a request to withdraw is pending.

Conversion to a non-disability status has occurred or we expect it to occur within the next 3 months. For example, the disabled individual is within three months of full retirement age. For additional information on attainment of full retirement age, see RS 00615.004.

Review of a query response per DI 13005.020B.1. in this section, or information received from the beneficiary or any other source that shows a CDR mailer Form SSA-455 or Form SSA-455-OCR-SM, as described in DI 13004.005, was initiated after the date the case was alerted for a full medical review. For details on “incorrect or accidental” alerts, see DI 13005.020G in this section.

Review of a query response or other information received from the recipient or other source shows that the recipient had a ticket under the Ticket to Work Program and the ticket was “assigned in use” before:

  1. Selection for CDR mailer processing; or

  2. Selection for a full medical CDR (in the situation when the DCF or other record shows the case processed as a CDR mailer and subsequently a full medical CDR was initiated, the date of notice to the disabled individual or representative payee of initiation of the subsequent full medical CDR is controlling). For more details on the Ticket to Work Program and protection from medical review, see DI 13010.012, 55025.010B, and DI 55025.001C.

The disabled individual is working, has a medical improvement possible (MIP) or medical improvement not expected (MINE) medical re-examination diary, and has not completed a trial work period, see DI 13005.005.

NOTE: If the disabled individual is working and has a medical improvement expected (MIE) medical re-examination diary, continue to process the CDR, if necessary as a medical work CDR, per DI 13005.005, DI 13010.012 and DI 13010.035.

The disabled individual is in a foreign country, and the disabled individual's residence does not receive service from a border FO. The FO must transfer the case to Office of Earnings and International Operations (OEIO), which will assume jurisdiction for the CDR. The FO should forward the case to:

(E15)
OIO/DIO/IBO/FSU
6100 Wabash Ave
Baltimore MD 21215-3757

The disabled individual has an appeal pending on an initial determination, and the medical review diary has matured.

The disabled individual dies and there is no unresolved or pending issue requiring a determination as to whether disability ended prior to death, see DI 13010.197.

Miscellaneous reasons. Explain on the Form SSA-5002 (Report of Contact) or on the Form SSA-5526-U3 in the “Remarks” section.

NOTE: If the Title II case of a concurrent (Title II and Title XVI) age-18 medical redetermination is screened out, continue to process the Title XVI age-18 medical redetermination if none of the screen-out criteria meets the procedures in DI 13005.020D.3. in this section.

2. Title XVI-only adult cases (not including age-18 medical redeterminations)

The FO will screen out Title XVI-only adult cases (not including age-18 medical redeterminations) for the following reasons:

Reason

There is a UMC or OMC case. For additional information on processing OMC and UMC cases, see DI 13015.265.

The medical review diary is not mature and it will not mature in the next 3 months, and there is no other reason (for example, a report of medical improvement) to process a CDR. To determine the medical reexamination diary date, review the most recent medical CPD document(s) when applicable:

  1. Form SSA-831-U3,

  2. Form SSA-832,

  3. Form SSA-833, or

  4. The highest disability decision from OHO.

The recipient is in non-payment status (for example, “N01” or “N03”) and you expect the recipient to remain in non-payment status for at least 12 months. For more instructions on processing cases in non-payment or suspension status, see DI 13005.020E.

The claim is withdrawn or a request to withdraw is pending.

The recipient’s disability status converted from “Disabled” or “Blind” to “Aged”.

Review of a query response obtained per DI 13005.020B.1. in this section or information received from the recipient or other source shows that a CDR mailer form SSA-455 or SSA-455-OCR-SM, as described in DI 13004.005, was initiated after the date the case was alerted for a full medical review. For details on “incorrect or accidental” alerts, see DI 13005.020G in this section.

Review of a query response or other information received from the recipient or other source shows that the recipient had a ticket under the Ticket to Work Program and the ticket was “assigned in use” before:

  1. Selection for CDR mailer processing; or

  2. Selection for a full medical CDR (in the situation when the DCF or other record shows the case processed as a CDR mailer and subsequently a full medical CDR was initiated, the date of notice to the recipient or representative payee of initiation of the subsequent full medical CDR is controlling). For more details on the Ticket to Work Program and protection from medical review, see DI 13010.012, DI 55025.010B, and DI 55025.001C.

