TN 32 (04-10)

DI 13010.160 Suspending Benefits for Title II

A. When to suspend benefits

The field office (FO) or payment center (PC) may suspend benefits when:

  • A beneficiary returns to work before the expiration of the disability waiting period or within a year of his or her established onset date (and prior to the final adjudication), and you need to reopen the prior award to a denial. For return to work issues, see DI 13010.105, Return to Work Within a Year of Onset (Title II).

  • A beneficiary reports that he or she:

    1. has been working full-time for 2 or more months with no significant medical restriction;

    2. acknowledges medical improvement as of the month of return to work;

    3. expects to be able to continue working; and

    4. does not want to have medical evidence from the last 12 months included in the file before a determination is made on termination of benefits.

  • We conduct a work issue continuing disability review (CDR), or Expedited Reinstatement (EXR) Initial Reinstatement Period (IRP) determination, and you must suspend or terminate benefits based on substantial gainful activity (SGA).

  • The beneficiary requests a voluntary suspension of benefits during CDR or IRP case development to avoid or reduce any overpayment. For instructions on inputting a suspension based on a voluntary request, see DI 13010.160C (in this section).

  • A work issue CDR determination is still in process, the beneficiary is currently performing SGA, and development is ongoing regarding retroactive work activity. For processing suspensions while developing for SGA, see DI 13010.160D (in this section).

    NOTE: If the FO suspends benefits upon receipt of a case, the PC must expedite any necessary development and process the case. The PC follows all due process requirements according to instructions in DI 40515.005, Due Process Requirements – Title II

1. Acceptable source of FO contact

The beneficiary or representative payee is responsible for reporting events that may affect payments; therefore, attempt to make all telephone or mail contacts with the person receiving the checks.

If someone other than the beneficiary or the representative payee reported work, determine whether he or she is an acceptable source of information by following the guidelines in GN 03001.012.

2. Due process prior to suspension

Provide a manual due process prior to suspending benefits (including auxiliary payments, if any) unless the suspension is the result of a voluntary request. Advise the beneficiary of the reasons for suspension, and the right to submit additional evidence. For instructions on Due Process, see DI 13010.185.

NOTE: eWork prepares the due process notice for Work CDR determinations and automatically posts the DUE PROCESS issue for future action on the eWork development worksheet. eWork does not prepare a due process notice for interim suspensions (S0 inputs).

B. Suspension of benefits

1. Direct input of suspension

The eWork system automates the POS DIB CESS action. Use the Disability Cessation (PEC1) screen in the post entitlement (PE) online system (POS) to suspend or terminate benefits after you complete a CDR and have found SGA by using eWork. The DIB CESS effectuates the S7 suspension, and generates a suspension notice. For manual input procedures on eWork exclusion cases, see MSOM T2PE 003.024.

a. When the suspension input excepts and does not process

  • The DIB CESS input action excepts and the suspension is not effectuated and the final notice is not released.

  • Do not use the FAX procedure in DI 13010.215B1b or make another DIB CESS input.

  • The Terminations, Attainments, Transfers and Terminations (TATTER) program automatically generates an exception alert for Office of Central Operations, Processing Center (OCO, PC) to resolve.

  • The FO may input an interim suspension to prevent improper payments while the exception is resolved. See interim suspension guidelines and procedures in DI 13010.160B.2 in this section.

Monitor the exception by establishing a work issue on the eWork development worksheet. Check the progress of the exception using the Processing Center Action Control System (PCACS) or Paperless Read Only Query System (PPL ROQS).

b. When suspension is a POS exclusion and does not process

If the case does not process due to a POS exclusion, see DI 13010.025 and use the FAX procedures in DI 13010.215B1b.

eWork:

  • identifies POS exclusions,

  • prepares the FAX form to be sent to the PSC,

  • prepares final notice for the FO to release to the beneficiary, and

  • posts a DIB CESS tickle issue to the eWork development worksheet.

Track the processing of the exclusion by reviewing the DECEFFECT issue on the eWork development worksheet. The FO may input an interim suspension to prevent improper payments while the exclusion is resolved. See interim suspension guidelines and procedures in DI 13010.160B.2.

2. Continuing Disability (CDIB) interim suspension input

Input an S0 suspension using the CDIB work suspension input in POS and add a special message to the Master Beneficiary Record (MBR) stating why you are inputting the suspense. The CDIB suspense input results in a S0 suspense code on the MBR which is effective with the current operating month (COM). Use the CDIB suspension action for POS exceptions as an interim step to prevent further months of improper payments. For more information on SO suspension, see MSOM COMMON 005.008 and SM 03020.050.

FO technicians should use discretion when utilizing the CDIB input and carefully follow the CDIB input procedure.

