TN 1 (02-06)

DI 28057.045 Expedited Reinstatement and Initial Claim Filed for the Same Benefit

A. Background

Most individuals who meet the requirements for EXR also meet the requirements to file a new initial claim. The individual must decide which avenue he or she wishes to pursue to entitlement.

The process of requesting and processing EXR and initial claim actions is expected to be a sequential process. The individual should file under the process that will be the most advantageous and then possibly pursue the other avenue if the first approach is denied. However, an individual may wish to file for both approaches immediately.

The FO will advise an individual who wishes to file a request for EXR and an initial claim that only one action can be processed to completion. If the individual files both and requests provisional benefits (and Medicare in the provisional period), the initial claim can be processed to allowance only if the individual withdraws the EXR request and refunds benefits and Medicare payments in accordance with normal withdrawal policy and procedures.

The DDS must make medical determinations on both the initial claim and the EXR request, unless advised otherwise by the FO during the determination process. If a favorable medical determination is made on both, the FO must contact the claimant for a decision on which action he or she wants to continue processing before processing either award action.

B. Definition – Filing for the Same Benefit

These are cases where an individual has an EXR request and a new initial application for the same benefit pending at the same time. This could occur at the point of intake if the individual insists on filing for both EXR and a new application on the same account. This could also occur when an individual's EXR or initial claim is denied and then he or she wishes to pursue his or her appeal rights on that issue while also pursuing the other avenue.

A same benefit is intended to refer to a type of benefit on an account. EXAMPLE: A NH requests EXR for DIB and also files a new DIB application.

C. Procedure – Cases Received in DDS

1. File Received By DDS

The FO will send both the EXR request and initial application to the DDS for medical determinations in the same file, if possible.

2. EXR Flag On the File

  1. a. 

    Both actions will be received under one EXR flag, if possible. The flag will be annotated by the FO to show that (see DI 13050.105 for the EXR flag):

    • action is needed on the EXR request and initial claim; and

    • the folder is returned to the FO when both actions are complete.

  2. b. 

    The flag should indicate if an action is already pending in the DDS so the actions can be more easily associated.

3. Action Escalated to Reconsideration

When a reconsideration on one issue is either received or pending in DDS and the other issue requires a medical decision, combine the cases and escalate to the reconsideration level. The FO should have identified the issues on the EXR flag.

4. Systems Issues

Establish these actions independently. Establish and process initial applications (and associated appeals) according to normal claim procedures. Establish and process EXR requests according to the instructions contained in this section.

D. Procedure - DDS

Use the following procedures for cases received:

  1. 1. 

    These cases can be recognized by the information on the EXR folder flag (see DI 13050.090C.2.).

  2. 2. 

    If both the application and EXR request are received in one Modular Disability Folder, and the actions cannot be kept together, photocopy material as necessary.

  3. 3. 

    Customize receipt and clearance procedures as necessary to accommodate variations in adjudicative protocols and system limitations that preclude controlling multiple actions on the same benefit. Establish manual control processes if necessary.

  4. 4. 

    Adjudicate the initial application/reconsideration following normal procedures. Adjudicate the EXR request/reconsideration following DI 28057.020.

  5. 5. 

    Fax (or use a locally arranged expedited processing procedure) to expedite the 831 for initial applications or the 832/833 for EXR requests, as appropriate, to the FO when a favorable medical determination is made.

  6. 6. 

    Return the folder to the FO when both decisions have been made. If the EXR decision is unfavorable, place the personalized explanation inside the folder so the FO can issue the denial notice and attach the explanation. The DDS should NOT send any EXR cases directly to OCO/PC.

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DI 28057.045 - Expedited Reinstatement and Initial Claim Filed for the Same Benefit - 12/01/2011
Batch run: 04/14/2014