The recipient is deceased and there is no unresolved or pending issue requiring a determination as to whether disability ended before death, see DI 13010.197.

Miscellaneous reasons. Explain these reasons on the Form SSA-5002 or the Form SSA-5526-U3 in the “Remarks” section.

NOTE: For a Title XVI-only CDR that goes into suspense payment status after referral for CDR processing, see DI 13005.020E in this section.

3. Title XVI-only child cases (including age-18 medical redeterminations and LBW)

The FO will screen out CDRs for Title XVI-only child cases (including age-18 medical redeterminations and LBW cases) for the following reasons:

Reason

The claim is withdrawn or a request to withdraw is pending.

The recipient is or was in non-payment status (for example, “N01”or “N03”) and you expect the recipient to remain in non-payment status for at least 12 months. For more details on processing cases in a suspense payment status, see DI 13005.020E in this section.

There is an UMC or OMC case. For additional information on processing OMC and UMC cases, see DI 13015.265.

The 12-month rule for non-permanent impairment cases only: Determine when the most recent prior medical decision occurred for a non-permanent impairment case (except age-18 medical redeterminations or LBW cases). Screen out cases in which a fully developed DDS or OHO decision (initial claim, CDR, or childhood redetermination, but not a modified decision) was made within the last 12 months; and the medical diary is not mature and will not mature in next 3 months. Do not screen out a case based on a future diary, if the case does not meet both criteria.

For age-18 medical redeterminations, when the disabled recipient was not in payment status (PSY) “C__”, “E__”, or “M___” the month before the month the recipient attained age 18.

NOTE: If the disabled individual becomes eligible for payments the month before the month of attaining age 18, the case will require an age-18 medical redetermination.

For age-18 medical redeterminations, review the claim folder(s) to see whether it shows a completed disability determination using the adult sequential evaluation of disability for initial claims. Usually, the date of the favorable DDS determination is an indicator if:

  1. The date of the DDS determination pre-dates the date of attaining age 18, assume the adult criteria did not apply; or

  2. The date of the DDS determination is on or after the date the recipient attains age 18, assume application of the adult criteria.

In addition, the Type of Master Record (TMR) data on a Supplemental Security Record (SSR) query reply should reflect the change from disabled child (DC) to disabled adult (DI) status (for example, “TMR:DC, DI-mm/yy,” when the mm/yy indicates the month and year following the month and year in which the individual attained age 18).

If the FO is uncertain if application of the adult criteria occurred, contact the Regional Office disability coordinator, see DI 13005.020I.2. in this section.

NOTE: The CDR should not be loaded into EDCS without the TMR change from DC to DI status. ECDS requires a living arrangement change to update the TMR to a DI status. Once the TMR status updates, the FO should load the case into EDCS.

E. Cases that change into pay suspense after referral for a CDR or age-18 medical redetermination

After the alert for a CDR occurs, process the case for payment suspension as follows:

  1. Address: In this case, complete the address development including suspension for whereabouts unknown (WU), see DI 13015.001 and DI 13015.005. Complete the CDR when you have a valid address. For Title XVI cases, terminate benefits if the individual remains in suspense for over 12 months.

    The FO will use the DCF CDR Development Worksheet (CDRW) screen to establish controls for resuming the CDR when address development is complete, see MS CDR 001.013.

  2. Representative Payee: In this case, complete the representative payee development. Once the FO selects a representative payee, the FO will complete the CDR.

    The FO will use the DCF CDRW screen to establish controls for resuming the CDR after resolution of payee development.

  3. Other reasons: Do not pursue a CDR for individuals in suspense or non-payment status (for example, prisoner, out of the country, excess resources). Annotate the DCF, MBR and SSR with the remark: “CDR required before benefits can be reinstated.”

