TN 26 (02-09)

DI 13010.170 Completing the SSA-833 (Cessation or Continuance of Disability or Blindness Determination and Transmittal – Title II)

A. Policy for Cessation or Continuance of Disability or Blindness Determination and Transmittal (SSA-833)

Use the SSA-833 (exhibit: DI 13095.095) to document cessation or continuance of disability due to a substantial gainful activity (SGA) determination in post-entitlement situations. When using eWork, the program prepares the SSA-833.

This subchapter explains how to complete the SSA 833 in the following post-entitlement situations:

Situation

Reference

EPE-single issue case

DI 13010.170B.2.

Multiple determinations

DI 13010.170B.6.

Extended Period of Eligibility

DI 13010.210

Policy - Reinstatement of Disability Benefits

DI 13010.210G.

Policy - Return to SGA After Reinstatement

DI 13010.210H.

See Also:

For instructions on how to complete the SSA-833 in other situations:

Situation

Reference

Procedure - Field Office Actions – Title II

DI 13050.060B.1.

Completion of the SSA-832-U5/SSA-833-U5

DI 28040.220

Preparation of Form SSA-833-U3 Impairment Severity Determination

DI 28055.030

Completion of Form SSA-833-U5

DI 28065.035

General Completion of the SSA-833-U5 for Statutory Blindness Cases Discussed in this Subchapter

DI 41005.001

B. Procedure for Manually completing the SSA-833 in post-entitlement situations

The following chart describes items on the SSA-833, and provides an explanation on how to complete them. You may use either an “X” or a checkmark for blocks.

1. SSA-833 

Item

Explanation

1A – Social Security Number

Enter the Social Security Number (SSN) of the primary beneficiary/recipient. Show the wage earner's SSN in childhood disability cases (CDB) and disabled widow benefits (DWB) cases.

 

Enter the Beneficiary Identification Code (BIC), shown under the BIC caption on the latest award document, to the right of the SSN; e.g., “A” for a disabled wage earner. Also enter any numerical suffix following a designated BIC; e.g., “C1” for a CDB.

1B – Type of Claim/Case

Complete the appropriate block.

1C – Other Entitlement

Complete the appropriate block. Complete the “Title XVI” block on concurrent Title II/Title XVI determinations. Complete the “Title II” block if there is other Title II involvement (e.g., DIB-CDB, DIB-DWB, etc.).

2A – Name of Payee (If Any)

Enter the representative payee's name, if any, including the term “for,” “on
behalf of,” or “guardian of.”

Reference:   See item 29 below if there is a representative payee.

2B – Name of Disabled or Blind Individual

Enter the first name, middle initial, last name of the disabled or blind individual. Print the first three letters of the surname in capital letters in the embedded block (e.g., JOHnson).

2C -Address

Enter the latest mailing address for the disabled/blind individual, or, if applicable, the representative payee. Always include the zip code.

Do not show the bank address if direct deposit is involved.

Line out the address entry and enter “beneficiary/recipient deceased” in any case where the beneficiary/recipient filed on his/her own behalf and is deceased.

CAUTION: If the most current address is different from the one shown in the file, change the address so that all of our records (MBR, SSR, etc.) have the correct address.

3 - Wage Earner's Name

Enter the name of the wage earner whose SSN appears in item 1A, if the disabled individual is a CDB or DWB.

4 -Date of Birth

Enter a 6-digit figure (e.g., 01/03/59).

5 -Date Disability Began

Enter the date from item 15A or 28B of the latest approved SSA-831-U3 (Disability Determination and Transmittal) in file. Query the date of disability onset (DDO) field on the Master Beneficiary Record (MBR), to obtain the date disability began if the SSA-831-U3 is not available see SM 00510.200.

6 -FO Address

Enter a complete field office (FO) address and zip code.

7 -FO and DDS Code

Enter the FO code only.

NOTE: The Disability Determination Service (DDS) code applies only to DDS jurisdiction cases.

8 -Adjudicative Level

Complete the appropriate block.

9 -Determination Findings

Always complete the disability block. Complete items 9A and B only if the case does not involve a statutorily blind person.

9A -Continues

Complete in continuance cases.

