TN 3 (10-17)

DI 28003.005 Disability Determination Services (DDS) Actions for Screening Continuing Disability Reviews (CDR) and Referrals

A. Reviewing medical folders for the screen-out criteria

The disability examiner or adjudicator must:

  • review the folder to make sure the comparison point decision (CPD) and supporting documentation are in the folder;

  • determine whether it is appropriate to conduct a CDR after using the same screen-out criteria as the field office (FO); and

  • stop the CDR and return it to the FO if the case meets one or more of the screen-out conditions.

For FO procedures on the referral of CDRs to the DDS, see DI 13005.020.

NOTE: For instructions on processing electronic CDR cases, see DI 81020.000.

B. What not to screen out

It is essential that we complete CDRs timely on cases that cannot be screened out of the CDR process. Do not screen out the following types of cases:

1. A case based on the age of the disabled individual, except for certain Title II and concurrent (Title II and Title XVI) cases

The DDS will not screen out a CDR based on the age of the disabled individual, except Title II and concurrent (Title II and Title XVI) cases as described in DI 28003.005C.1. in this section. The Social Security Administration will defer certain beneficiary groups based on age, under the agency's CDR plan.

Exception: If we select a case for a CDR, do not stop the review because of the disabled individual's age, except when the case involves the following:

  • A disabled worker who is within three months of attaining full retirement age (FRA), see RS 00615.003A; or

  • A disabled surviving spouse who is within three months of potential conversion to a survivor benefit based solely on age and relationship, see RS 00615.003B.

2. A case based on an individual court case or class action membership

Do not screen out a case from the CDR process on the basis that the case involves an individual who has a civil action pending or who is a member of an active class action. It is not appropriate to delay a scheduled CDR due to a claim that may be involved in an active individual court or class action case. There are no individual case or class action exceptions.

When we complete the CDR, we will process the case under the individual court or class action order. For examples of court cases not to screen out refer to DI 13005.020C.2.

3. A Title XVI child case on the basis of a future medical reexamination diary date (and the exception to this rule)

Do not screen out a case that involves a Title XVI:

  1. age-18 medical redetermination case with a future medical reexamination diary.

  2. low birth weight (LBW) case with a future medical reexamination diary.

  3. disabled child with a future medical reexamination diary.

EXCEPTION: Screen out a Title XVI child (not LBW) case if the case meets both of the following conditions:

  • a fully developed DDS or Office of Disability and Adjudication Review (ODAR) decision (initial claim, CDR or age-18 medical redetermination, but not a modified decision) was made within the last twelve months, and

  • the medical diary has not matured and will not mature in the next three months

4. A case on the basis of an human immunodeficiency virus (HIV) infection

Do not screen out CDR cases involving an allegation or diagnosis of HIV infection.

NOTE: A diagnosis of HIV infection is not a reason to screen out a CDR; however, other screen-out criteria may apply to an HIV case. For additional information on CDR screen-out criteria, see DI 28003.005C in this section.

C. Screen-out criteria by case type

Use the charts below to determine whether there is a reason to screen out a case by the case type:

1. Title II and concurrent (Title II and Title XVI) cases (except for concurrent age-18 medical redeterminations)

The DDS can screen out Title II CDRs and concurrent Title II and Title XVI CDRs (except for concurrent age-18 medical redeterminations) for the following reasons:

Reason

There is a prior uneffectuated medical cessation (UMC) or overdue medical cessation (OMC). For additional information on processing OMC and UMC cases, see DI 28075.200.

The medical diary has not matured and will not mature in the next three months, and there is no other reason (for example, a report of medical improvement) to complete a CDR.

NOTE: Determine the medical reexamination diary date based on the date provided on the most recent CPD document(s). For example, the most recent medical SSA-831-U3 (Disability Determination and Transmittal), SSA-832 (Cessation or Continuance of Disability or Blindness Determination and Transmittal-Title XVI), SSA-833 (Cessation or Continuance of Disability or Blindness and Transmittal-Title II), or disability decision from ODAR.