    The FO will not reinstate benefits until they receive the complete CDR package from the individual (for example, Forms SSA-454–BK (Continuing Disability Report), and SSA-827 (Authorization to Disclose Information to the Social Security Administration)).

    If payments resume, the FO will use the CDRW screen to establish controls for resuming the CDR, see MS CDR 001.013.

F. Routing career Railroad Retirement Board (RRB) cases

The FO must route career RRB cases to the Great Lakes Program Service Center (GLPSC)/Disability Processing Branch (DPB) for processing and coordination with the Railroad Board.

G. Incorrect and accidental CDR alerts

On occasion, a case receives an incorrect alert and selection for a CDR. If a case like this is not screened out in the FO, the DDS will treat the case as a “No Decision”, see DI 28003.005G. In “No Decision” situations, the DDS will return the case to the FO and provide an explanation for the basis of the return on the Form SSA-408 (Route Slip). For electronic case procedures, see DI 81010.000.

The FO must prepare and release a close-out notice according to NL 00705.355, and determine when and where to send the claim folder(s). The FO must also stop the CDR by updating the DCF. To update the DCF, select EVENT 5 “SSR/MBR/OTHER CONDITIONS-STOPCDR” on the CDR FO input screen (IFOA), see DI 13010.620.

In addition to any special instructions that are described in this section, the cases are subject to all the screening procedures discussed in DI 28003.005. Once the FO identifies that the CDR alert is incorrect or accidental, the FO must stop the CDR on the case and screen out under DI 13005.020H in this section.

H. Processing screened out cases

Follow these guidelines to process a screened out CDR. For additional information on processing a case in EDCS, see DI 81010.140:

  1. Do not initiate the CDR.

  2. If initiation of the CDR occurs, prepare and release a close out notice, see NL 00705.355.

  3. Make any necessary system inputs and transfer the case folder(s) to the appropriate location.

    • Title II case - Close out the CDR, by selecting EVENT 5 “SSR/MBR/OTHER CONDITIONS-STOPCDR” on the IFOA screen and annotate in “Remarks” why the CDR was screened out and stopped.

    • Return the case folder(s) to SSANRC. Address the SSANRC using a SSA-408 or the reverse of the SSA-5526-U3.

    • Title XVI case - Close out the pending CDR on the DCF by selecting EVENT 5 “SSR/MBR/OTHER CONDITIONS-STOPCDR” on the IFOA screen and annotate in “Remarks” why the CDR was screened out and stopped. Update any necessary system(s) and clear any case controls, such as updating the medical diary information in the Medical Review (MR) field of the SSR.

If there is no need for any other post-entitlement actions in the FO, transfer the case folder(s) to the Wilkes-Barre Folder Servicing Operation (WBFSO) using an SSA-408.

I. Deferring a CDR

1. When to defer a CDR

You may defer the CDR for one of the following situations:

  1. Reasons unrelated to the disability (for example, weather, travel, hospitalization (short duration)); or

  2. Life-threatening situations (only upon Regional Office approval), see DI 13005.070.

2. How to handle a deferred case

Handle deferred cases as follows:

  1. Short-term deferral: If FO expects to complete development within two months, retain the folder. When the FO development is complete, the FO will use the CDRW screen to establish controls for resuming, see MS CDR 001.013.

  2. Long-term deferral: Document the folder with the reason for the deferral and a specific diary date not exceeding six months. Use the CDRW screen to establish controls for requesting the folder and resume the CDR when the diary is mature, see MS CDR 001.013. The FO will return the case to the PSC or WBFSO, according to DI 13005.020H in this section.

3. Requesting guidance for deferral of a CDR

Call your Regional Office for guidance if it appears that the CDR is entirely inappropriate or it should be deferred but is not covered by any of the instructions in DI 13005.020D or DI 13005.020E in this section. These situations should be rare.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0413005020
DI 13005.020 - Field Office Actions for Processing and Screening Continuing Disability Review (CDR) Folders and Alerts - 10/03/2017
Batch run: 10/03/2017
Rev:10/03/2017