TN 1 (02-06)

DI 28057.020 Effectuating Determinations

A. Background

Document the expedited reinstatement (EXR) determination made in accordance with DI 28057.015 on a SSA-832 (title XVI) or SSA-833 (title II).

B. Procedure - Not the “Same As or Related”

If the impairment is not the same as or related to that of the individual's most recent disability entitlement the individual is not eligible for EXR. Deny the request for EXR by taking the following actions:

  1. Document the file that the alleged impairment(s) is not the same as or related to the comparison point decision (CPD) impairment(s).

  2. Complete a SSA-832-C3/U3 or a SSA-833-C3/U3 per DI 28057.020F.

  3. Prepare personalized language on Form SSA-4268 for the field office to include in the denial letter.

  4. Close out the EXR CDR controls per DI 28057.020G.

  5. Return the case to the FO to process the EXR denial and develop a new initial claim if appropriate.

C. Procedure – Unfavorable Decision Under MIRS

If the individual has experienced medical improvement related to the ability to work and the individual is capable of engaging in SGA, (following procedures in DI 28030.000) the individual is not eligible for EXR.

  1. Complete a SSA-832-C3/U3 or a SSA-833-C3/U3 per DI 28057.020F.

  2. Prepare personalized language on Form SSA-4268 for the field office to include (as an attachment) in the denial letter.

  3. Close out the EXR CDR controls per DI 28057.020G.

  4. Return the case to the FO so the FO can process the EXR denial and develop a new initial claim if appropriate. Alert the FO that if a beneficiary is concurrently entitled (i.e, title II and title XVI) a medical CDR should be initiated on the other title, per DI 13001.005A.12.

D. Procedure – Favorable Decision Under MIRS

If no medical improvement related to the ability to work has occurred, find the individual is disabled and, therefore, eligible for EXR. Take the following actions:

  1. Determine the appropriate month of entitlement.

  2. Complete a SSA-832-C3/U3 or a SSA-833-C3/U3 per DI 28057.020F.

  3. Close out the EXR CDR controls per DI 28057.020G.

  4. Return the case to the FO to process the EXR approval. Expedite award notification to the FO via a locally established procedure.

E. Procedure - Failure to Cooperate

If the individual does not co-operate, follow the Failure to Cooperate procedures in DI 28075.005. Prepare the SSA 832/833, checking blocks B and C. The date for both is the date of the EXR request. Prepare personalized language on Form SSA-4268 for the field office to include as an attachment to the denial letter.

F. Procedure – SSA-832/833 Completion

Complete the SSA 832/833 in the usual manner for a CDR except as follows:

  1. Item 5: Enter the established onset date from the entitlement file (the entitlement SSA-831).

  2. Item 9:

    • If the individual is under a disability, check block A.

    • If the individual is not under a disability or the impairment is not the “same as or related”, check both blocks B and C. The date for both is the date of the EXR request.

  3. Item 10: Check block D, “Other”

  4. Item 11:

    • Title II Cases: For a determination that the current impairment is not the “same as or related to” the CPD impairment, show code 28.

    • Title XVI Cases: For a determination that the current impairment is not the “same as or related to” the CPD impairment, show code 61.

    • For a determination that the individual is not under a disability based on MIRS, use the codes for a CDR MIRS cessation (see DI 28084.015).

  5. Item 20: Enter WRM code of 31 (defined as “Expedited Reinstatement”).

  6. Item 24: Enter remark, “Expedited Reinstatement”. For cases where the individual is found to be under a disability, also enter “MOE MMYY”. This date is the new EXR month of entitlement date for Title II cases or the new month of eligibility for reinstatement in Title XVI cases. This is based upon the individual's disability and the work determination on the SSA-823.

    • Review the remarks section of the SSA-454 for the month of the EXR request; and

    • Review the SSA-823 for the SGA determination and identification of the earliest possible month of non-SGA in the 12-month retroactive period. See DI 28057.015E. for determining the Title II month of entitlement, and DI 28057.015F. for determining the Title XVI month of entitlement.

  7. Item 29: Leave blank. The FO issues all denial notices (including failure to cooperate) and OCO/PC issues all award notices.

G. Procedure - Case Clearance

Use the following procedures to clear the case:

  1. Enter on the NDDSS using normal procedures found in SM 06001.499 and SM 06001.502.

  2. Input WRM code 31, Expedited Reinstatement Case, to identify these cases for management information purposes.

  3. For title II decisions based on impairment not being the same as or related to, input a “Reason for Cessation” code of 28.

  4. For title XVI decisions based on impairment not being the same as or related to, input a “Reason for Cessation” code of 61.

  5. For findings that the individual is not under a disability based on MIRS, use the codes for a CDR MIRS cessation.

  6. Enter an SO code of “N”.

  7. If the determination is to deny the EXR request, add a remark to the route slip, “Terminate provisional payments”.

  8. Forward the folder to the appropriate Disability Quality Branch (DQB) if the case is selected for quality assurance review.

  9. If the decision is favorable, fax the EXR determination (SSA-832/833) to the FO, so the FO can initiate necessary non-medical development (see DI 11010.340) (or use another locally arranged alternative to expedite processing).

  10. Forward the folder to the FO under cover of a route slip for any appropriate action if the case is not selected for DQB review. Expedite the determination to the field office using a locally arranged procedure.

NOTE: In unfavorable findings, include the personalized language to accompany the EXR denial notice on Form SSA-4268. If the current impairment(s) is not the same as or related to the prior disabling impairment, make sure this attachment includes the rationale for this finding.

H. Policy – Notices

Notices for unfavorable EXR determinations are prepared and forwarded by the FO. Approval letters are prepared and forwarded by OCO/PC. All cases, regardless of whether they are favorable or unfavorable, should be returned to the FO. The FO will then forward the awards to OCO/PC for processing.

Prior to returning the EXR case to the FO, include in the file the appropriate personalized language for the FO, on Form SSA-4268, to include in the formal denial notice to be sent the individual requesting EXR. The DDS does not issue the notice in EXR cases.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0428057020
DI 28057.020 - Effectuating Determinations - 02/12/2016
Batch run: 02/12/2016
Rev:02/12/2016