The disabled individual:

  • is working,

  • has a medical improvement possible (MIP) (three year) or medical improvement not expected (MINE) (five or seven year) diary, and

  • has not completed a trial work period.

If the DDS determines that the disabled individual is working and has a medical improvement expected (MIE) diary, continue to process the CDR, if necessary as a medical or work CDR, see DI 28050.010. If FO assistance is necessary, return the folder to the FO for processing under DI 13010.000.

The disabled individual is in a foreign country and a border FO does not service his or her residence. The Office of Earnings and International Operations (OEIO) will assume jurisdiction for the CDR. The DDS should forward the case to:

(V22) OIO/IDO
PO Box 17787
Baltimore, MD 21235-7787

The FO notifies the DDS that the claim is withdrawn or a request to withdraw the claim is pending.

For Title II cases, conversion to non-disability status has occurred or we expect to occur in the next three months. For example, a disabled worker is within three months of attaining FRA or a disabled surviving spouse who is within three month of potential conversion to a survivor benefit that would be based solely on age and relationship, see RS 00615.004).

Review of a query response and information received from the disabled individual or other source (typically, the FO) shows that a CDR mailer form SSA-455 (Disability Update Report) or SSA-455-OCR-SM, as described in DI 28001.003, was initiated after the date the case was alerted for a full medical review. This includes “Incorrect and Accidental” alerts discussed in DI 28003.005E in this section.

Review of a query response and other information received from the disabled individual or other source shows that:

  • he or she was using a ticket under the Ticket to Work Program, and

  • the ticket was in use before the case was selected for CDR mailer processing, or prior to the initiation of a full medical CDR. For additional information on work incentives, see DI 55000.000.

NOTE: If the disability control file (DCF) or other record show the case was processed as a CDR mailer and a subsequent full medical CDR was initiated, the date of notice to the disabled individual and representative payee of initiation of the subsequent full medical CDR is controlling.

The disabled individual is deceased and there is no unresolved or pending fraud issue requiring a determination as to whether disability ended prior to death. For instructions on processing special situations in work CDRs, see DI 13010.197.

Miscellaneous reasons. Explain the reason on an SSA-5002 (Report of Contact) or in the “Remarks” section of the SSA-5526-U3 (Request for Assistance - Disability).

NOTE: If the Title II portion of a concurrent (Title II and Title XVI) age-18 medical redetermination is screened out, continue to process the Title XVI age-18 medical redetermination if none of the screen-out criteria in DI 28003.005C.3. applies.

2. Title XVI-only adult cases (not including age-18 medical redeterminations)

The DDS can screen out Title XVI-only adult CDR cases (not including age-18 medical redeterminations) for the following reasons:

Reason

There is an UMC or OMC case. For additional information on processing OMC and UMC cases, see DI 28075.200.

The medical diary has not matured and will not mature in the next three months, and there is no other reason (for example, a report of medical improvement) to do a CDR.

NOTE: When determining the medical reexamination diary date, rely on the date provided on the most recent CPD document(s). For example, on the most recent medical SSA-831-U3, SSA-832, SSA-833, or disability decision of ODAR.

The FO alerts the DDS that the disabled individual is in non-pay status (for example, “N01” or “N03”) and is expected to remain in non-pay status for 12 months.

The FO notifies the DDS that the claim is withdrawn or a request to withdraw the claim is pending.

The disabled individual’s status converted from “Disabled” or “Blind” to “Aged”.

Review of a query response and information received from the disabled individual or other source (typically, the FO) shows that a CDR mailer form SSA-455 (Disability Update Report) or SSA-455-OCR-SM, as described in DI 28001.003, was initiated after the date the case was alerted for a full medical review. This includes “Incorrect and Accidental” alerts discussed in DI 28003.005E in this section.

Review of a query response and other information received from the disabled individual or other source shows that:

  • he or she was using a ticket under the Ticket to Work Program, and

  • the ticket was in use before the case was selected for CDR mailer processing or prior to the initiation of a full medical CDR. For additional information on work incentives, see DI 55001.000, DI 55002.000 and DI 55025.000.