9B - Ceased

Complete if disability ceased and enter the month, day and year of cessation.

In failure to cooperate (FTC) cases, disability ceases in the first month in which the individual fails, without good cause, to do what SSA/DDS has requested and the individual was aware of the requirement to cooperate and the repercussions of failing to do so. For further information on failure to cooperate cessations, see DI 28075.005F.

9C - Period of Disability Terminated at the Close of the Last Day of

Complete to show termination of disability (MM/YY). Rationale:  Enter the last day of the second month after the month in which cessation occurs, e.g., ceased in 12/15/92; terminated 02/28/93.

Reference:  For instructions governing Extended Period of Eligibility (EPE) cases, see DI 13010.210.

9D - EPE Begin Month

Complete to show the beginning month of an EPE (MM/YY). Enter the month immediately following the month of completion of the Trial Work Period (TWP).

9E - EPE Reinstatement Allowed

Complete to show that EPE reinstatement is allowed. Enter the first non-SGA month during the EPE (enter MM/YY) after a prior suspension for SGA.

9F - EPE Reinstatement Denied

Complete to show that EPE reinstatement is denied (MM/YY).

9G - EPE Suspension after Reinstatement

Complete to show that benefits are suspended after reinstatement. Enter the month and year a reinstated beneficiary returns to SGA during an EPE (show MM/YY).

9H - EPE Benefit Termination Month

Complete to show the benefit termination month (BTM) for EPE cases.

Enter the first MM/YY for which disability benefits cannot be paid after EPE; i.e., the month after the month in which the EPE ends.

Reference:  For further information on payment of benefits during the EPE, see DI 13010.210E.

9I - 301 Case

Do not complete.

9J -Blindness

Do not complete.

10 - Basis For Determination

Complete appropriate blocks A-D.

Explain in item 24, if “OTHER” is checked.

Reference:  For information on impairment-related work expenses (IRWE), see DI 10520.001.

11 - Reason for Cessation

Enter both a 1 position (example: “M” for medical) and a 2-position reason for cessation code (example: “14” for whereabouts unknown)

For a complete listing of Title II reason for cessation codes, see DI 13095.105.

First, choose the more specific 2-position code, and then change it to the more general 1-position code. If more than one code applies for either of the 2 types of cessation codes, choose one code for each type.

Enter this 1-position code between “REASON FOR CESSATION” and “CODE”. Then, circle the 1-position code.

Finally, enter a 2-position code in the “CODE” block.

12 - Reason For Continuance and Medical List No.

Enter the reason for continuance code.

Reference: For Title II continuance codes, see DI 13095.115.

The medical listing number is completed only in medical determinations.

Reference:  For medical listing code numbers, see DI 34001.001 and DI 34005.001.

13 - Continuation Sheet

Complete when a rationale is required. Use a SSA-4268-U4 form (Explanation of Determination) as a continuation sheet in all cases (For instructions on rationale preparation, see DI 28090.000).

14 - Vocational Rule

Do not complete.

15 - Vocational Background

No entry

16 - Occupational Years

No entry

17 - Educational Years

No entry

18 - Special Use

No entry required.

19 - Vocational Rehabilitation Action

Do not complete.

20 - Why Review Was Made

Enter the appropriate code from DI 13095.135.

21 and 22 - Primary and Secondary Diagnosis

Enter the primary diagnosis in item 21 and the secondary diagnosis in item 22.

Obtain this data from the most recent SSA-831-U3 or SSA-833 in the file. Or, you may also look at the QMMD (Query/Modify Medical Data) screen in the disability control file (DCF) to obtain this data.

Refer the case, and the completed SSA-833 and folder to ODIO-PSC-DPB (after all actions are completed), if this information is not available.

Annotate the routing slip “Route to disability examiner for entry of diagnoses (Item 21 and 22) and codes.”

23 - Diary

Do not complete.

Refer the completed SSA-833 and folder to ODIO/ PSC-DPB after all actions are complete.

Annotate the routing slip “Route to disability examiner for appropriate diary (item 23).”

NOTE: This is only necessary when a manual diary needs to be established. This should be rare. Most actions are either automatically controlled by the Disability Control File (DCF), or entered in the DCF before the case clears. A diary is entered in the DCF, as well.

