TN 3 (01-07)

DI 13050.005 General Workflow

A. Policy - Field Office Responsibilities

1. Overview

Discuss the criteria for reinstatement with the individual and provide a comparison of the possible effects of requesting expedited reinstatement (EXR) versus filing a new initial claim (see DI 13050.020 for a complete discussion). If the individual decides to request EXR; assist the individual with the request for reinstatement, obtain the prior folder, and determine whether the individual meets the applicable non-medical criteria discussed in DI 13050.001.

It is important that the FO fully identify all SGA and non-SGA months in the 12 month period prior to the month of filing. These months must be clearly documented on the SSA 820 or 821, and the SGA determination recorded on the SSA-823 (see DI 13050.045C.1.b.). The DDS will use these months to determine the month of EXR entitlement if the individual is found to be disabled under MIRS.

NOTE: If the individual stopped performing SGA in or prior to the EPE termination month, be alert to the possibility of reopening the prior EPE termination (if allowable under the rules of administrative finality).

2. FO Jurisdiction Denial

Deny a request for EXR that does not meet the non-medical requirements for EXR, such as:

  • An event occurred that would preclude entitlement (e.g. a CDB has married -- see DI 13050.060A.2); or

  • entitlement was terminated for reasons other than earned income (title XVI) or SGA (title II); or

  • the request for EXR is filed after the 60-month filing period has expired and good cause for late filing is not found; or

  • the individual is engaging in substantial gainful activity in the month the EXR request is filed; or

  • the individual does not meet a factor of entitlement in the month the EXR request is filed (excess resources, etc.).

3. Medical Determination Needed

When an individual meets the non-medical requirements for EXR, forward the folder to the DDS for an EXR medical decision and initiate provisional benefits through POS for Title II (see DI 13050.025I.). Title XVI provisional payments should be initiated per DI 13050.030.

The DDS first determines if the individual's current medical impairment(s) is the “same as or related” to the medical impairment(s) that was the basis for the prior disability entitlement. The DDS must find that “same as or related” is met unless evidence establishes it is not met.

When “same as or related” is met, the DDS determines if the individual is disabled by applying the medical improvement review standards (MIRS). If the DDS determines that a claimant is not disabled, and the EXR is denied, a medical CDR may be required on any other claim (see DI 13001.005I., Events Which May Initiate a CDR). The DDS returns the file to the field office with either an approval or denial determination.

4. Award or Denial Procedure

a. Award

Process a title II EXR approval with an EF-101 and fax the SSA-833 to the appropriate PC or OCO for paperless folder documentation only, using the fax cover sheet in DI 13050.105 Exhibit 4 (see DI 13050.060 for detailed award processing instructions). For detailed phone, fax, and address information for the PCSs, go to the following link: Process a title XVI award through start date procedures (SM 01701.080 and DI 13050.060E.). When all FO and OCO/PC award processing actions are completed forward the EXR folder for filing.

b. Denial

When the DDS returns the file, send the medical denial notice to the individual and include the denial information that the DDS has prepared. Terminate provisional benefits using the DIB Cess screens (see MSOM T2PE 003.024 and SM 01701.080). A medically denied EXR claim may raise an issue as to whether disability continues on another claim, per DI 13001.005I.

B. Policy - DDS Responsibilities

The DDS reviews the medical evidence and determines if the individual's current impairment is the same as or related to the impairment that led to the previous entitlement to benef