NOTE: In the situation where the DCF or other record shows that the case was processed as a CDR mailer and subsequently a full medical CDR was initiated, the date of notice to the beneficiary and representative payee of initiation of the subsequent full medical CDR is controlling.

The recipient is deceased and there is no unresolved or pending fraud issue requiring a determination as to whether disability ended prior to death. For special situations in work CDRs, see DI 13010.197.

Miscellaneous reasons. Explain the reasons on an SSA-5002 or in the “Remarks” section of the SSA-5526-U3.

3. Title XVI-only child cases (including age-18 medical redeterminations and LBW)

The DDS can screen out Title XVI-only child cases (including age-18 medical redeterminations and LBW) for the following reasons:

Reason

The FO notifies the DDS that the claim is withdrawn or a request to withdraw the claim is pending.

The FO alerts the DDS that the disabled individual is in non-pay status (for example, “N01” or “N03”) and expected to remain in non-pay status for 12 months.

There is an UMC or OMC case. For additional information on processing OMC and UMC cases, see DI 28075.200.

For a nonpermanent impairment case (except a LBW or age-18 medical redetermination case), determine when the most recent CPD was made. Screen out cases when a fully developed DDS determination or ODAR decision (initial claim, CDR, or childhood redetermination, but not a modified decision) was made within the last twelve months and the medical diary has not matured and will not mature in the next three months. If the case does not meet both criteria, do not screen out solely based on a future diary.

In rare cases, the DDS, based on the medical evidence in the folder, can defer the CDR until the diary maturity date. For example, at the initial allowance the child had a “heart anomaly” that could be corrected in 18 months. Deferring the CDR until that time would be acceptable. Depending on the time between deferral and the more appropriate review date, this case could be held in the DDS or FO (consistent with the deferral policy in DI 28003.010), or closed out.

For an age-18 medical redetermination, the disabled individual was not in payment status (PSY) C__, E__, or M__ the month before the month the he or she attained age 18. For a list of payment status codes, see SM 10802.130. If the DDS requires additional payment information or is uncertain as to the disabled individual’s payment status as of age 17 years, 11 months, it should contact the servicing FO.

For an age-18 medical redetermination, when review of the claim(s) folder shows completion of a disability determination using the adult sequential evaluation process for initial claims.

NOTE: The disability determination must be on or after the disabled individual attained age 18, not before. If the DDS made a prior Title II disability determination after age 18, the DDS should follow existing adoption policies unless the Title II determination was an adoption of an earlier Title XVI determination, see DI 23570.020.

D. Career railroad retirement board cases

Return career railroad cases to the FO for routing to Great Lakes Programs Service Center (GLPSC)/ Disability Review Section (DRS) for processing and coordination with the Railroad Retirement Board. Process non-career railroad cases following normal procedures. For additional information on processing railroad cases, see DI 44001.101.

E. Incorrect and accidental CDR alerts

The DDS may stop a CDR, if the case is incorrectly selected and alerted for a CDR. Follow the screen out procedures in DI 28003.005F in this section.

F. Returning screened out CDRs to the FO

The DDS will process screened out CDRs as a “No Determination” (ND). The DDS should document the reason for the screen out and return the case to the appropriate location and following the ND instructions in:

  • DI 28030.001E Initial Receipt of the Case by the Disability Determination Services (DDS),

  • DI 32001.015 Disability Determination Services Systems Input and Clearance of Claims,

  • DI 32005.020 Disability Determination Services “No Determination” Routing-Paper Case Only,

  • DI 32010.005 No Decision Continuing Disability Review (CDR) Cases-Routing Instructions (Paper Cases Only), and

  • DI 81020.127 Processing “No Determination” (ND) Claims.

The DDS must provide an explanation for the basis of the ND on the SSA-5002 addressed to the FO. The DDS must also appropriately annotate on the SSA-5002 that the FO is required to prepare and release a closeout notice. For additional instructions on processing ND cases in the Electronic Disability Collect System (EDCS), see DI 81020.127.


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DI 28003.005 - Disability Determination Services (DDS) Actions for Screening Continuing Disability Reviews (CDR) and Referrals - 10/03/2017
Batch run: 10/03/2017
Rev:10/03/2017