TN 3 (01-07)
DI 13050.060 Expedited Reinstatement Awards - Title II
A. Policy - favorable medical decision
The DDS makes a determination regarding entitlement and prepares an SSA-833 to document the determination on a Title II request for EXR. The DDS faxes (or uses another locally agreed upon procedure to expedite the decision) the SSA-833 allowance to the FO (see DI 11010.340).
1. Month of entitlement and retroactivity
If it is found the individual is under a disability and entitled to EXR, benefits can be reinstated retroactively for up to 12 months before the EXR request date (but not earlier than January 1, 2001) provided all factors of entitlement are met. The month of entitlement is the earliest month that the individual did not perform SGA and met all of the EXR eligibility requirements. The month of entitlement can not be before the benefit termination month (BTM) of the previous entitlement.
No retroactive payment is due for any month in which the individual engaged in SGA. The month of entitlement must be a non-SGA month. Normal suspension and terminating events apply to all reinstated benefits. Reinstated benefits due are reduced by the amount of provisional payments made.
EXAMPLE: Mr. Smith was previously entitled to SSDI for back problem and his earlier entitlement terminated due to work on 11/03. In 6/04, Mr. Smith has an accident that re-injures his back and he is unable to work. In 9/04, he decides to request EXR. When the FO develops the case to send to DDS, they provide a request date of 9/04 and note that the following SGA and non-SGA months in the 12-month retroactive period:
SGA Months: 9/03, 10/3, 11/03, 12/03, 1/04, 2/04, 3/04, 5/04
Non-SGA Months: 4/04, 6/04, 7/04, 8/04
The DDS decides that Mr. Smith meets the medical requirements of EXR in the month of filing (9/04). They then look at the first non-SGA month in the retroactive period, which is 4/04. They determine that though Mr. Smith did not perform SGA, he did not meet the MIRS criteria in 4/04. They then look at the next non-SGA month (6/04) and determine that Mr. Smith did meet the MIRS criteria in that month. Therefore, the month of entitlement for EXR is 6/04, which is the first month of the initial reinstatement period (IRP).
2. Auxiliary benefits
Auxiliaries previously entitled to benefits on a reinstated number holder's record, who continue to meet initial entitlement requirements, will be reinstated to benefits with the first month of reinstatement for the disabled number holder. A new paper application must be filed following the EF-101 procedures for both previously entitled and new auxiliaries. If auxiliary entitlement was based on the auxiliary's disability, the auxiliary must continue to meet the disability requirements before he or she can be reinstated (DDS must conduct a medical review before we can reinstate the auxiliary). For more information on the technical requirements for childhood disability benefits (CDB), see DI 11020.015.
B. Procedure - field office actions- Title II
Determine an EXR approval by reviewing the SSA-833:
Item 9 will have block A indicated;
Item 10 will show “other”;
Item 20 will show WRM code 31 (for EXR); and
Remarks will show “Expedited Reinstatement MOE MM/YY”.
Prepare an EF-101 under District Office Final Authorization (DOFA) procedure (GN 01010.027).
Complete the EF-101 following normal amended award procedures (see MSOM T2PE 009.001) except:
The application date is the request date for EXR (use the earlier protective filing date, if one exists).
Although EXR establishes a new period of disability, for PIA computation purposes use the onset date of the previously terminated period of entitlement. The PIA is computed as if the EPE termination and any provisional payments never happened. Never use the EXR date of onset for PIA computation purposes. Ensure all years of earnings not previously included in the MBR PIA history are used to compute the EXR payment PIA. Enter the PIAs, starting with the reinstatement date, on the EFPIAD screen of the EF-101 (for more information on EPE PIA computations, see RS 00605.238).
The monthly benefit payable equals the amount payable at the time the previous period of entitlement terminated, increased by any intervening COLAs, and recomputations due. Dual entitlement benefits payable are also the previous rates increased by any intervening COLAs and recomputations due. For more information on computations, see RS 00615.000.
On the EFBNDIB screen, the DDO field must show an onset date of the last day of the month prior to the month of entitlement (DOED) for EXR. For example, if the EXR DOED is 04/06, the DDO would be 03/31/2006. The DAC of “F” must be coded on the EFBNDIB screen.
The month of entitlement (MOE) may be retroactive from the request date for up to 12 months, but no earlier than 01/2001 and no earlier than the previous benefit termination month (BTM). The FO must use the MOE established by the DDS and shown on the SSA-833; the FO cannot change the MOE. If it is determined that MOE established by the DDS cannot be used (e.g. due to SGA in that month) the case must be sent back to the DDS to determine a new MOE.
If the incorrect MOE is discovered in the PSC/OCO, the DPB in PSC 1-6, the DE in ODO or the DPU in PC 8 can determine a new MOE.
Code deduction/suspension/termination months due to SGA, Workers Compensation, PDB, Windfall, etc. on the appropriate screens of the EF-101.