Use the CDIB input ONLY when ALL three conditions exist:

  • the final action is an ongoing suspension or termination;

  • a final determination notice has NOT been sent.

    NOTE: See the “Adjudicative Forms” screen on eWork. If this screen only shows a “Due Process” notice, then we did not issue a final determination notice If this screen shows both a Due Process notice and a Decision Notice, then a final determination notice has been produced by eWork, and the case is not a candidate for SO suspension by FO direct input to POS.

    and

  • the MBR verifies the claimant is in current pay.

After completing the suspension input, check to make sure the MBR updates and correctly shows LAF S0 effective with the COM in which the S0 suspension processes through POS.

NOTE: The FO may also have to reinstate benefits from a suspense status code of S0, to a current pay (ledger account file (LAF) C) status code on the MBR (i.e., the beneficiary works SGA and non-SGA months in the extended period of eligibility (EPE). When a beneficiary has some months of SGA, and some months of non-SGA during the EPE, the reinstatement action may “except,” and the Benefit Authorizer (BA) from the PC takes the necessary action to reinstate benefits. For detailed information on reinstating benefits from an SO input, see SM 03020.050 and MSOM COMMON 005.008.

C. Beneficiary requests voluntary suspension

A voluntary request for suspension to avoid or reduce a possible overpayment may be processed when the beneficiary has:

  • Completed the grace period after the trial work period (TWP), or

  • Is not entitled to a TWP, or

  • Is in the EXR initial reinstatement period.

Suspend benefits with the first non-payment month (e.g. after grace period).

1. Documenting request to suspend benefits

Obtain a signed statement from the beneficiary or representative payee, or document the request to suspend benefits to avoid or reduce a possible overpayment. Use one of the following methods to document the record:

  • SSA-820 or SSA-821 (Work Activity Report)

  • SSA-795-SP (Statement of Claimant or Other Person)

  • SSA-5002 (Report of Contact (RPOC), or

  • the eWork Development Worksheet.

Inform the beneficiary that we are temporarily suspending his or her benefits while we are evaluating work activity.

2. If the beneficiary requests a voluntary suspension action to reduce or avoid an overpayment, a due process notification is not required

Take the following actions to input voluntary suspension:

  • Input an S0 suspension through the CDIB work suspension input in POS Suspension actions input through CDIB are effective with the current operating month. For more information on SO suspension, see MSOM COMMON 005.008 and SM 03020.050.

  • Document the eWork development worksheet and the remarks screen of the DCF with the reasons for and the date of the suspension;

  • Continue all needed development and make a work CDR determination following normal procedures;

  • Provide due process if benefits are not payable for any additional months prior to the voluntary suspension, and effectuate the determination with a DIB CESS input, or follow fax procedures if the case is a POS exclusion;

    NOTE: POS accepts the input of an EPE or IRP action, but TATTER rejects the action when the beneficiary is in S0 suspense. An exception is generated with the message:

    1. “PRIOR LAF PROHIBITS EPE PROCESSING” for EPE actions, or

    2. “PRIOR LAF PROHIBITS PROCESSING” for IRP actions.

The PC must then resolve the exception alert. Monitor the exception by establishing a work issue on the eWork development worksheet. Check the progress of the exception using PCACS or PPL ROQS.

D. Suspension action during CDR development

When you receive information which indicates a beneficiary is performing SGA (and the trial work period (TWP) is complete):

  • suspend benefits,

  • begin development immediately,

  • take all necessary actions to make a work determination, and effectuate a timely suspension of benefits.

Under some limited circumstances, you may suspend benefits if the information clearly shows that disability has ceased due to SGA and you are unable to complete a determination soon enough to prevent additional months of overpayment. Process a suspension action prior to the SGA determination only when all three of the following situations apply:

  • Documentation that the beneficiary is currently performing SGA exists (e.g., SSA-820 or SSA-821), SSA-795, or electronic evidence);

  • The Disability Control file (DCF) or eWork shows documentation that the beneficiary has completed the grace period after the Trial Work Period (TWP), or that the beneficiary is not entitled to a TWP; and

  • A work review is established in eWork to ensure proper controls.

1. Due process

Provide due process prior to suspending benefits (including auxiliary payments, if any). Provide advance notice of the proposed suspension, including the reason for the suspension, and the right to submit additional evidence.

Prepare a manual notice following the guidelines in DI 13010.185, Due Process in Work Issue Cases.

2. Suspension input

When due process time is up (15 days from time of mailing), input an S0 suspension action through the CDIB screen as outlined in DI 13010.160C.2 (in this section). After you complete the work suspension action, continue with work CDR development and make a work issue determination. Afford due process again if benefits are not payable for any additional months prior to the suspension action. For more information on due process, see DI 13010.185.

E. Related references