TN 5 (05-10)
DI 27015.001 Completing Form SSA-831-U3 for Reconsideration Cases
A. Introduction To SSA-831-U3 (Disability Determination and Transmittal)
The Disability Determination Services (DDS) is responsible for completing part of the SSA-831-U3 (Disability Determination and Transmittal). The following instructions explain the entries on the SSA-831-U3 (Disability Determination and Transmittal) that are required in reconsideration cases. If an item is not listed, leave it blank. (See DI 27015.006, Exhibit).
A paper transmittal SSA-831 is only completed for claims that cannot be created in the Electronic Disability Collect System. For instructions, see DI 81010.030.A – Certified Electronic Folder (CEF) – Exclusions and Limitations.
B. Completing items 1-14 of SSA-831-U3
The completion of items 1-14 on the SSA-831-U3 at the reconsideration level is primarily the responsibility of field office (FO) personnel, see (DI 11010.205). However, the DDS is responsible for reviewing the FO-completed items on the SSA-831 for possible discrepancies and contacting the FO to resolve discrepancies such as: name, SSN, or type of claim on the SSA-831 (or other FO-completed transmittal).
NOTE: In a Title XVI claim, if a disabled child (DC) claimant attains age 18 while the claim is in DDS jurisdiction, do not change the entry in item 8 (Type of Claim). See DI 25201.010- If You Attain Age 18 After You File Your Disability Application but Before We Make a Determination or Decision, for details.
Since Presumptive Disability does not apply to reconsideration cases, see DI 23535.001B), do not complete items 11A and 11B.
C. Completing items 15- 24 of SSA-831-U3
The process for completing items 15 – 24 on the SSA-831-U3 at the reconsideration level is generally the same for initial claims. For instructions, see DI 26510.000 Completion of Form SSA-831-C3/U3 – Title II, Title XVI and Concurrent Claims – Table of Contents.
D. Completing items 25 and 25A of SSA-831-U3 — (Revised Determination)
1. SSA-831-U3 block 25 a
Check or “x” block 25 in all reconsideration cases except escalated determinations.
2. SSA-831-U3 block 25a
Check or “x” box B, “Recon,” in block 25a, on all reconsideration and escalated reconsideration cases. Check or “x” box C, “Recon Disability Hearing Unit,” if the case is a Disability Hearing Unit jurisdiction case per DI 29001.001B.
E. Completing items 26- 29 of SSA-831-U3
The process for completing items 26- 29 on the SSA-831-U3 at the reconsideration level is generally the same for initial claims. However the disability examiner and medical consultant or psychological consultant must be different from the reviewers who made the initial decision. For instructions, see DI 26510.000 – Completion of Form SSA-831-C3/U3 – Title II, Title XVI and Concurrent Claims – Table of Contents and DI 27001.001E.2 — The Reconsideration Process.
F. Completion of items 30 – 33 of SSA-831-U3 - Disability Examiner – DDS, Date, Physician or Medical Spec. Signature, Date, Physician or Medical Spec. Name, Spec. Code)
For instructions, see DI 26510.090 – Completing Items 30-33 (Disability Examiner – DDS/Date/Physician or Medical Specialist Specialty Name and Code) on the SSA-831
G. Completing item 34 (Remarks) on a reconsideration SSA-831-U3
Use item 34 to alert SSA personnel to any special circumstance or situation in previous items of the SSA-831 in accordance with current systems limitations.
NOTE: This chart includes only a few examples of special situations that might be annotated in Item 34 and is not an exhaustive list. See also, DI 26510.095 – Completing Item 34 (Remarks) on the SSA-831.
Enter in Remarks
Claimant cannot be located at last known address or claimant's whereabouts unknown.
“Claimant's whereabouts unknown.”
Disability Determination Services (DDS) Quality Assurance (QA) reviewed SSA-831
“DDS QA.” (Determined by current legacy system limitations)
Recon reverses initial decision — denial to allowance /allowance to denial
Recon affirmation — initial and recon denial
Recon revises initial onset date
“Recon Reversal — Earlier (or Later) Onset Established.”
Recon affirmation — initial and recon allowance with no change in onset date
Recon Affirmation — No Change in Onset.
Pending recon shares a common issue with a new claim filed under a different title
Recon Escalation — Combined Initial and Reconsideration Determination.
Recon pending and related claim filed under same title (DIB/CDB, DIB/DWB, or CDB/DWB)
Recon Escalation — Combined Initial and Reconsideration Determination.
DDS has received a statement regarding capability — allowance only
“Claimant capable (or incapable) per Dr. (name) report of (date).”
Listing 12.05A met — allowance only
“Claimant incapable — Listing 12.05A.”
DDS has been unable to secure evidence of capability — recommendations based on evidence in file — allowance only (DI 23001.000).
“Capability unresolved — review of medical evidence (identify by source and date) suggests claimant is capable/incapable.”
DDS has been unable to secure evidence of capability — allowance only.
DDS recommends payment of benefits before completion of its onset development (DI 25501.000).
AOD is less than 5 full calendar months before the month of death and no earlier onset is possible.
“Return folder to DDS after award payment — possible earlier date of onset (insert date) to be developed.”
“Death in waiting period -- no possibility of earlier onset”
EOD different from AOD.
More than one optional diary reason applies
“Change in Onset.”
“Diary reasons (show applicable reason codes)”
Optional MIE Diary
“Optional MIE Diary set because (reason why set).”
Vocational Diary established
“Vocational Diary Established”
TWP Diary established
“TW Diary (month/year)”
Collateral estoppel is the basis of the determination
Earnings discrepancy indicated by the presence of an unprocessed Form SSA-7000-U5, SSA-7010-U5 or SSA-4500-U6 in file.
At the time of determination claimant working and work in any month after the filing date constitutes “services” for TWP purposes
An interim notice is prepared
“SSA-L1157-U2 DI or SSA-L1157-U2 SI”
Representative payee files for claimant after receipt of SSA-831-U3 in DDS, insufficient space in Item 5 to show change
Recon reverses DAA decision
“John Doe for Mary Doe”
“Recon Reversal of DAA”
Recon reverses DAA material determination
“Recon reversal-DAA not material DAA condition (X, Y, or Z)”
Recon affirms DAA material determination
Claimant dies prior to adjudication and a determination is necessary for Medicaid purposes only
“Recon affirmation-DAA material (A, D, or B)”
Died (date of death) Determination for Medicaid Only
If the FO annotates "child in care" a claimant is seeking initial or continuing entitlement based on having a disabled child in care that is alleged to have both a physical and mental impairment. Enter this remark if a documented mental impairment exists which is not shown as the primary or secondary diagnosis.
Type of mental impairment, type of report, e.g., "Intellectual Disability, Dr. Moore's Report, July 22, 2006”
Childhood case allowance – medical evidence indicates that maternal drug alcohol addiction is an underlying cause of the impairment (i.e., child born addicted) and FO not previously alerted by DDS, or situation not previously indicated
“Possible rep. payee issues – impairment related to maternal drug or alcohol abuse – see medical report from_____dated_____.”
Childhood case allowance – medical evidence indicates the child’s mother or father is an alcoholic or drug addict and FO not previously alerted by DDS, or situation not previously indicated.
“Possible rep. payee issue – mother/father suffers from drug/alcohol abuse – see medical report from _____dated_____.”
Childhood case allowance – medical evidence indicates that the child may suffer from abuse and FO not previously alerted by DDS, or situation not previously indicated
“Possible rep. payee issues – medical evidence indicates child abuse – see medical report from _____dated_____.”
DI 81020.130 – Electronic Case Closure