Answer “Y” to WC/PDB Involved on the EFACCT screen to bring the WC/PDB screens into the path
The involvement of Garnishment and Tax Levy are indicated by responses on the EFBENE screen
SSI Windfall Offset is indicated on the EFBEN2 screen
Common screens which affect entitlement are selected from the EFCOMM screen
If SGA or EPE are involved, the question should be answered, “Y” on the EFBNDIB screen. This brings the EFDIBWK screen into the path where the suspension/termination information can be coded.
The EFBNCM lists a selection of three separate menu screens. These screens provide access to Common Screens used for suspension, termination and reinstatement events for miscellaneous situations, disability events and foreign events.
Alert OCO/PC that the case is an EXR case and requires priority handling. Also alert OCO/PC about Medicare and other special issues involved, using the Remarks section of the EFBCRN screen.
Insert remark, “Expedited Reinstatement Case – Priority Handling.”
Include remark to alert OCO/PC to any provisional benefits paid.
If prior period of HI/SMI was not terminated due to extended Medicare, no action is necessary. Medicare eligibility continues.
If HI/SMI terminated prior to the EXR award date, add remark: “Award Medicare based on EXR – See HI 00801.166 – new IEP applicable”.
If appropriate, include remarks about WC, PDB or other special issues.
Adjudicate and transfer EF-101 per MSOM T2PE 009.035 and MSOM T2PE 009.036.
Send a copy of the EF-101 to ORS.
Store an electronic copy of the SSA-833, the SSA-371, SSA 16, SSA 10 and SSA 4 (if applicable), SSA 820/821, SSA 823 and the EXR flag sheet found in DI 13050.105 (Exhibit 4) and fax them into eView using the “MDF E” barcode and annotate the “Note” field with “EXR Documentation” or into NDRED using the “other” document type and annotate the “Remarks” field with “EXR Documentation.”
Transfer the EXR event on the DCF to OCO/PC per DI 13010.620. Follow-up using critical case procedures, if needed.
Tickle case for two weeks to verify via MBR review that OCO/PC has processed the reinstatement. If the reinstatement has not been processed, make a critical case telephone contact with the module assigned to the case.
Query PCACS to verify location/jurisdiction of the EF-101 action.
Access Detailed Office/Organization Resource System (DOORS) to obtain correct telephone number for the ODO Telephone Process or PSC module, per MSOM DOORS 002.002, MSOM DOORS 002.003.
Set a one week tickle to requery the reinstatement.
Follow RS 02803.145B.2.c if the reinstatement has not been processed after an additional week.
Once the reinstatement has been processed, send the folder to the National Record Center (NRC), 6002 East GeoSpace Dr., 601 South 291 HWY, Independence, MO 64056 for storage. Include the paper SSA-833 in the folder. Attached the correct coversheet for non-actionable Title II folders and mark the folder “All FO/PC Actions complete.”
OCO/PC will issue the reinstatement notice.
C. Procedure - processing center (PC) actions
OCO/PC receives EF-101 from FO and performs a cursory review of the EF0101 under DOFA procedures. OCO/PC will also receipt the SSA-833 to document the electronic file. Normally review of the SSA-833 is not needed.
Perform a cursory review of the EF-101 under DOFA procedures. Call the FO if necessary to resolve any issues.
Stop provisional benefits, if necessary, and process the disability reinstatement, adjusting for Provisional Benefits paid and Medicare issues (see SM 00856.300 and SM 00856.400). The Medicare reinstatement action is considered a new initial enrollment period (IEP) and equitable relief provisions are applied as appropriate. (See HI 00801.166)
Ensure the DAC of F (never a DAC of X) is coded per (SM 00856.300B.1.).
Send the reinstatement notice to the beneficiary using AURORA notice E3956. See NL 00703.956.
Clear the EXR event in the DCF as a continuance per DI 13010.625.
D. Policy – payment of representative’s fees
GN 03910.010 asserts a beneficiary’s right to representation, which includes expedited reinstatement. Individuals have the right to representation while applying for EXR and any related appeals. A representative who wants to charge or collect a fee for services provided in these administrative proceedings must first obtain SSA’s authorization, except when the conditions described in GN 03920.010 are present.
If SSA makes a favorable medical determination on the EXR request, and the claimant’s Title II benefits are reinstated, and the claimant’s representative requests a fee for the administrative services he/she provided the claimant, SSA does not include these provisional payments in authorizing a fee under the fee agreement process. In addition, SSA does not use these provisional payments to calculate the amount of the Title II past-due benefits to withhold for direct payment of a representative’s fee under the fee agreement or fee petition process, or to pay a fee authorized by a court. Refer to GN 03920.017, Payment of Representative’s Fee, and GN 03920.030, Representative’s Fee – Title II Past-Due Benefits.