TN 6 (08-90)
DI 27515.020 New Title II DIB Claim - Title XVI Disability Previously Established
Whenever a prior folder is not associated, if possible adopt a disability allowance based on the finding of facts and information available on a query and/or the final copy of the SSA-831-U3.
If necessary secure the folder (DI 20505.015) on a post basis to resolve outstanding issues, e.g., an earlier onset of disability for title II purposes or a possible CDR issue needing resolution.
B. Procedure - General
Prepare a title II disability determination adopting the prior title XVI determination or decision under Federal criteria unless the rules of adoption are not met (DI 27515.001A.)
Adopt the prior title XVI allowance if in suspense for nondisability issues see DI 11055.001 and DI 40120.001
Undertake current development if reopening and revision of a prior decision is possible but MIRS standard must first be met.
See DI 27515.050 for CDR issues.
Develop an earlier onset postadjudicatively (see DI 25501.270) unless a duration issue exists.
Obtain the prior folder (see DI 20505.015) where necessary to establish the onset date in accordance with the guidelines below:
NOTE : Under adoption a title II onset date may be established later than the date set by a prior title XVI determination because of the performance of SGA after title XVI onset or because the date first insured is later than the title XVI onset date.
C. Procedure - Specifics
1. How to Process Title XVI Claims - Variables in Onset Date
|If the title XVI onset is...||Then...|
|the date of filing and evidence supports earlier onset date.||Establish the earlier onset in the title II determination /decision as warranted by the evidence.|
|a conversion case which has been continued under Federal criteria||Establish the title II onset date as the continuance under Federal criteria unless evidence warrants an earlier onset.|
later than the title XVI date of filing.
Adopt the title XVI onset date for the title II.
Reopen the title XVI determination/decision if warranted.
Adopt title XVI onset, if favorable to the title II claimant and reopening under the rules of administrative finality not possible.
2. How to Process Title XVI Claims - New and Material Evidence
|If the Title XVI Onset is later than the title XVI date of filing and new and material evidence ...||Then ...|
permits reopening to an earlier onset.
permits reopening of prior title XVI decision by ALJ or AC.
Follow DI 27515.015 B.1.
establishes an onset date in period adjudicated by prior title XVI determination or , cannot be used to reopen under administrative finality
Establish title II onset date in accordance with DI 27515.015B.3.
3. How to Process Title II Claims
|If prior title II denied and title XVI allowed and...||Then...|
|insured status is met and prior title II determination can be reopened under rules of administrative finality.||Establish title II entitlement on the basis of the prior title II application.|
|the prior title II cannot be reopened .||Use only the current title II application as the basis for entitlement|
|title XVI disability ceased before the 14th month prior to the current title II filing (precludes closed period).||Prepare a title II denial (see DI 27515.035)|
evidence submitted with title II shows title XVI should cease
Cease title XVI as of the current month (unless retroactive cessation can be made, i.e., fraud, SGA, or MI advised by treating source).
Establish closed period on title II with ending date to correspond to title XVI cessation date.
4. Preparation Title II Determination
Prepare a title II SSA-831-U3 determination/decision based on the title XVI determination (e.g., regulatory basis, impairment code, diary, etc.).
Note in remarks (item 34 DI 26510.095A) if an earlier onset date is possible, and:
Check item 27 (Rationale) of the SSA-831-U3.
Prepare an SSA-4268-U4/C4.
Annotate the SSA-4268-U4/C4, if prior determination had a rationale, with the following in addition to any other required statement: “The findings of the prior title XVI determination (or decision) of (date) are adopted.”
Prepare a rationale in the regular manner for any findings for a period not adjudicated in the prior title XVI determination or decision.
Prepare rationale in accordance with DI 26516.005ff, if later onset date established due to SGA or date first insured .
Preparation of a PRTF, for mental cases, is not necessary.
D. Example - Special Situation
When a title II claim should have been filed with a prior title XVI claim entitlement to DIB, CDB or DWB benefits can be based on a prior title XVI application date, when it is discovered (due to subsequent title II claim) that the claimant met all entitlement requirements during the period covered by the title XVI determination.
A title XVI application protects a claimant's rights to any benefits he/she might be eligible for under title II, until a final decision is made on the claimants' entitlement under title II or the claimant is sent a “blanket denial” paragraph.
EXAMPLE : The claimant filed a title XVI application in June 1980, and disability was established beginning June 1980. No title II application was filed at that time because it was erroneously assumed that the claimant was not insured.
A title II claim was filed in November 1985, and it was found that the claimant was insured through December 31, 1980. Evidence submitted with the November 1985 claim established that the claimant's condition medically improved and he regained the capacity for SGA in May 1985. The medical evidence did not warrant establishing a title II onset before June 1980.
A title XVI determination of current cessation was prepared, based on the evidence establishing medical improvement and the claimant's capacity for SGA. The DDS established a closed period of disability under title II from June 1980 through the current decision date, based on the protective filing provisions of the title XVI application and the results of the title XVI CDR.