TN 2 (02-06)

DI 13050.065 Expedited Reinstatement Denials - Title II and XVI

A. Policy - Medical Denial

1. Background

When the DDS makes an unfavorable medical determination on an expedited reinstatement (EXR) request it completes a SSA-832 and/or SSA-833 to document the reason for the denial and returns the file to the field office. The DDS can deny an EXR request because the disability is not the same as or related to the prior disability or because the individual is not disabled when evaluated under the medical improvement review standards (MIRS).

The last provisional benefit payable is the month the denial notice is sent, if not stopped earlier for another reason. The disability determination (denial of EXR) may be appealed but the provisional payment determination may not be appealed (see DI 13050.085B).

Refer to HI 00801.165C and DI 13050.070 for the effect an unfavorable medical decision has on Medicare entitlement and SI 01730.010 for the effect on Medicaid.

NOTE: If the DDS medically denies an EXR request on a concurrent individual under the MIRS, initiate a medical CDR for the other title, per DI 13001.005A.8

2. FO Responsibilities

The FO sends a denial notice to the individual and any appropriate third party, and stops provisional benefits per DI 13050.025J. and DI 13050.030K. The notice will:

  • Explain the basis for non-entitlement, and

  • Inform the individual that he or she has the option of filing a new application for disability benefits, requesting a reconsideration of the EXR decision, or filing a new EXR application.

The request for reinstatement can be used as a protective filing for a new application if the individual chooses to file a new application. Process the EXR action based upon the individual's decision per DI 13050.020.

A denial of expedited reinstatement is an initial determination that carries appeal rights as discussed in DI 13050.085C. However, the action taken to terminate provisional payments due to a determination being reached on the EXR request cannot be appealed.

B. Procedure - Medical Denial

1. How To Determine An EXR Medical Denial

The FO will receive the folder from the DDS with a completed SSA-832/833 and a personalized explanation completed. Determine the basis for the medical determination by reviewing the SSA-832/833:

  • Item 9 will have blocks B and C indicated;

  • Item 10 will have block D indicated, which shows “other”;

  • Item 11 will show code 28 for title II not same as related denial, 61 for title XVI not same as or related denial, or normal CDR codes for MIRS denials-see DI 28084.015;

  • Item 20 will show WRM code 31 (for EXR); and

  • Remarks will show “Expedited Reinstatement”.

2. Denial Notice

The FO sends the appropriate EXR denial notice to the individual and any proper third party. Use the personalized denial language provided by the DDS to explain the reason the reinstatement request is denied. Title II Denial notices are contained in DPS. Refer to DI 13050.070E. for information about inserting appropriate Medicare language in denial notices.

3. Provisional Benefits

Terminate provisional benefits. The last provisional benefit payable is for the month in which the denial notice is mailed, provided the benefit is not subject to earlier termination for another reason (See DI 13050.025A.2 and DI 13050.030A.2).

a. Title II

If the denial is based on medical improvement, (item 11 of the 833 indicates a MIRS denial):

  • input a medical cessation through POS to stop provisional payments (see MSOM T2PE 003.024)

  • Use option 10 CESSATION to clear the EXR event from the DCF.

If the denial is based on “not the same as or related impairment (item 11 of 833 indicates code of 28)

  • Do not use POS. Send an HP request to payment center to stop the provisional payments.

  • Use option 5, SSR/MBR/OTHER CONDITIONS –