24 - Remarks

Enter the SSN of a CDB or DWB in a cessation.

Enter any of the following remarks, if appropriate. More than one remark can be entered. (The following list is not all-inclusive.)

“This revises determination approved (date of prior determination)” if the present determination revises a previous determination. “See Revised Determination of (date of revised determination)” on the prior determination.

A clarifying remark to explain any inconsistency.

Enter the claimant's attorney's complete name and address if the attorney has requested a copy of the notice.

24A and 24B - Multiple Impairments

Do not complete these items.

25 and 26 - Disability Examiner/Claims Representative and Date

Line through the words “Disability Examiner” or “Claims Representative” in item 25. Sign in item 25, and enter the date in item 26.

27 and 28 Physician or Medical Specialist Signature and Date

Do not complete these items.

29 - Letter and or Paragraph Number

Enter the appropriate letter or paragraph code.

Reference: For notice language, see NL 00701.003.

Enter the letter number, e.g., 1013 without the letter prefix (SSA-L).

Include the letter prefix for paragraphs, e.g., T22.

Send the notice to the mailing address of the legally competent beneficiary/recipient who has a representative payee. Make sure you send a copy of the notice to the representative payee. Show at the bottom of both notices “Copies Sent to (name of the individual (s) that copies are being sent).”

30 and 30A - Physician or Medical Specialist. Signature and Date

Do not complete these items.

31 Through 33 - SSA Representative, SSA Code and Date

Do not complete these items.

34 - List Number

Enter a code if appropriate.

35 - Folder Sent To

If the case is not electronic, show where the folder is being routed, e.g., NEPSC-DPB. If the case is electronic, eWork completes this for you.

2. EPE single issue case

Use these instructions to complete the SSA-833-U5, or to verify eWork has completed the form correctly in EPE cases where a single issue of continuance or cessation is involved.

a. Continuance

Prepare the SSA-833-U5 according to the chart in DI 13010.170B.1.

b. Cessation

For an explanation of the beginning and ending date for a Title II EPE, see DI 13010.210. Prepare the SSA-833-U5, as indicated in the chart above, making the following changes:

After you “check” the “Disability” block in item 9:

  • check block B and enter the month and year of cessation (MM/YY) in the box provided;

  • leave block C blank unless the determination is being prepared after the EPE has ended and the disabled worker has engaged in SGA after the 36-month re-entitlement period;

  • check block D and enter the month and the year (MM/YY) the EPE began; and

  • check block H, and enter the month and year (MM/YY) of the projected or actual benefit termination month (BTM).

3. EPE reinstatement case

A reinstatement determination is a supplemental determination. It does not change the cessation of disability date. If we allow reinstatement, and payments continue, the reinstatement determination may change the benefit termination month. The determination changes the months that payments are made. If reinstatement is denied, it does not change the prior determination.

a. Reinstatement allowed

Complete the SSA-833-U5 as indicated in the chart in DI 13010.170B.1. with the same entries, including the month of cessation, as they were shown on the most recent determination with the following changes:

  1. Item 9-If payments are to continue, i.e., the individual is not engaging in SGA when we made the determination:

    • check block 9 “Disability”;

    • check block 9B and enter the previously determined month and year disability ceased (MM/YY);

    • check block 9E and enter the month and year of reinstatement (MM/YY); and

    • make no entry in block 9H because with benefits being reinstated the BTM cannot be determined.

  2. Item 12 - Complete as appropriate.

  3. Item 20 - Complete as appropriate. If the determination is the result of a request for reinstatement, enter code 14 or 15.

  4. Item 24 - In remarks indicate that this determination supplements the previous determination and the date of the prior determination, if known.

  5. Item 29 - Enter “DL” for dictated letter. If eWork is used, “eWork” will be annotated.

b. Reinstatement denied

Complete the SSA-833-U5 as shown in the chart in DI 13010.170B.1 with the same entries that appear on the most recent determination, with the following changes:

  1. Item 9:

    • Check block 9 “Disability”.

    • Check block 9B and enter the previously determined month and year disability ceased (MM/YY).

    • Check block 9F and enter the month and year of the determination (MM/YY).

