TN 28 (08-09)

DI 13010.197 Special Situations in Work Continuing Disability Reviews

Introduction

This subchapter addresses situations that may arise during the course of evaluating beneficiaries work activity, or when developing and processing a work continuing disability review (CDR).

A. Beneficiary dies and CDR not complete

When developing a CDR, you may learn that the beneficiary has died. Attempt to complete the CDR when there is an unresolved issue, e.g., there is work that could affect payment status. Take necessary action to develop and process the following applicable issues:

Issue or ActionRelated POMS Reference

Record the date of death in the file; and continue to control and process the CDR.

NOTE: This is a eWork exclusion, so you will manually update and clear the work action on the DCF.

Input death termination

  • GN 02602.050 – Processing Reports of Death

  • DI 13010.025 - FO Responsibilities in Work Issue CDRs

  • SM 03005.250 - Death Terminations

Processing possible survivors

DI 11010.335 - Developing Survivor Claims when the Processing Center (PC) has Jurisdiction of the Official Folder

Resolve any possible recovery actions from the estate

B. Potential suicidal or homicidal behavior

If a beneficiary exhibits suicidal or homicidal behavior, follow the instructions in DI 11005.080 and DI 13005.070.

C. Failure to cooperate and whereabouts unknown

Follow instructions in DI 13015.001 through DI 13015.025.

D. Handling adverse actions

A beneficiary (or his or her representative) may allege that Title II, Title XVI, or concurrent disability benefits have been:

  • paid or continued erroneously, or

  • reduced or terminated without advance notice.

    NOTE: Always consider Administrative Finality as described in GN 04001.000 and SI 04070.000.

1. Payment effectuated erroneously

a. Erroneously paid DIB denial or benefits through CPS

If we erroneously processed a disability denial as an allowance, or we erroneously paid benefits through the Critical Payment System (CPS):

  • Extend due process before terminating erroneous payments.

  • Return the case to the Disability Determination Services (DDS) with a brief outline of the facts that resulted in the erroneous award notice.

  • Request the DDS to extend due process and issue a revised determination notice.

  • Alert the DDS regarding dual entitlement situations.

Determine whether we issued an improper award notice or a check without notice. Receipt of an award notice or a check without a formal notice, even though erroneously issued, creates a substantive right on which the beneficiary may rely.

See Also:

DI 10501.050 – Due Process - Work Issue Cases

b. DDS prepared a denial determination and released a denial notice

We can cease the erroneous payment without advance notice; therefore, the beneficiary has no substantive right to rely on any erroneous payment. Take immediate action to terminate the benefits:

  1. Contact the Office of Central Operations (OCO) or the Program Service Center (PSC) to terminate Title II payments using the FAX procedure in DI 13010.090C (amend the FAX appropriately).

  2. Document the file with the date that you requested termination (In dual entitlement cases, take necessary action to terminate Title XVI benefits).

  3. Send a letter to the beneficiary advising him or her of the erroneous payment, using the following language:

    “You were informed on (month/day/year) that you were ineligible for disability payments. Because of a mistake, however, benefits were paid. We are now stopping these erroneous payments. You will be advised later regarding any overpayment. At that time you will be given the right to request waiver of repayment of the overpayment by showing that you were not at fault in receiving the overpayment and that to recover the money from you would be a hardship.

    If you believe that you have become disabled since the time of the previous decision, you may wish to file a new application for payments. If you have any questions, please contact your local social security office and have this notice available for reference.”

    NOTE: Do not include appeals language in the above letter since the beneficiary would have been given the appropriate appeals options in the DDS determination notice.

    NOTE: Notify erroneously paid auxiliaries who do not reside with the primary beneficiary, and modify the suggested language above as necessary.

2. Reinstatement after erroneous termination and or suspension

If we suspended or terminated benefits without proper due process, or we can establish good cause for not filing within the 10 day-appeal period:

  • Send a request to OCO or the PSC to reinstate benefits through the Modernized Development Worksheet (MDW) process. For instructions on ways to request assistance see GN 01070.420.

  • Use the Critical Payment System (CPS) to expedite the payments to the beneficiary. For instructions on CPS see SM 00635.001.

  • Reinstate benefits from the date of the original suspension or termination action. For instructions on how to process reinstatements see SM 00614.064.

  • Send the corrective due process notice and allow the full 15-day response period (10 days plus 5 days mailing time) when benefits are reinstated.

  • Verify the record reflects current payment status, pending correction in accordance with due process procedures.

    NOTE: For a DDS jurisdiction case, reinstate benefits and return the case to the DDS for processing.

E. Due process for overpayment and recovery actions

Before taking any action to adjust or reduce benefits to recover overpayments.

If a claimant requests a waiver, we cannot recover the benefits until a personal conference is held, refused, declined or not held due to a no show. If the claimant subsequently requests a hearing, the recovery continues through the hearing process.

See Also:

GN 02201.027 Overpayments for Title II Hearing Requests

GN 02250.380 Appeal of Waiver Determination

F. Payment termination not effectuated

If we notified a beneficiary of a disability benefit termination, and he or she did not appeal, and monthly payments continued for more than 2 months after the month of termination, or date of the cessation notice (whichever is later):

  • Send a second notice to the beneficiary explaining the oversight before ceasing checks.

  • Use the following sample language in the notice:

    “You were informed on (month/day/year) that you were no longer eligible for disability payments. Because of a mistake, however, the payments were not stopped at that time. We are now stopping your checks. You will be advised later regarding any overpayment. If you have been overpaid, you will have the right to request waiver of repayment of the overpayment by showing that you were not at fault in receiving the overpayment and that to recover money from you would be a hardship.

    If you believe that you have become disabled since the time of the determination, you may wish to file a new application for payments. If you have any questions, contact your local social security office and have this notice with you for reference.”

The only issue the beneficiary can appeal is the substantive disability issue, i.e., cessation. If the beneficiary did not appeal when notified of the prior cessation but decides to file an appeal now, develop for “good cause” for late filing.

See Also:

GN 03101.020 - Good Cause for Extending Time Limit

DI 13015.265 — Instructions for Processing Overdue Medical Cessation and Uneffectuated Medical Cessation Cases

G. Change in beneficiary’s status: Blind to disabled

In certain instances, the DDS may find it necessary to change a favorable determination that changes a beneficiary's status from blind to disabled:

  • The beneficiary continues to meet the criteria for disability, but no longer meets the definition of blindness.

  • This change does not normally result in an interruption of benefits (excluding any other basis for cessation); however, the DDS is required to notify the beneficiary of the change, including his or her right to appeal the decision.

Disability entitlement continues for statutorily blind beneficiaries who only meet fully insured status (i.e., do not meet 20/40 or Special Insured status) and are subsequently determined no longer statutorily blind but are still disabled (i.e., have a non-blind impairment).

When DDS changes a beneficiary's status from blind to disabled:

  • Evaluate earnings for substantial gainful activity (SGA) purposes.

  • Do not cease benefits on the basis of work activity unless due process requirements are met.

See Also:

DI 10501.001 – Meaning of SGA and Scope of Subchapter

DI 13010.185 – Due Process- Work Issue Case


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http://policy.ssa.gov/poms.nsf/lnx/0413010197
DI 13010.197 - Special Situations in Work Continuing Disability Reviews - 05/09/2017
Batch run: 05/09/2017
Rev:05/09/2017