    • Check block 9H and enter the previously determined benefit termination month (MM/YY).

  2. Item 24: In remarks enter “This supplements the determination of (date of most recent SSA-833-U5 determination)”.

  3. Item 29: Enter “DL” for dictated letter or “eWork” will be annotated

4. Suspension after reinstatement case

A suspension after reinstatement is a supplemental determination. It does not change the cessation of disability date (Item 9B). Complete the SSA-833 determination as shown in the chart in DI 13010.170B.1., and with the same entries (including the date of cessation) as they appear on the most recent determination, with the following changes:

  1. Item 9:

    • Check block 9 “Disability”.

    • Check block 9B and enter the previously determined month and year disability ceased (MM/YY).

    • Check block 9G and enter the month and year benefits should be suspended (MM/YY).

    • Check block 9H and enter the benefit termination month (MM/YY).

    • Do not check block 9C or make an entry on the line unless the SGA is after the reinstatement period.

  2. Item 11: Complete as appropriate.

  3. Item 20: Complete as appropriate.

  4. Item 24: Make entries in accordance with the chart above. In addition, enter the following remark: “This supplements the determination of (date of the most recent SSA-833-U5 determination).”

  5. Item 29: Enter “DL” for dictated letter or “eWork” if eWork generated the notice.

5. Termination after reinstatement case

Prepare a SSA-833-U5 determination of termination when a reinstated individual returns to SGA after the EPE re-entitlement period expires. This is a supplemental determination and does not change the cessation of disability date or EPE beginning date. (Items 9B or 9D)

Complete the SSA-833-U5 determination as shown in the chart in DI 13010.170B.1., and with the same entries (including the date of cessation), as they appear on the most recent determination, with the following changes:

  1. Item 9:

    • Check block 9, “Disability”.

    • Check block 9B, enter the previously determined month and year disability ceased (MM/YY).

    • Check block 9C, enter the month and year the period of disability terminated (MM/YY). For Extended Period of Eligibility, see DI 13010.210F.

    • Check block 9D, enter the previously determined month and year the EPE began (MM/YY).

    • Check block 9E, enter the previously determined month and year reinstatement was allowed (MM/YY).

    • Check block 9H, enter the benefit termination month (MM/YY).

  2. Items 11 and 20: Complete as appropriate.

  3. Item 24: Make entries in agreement with the chart in DI 13010.170B.1. In addition, enter the following remark “This supplements the determination of (date of most recent SSA-833-U5 and/or SSA-832-U5 determination).”

  4. Item 29: Enter “DL” for dictated letter or “eWork” if eWork is used.

6. Multiple determinations

Show multiple determinations on one form; make sure that the determinations do not involve more than one entry in a designated space or line. If you need to record more than one entry in a designated space or line, complete additional SSA-833(s) as required.

For example, you can have one determination for a cessation, reinstatement, and suspension after reinstatement. But, if a subsequent reinstatement is also involved, complete another SSA-833 determination to document that reinstatement. Issue a combined notice to reflect all actions when processing combined actions.

Enter each determination on the SSA-833 in accordance with the instructions for the individual action (i.e., cessation, reinstatement denied or allowed, suspension after reinstatement, and terminations). In each case, prepare the SSA-833, except for Items 9, 11, and 12.

When multiple EPE determinations are prepared, staple together the copies of the determination form.

NOTE: eWork records additional EPE suspensions and or reinstatements on a SSA-4268 (Explanation of Determination). You do not have to prepare additional SSA-833 determinations if using eWork.

Always enter the code applying to the end result of the determination in Item 11 or 12. For example, if the final action is to reinstate benefits use continuance code 38 in item 12 (EPE Reinstatement-Work Not SGA) from DI 13095.115.

In addition to any other appropriate remarks, enter “Multiple EPE Determination” in Item 24.

C. Procedure - routing the determination

Fax all eWork documentation and any supporting work development into eView or NDRed. For a list of documents see DI 13010.025B.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0413010170
DI 13010.170 - Completing the SSA-833 (Cessation or Continuance of Disability or Blindness Determination and Transmittal - Title II) - 07/20/2017
Batch run: 07/20/2017
Rev:07/20/2017