TN 8 (04-04)

DI 30005.216 Correcting Group I Medical Documentation Deficiencies Involving Onset

A. Introduction

A group I medical documentation deficiency involving onset exists if the correct date (i.e., either the DLI, prescribed period for a disabled widow/er claimant or age 22 for a childhood disability claimant) is clearly documented, and the medical evidence in file does not support the onset date established by the adjudicating component; i.e., the correct onset date could be after the DLI, prescribed period or age 22.

B. Policy - corrective action

1. Return before effectuation

The review component will return the deficient case for correction before effectuation in all Title II only claims and concurrent Title II/Title XVI claims in which payment on the Title XVI claim cannot be made immediately. See GN 04440.206 and GN 04440.207.

2. Return after effectuation – concurrent Title II/Title XVI claims

If payment can be made on the Title XVI portion of the concurrent Title II/Title XVI claim, but additional development regarding onset date, DLI, prescribed period or age 22 is needed in the Title II claim, the deficient case will be returned for corrective action after effectuation of the Title XVI determination.

EXCEPTION: If the claimant dies before the review is completed, the corrective action will be taken pre-effectuation. Follow DI 30005.216C. in these situations.

3. Routing

Group I medical documentation deficiencies involving onset are sent to the adjudicating component for corrective action.

C. Procedure - DDS – medical documentation deficiency involving onset — pre-effectuation correction

Upon receipt of the SSA-1774-U5 deficiency transmittal and folder:

  • Take the action requested in the SSA-1774-U5.

  • Return the corrected case to the review component.

See GN 04440.206C. for review component action in medical documentation deficiencies involving onset cases.

D. DDS procedure - medical documentation deficiency involving onset — post-effectuation correction

1. Introduction

If payment can be made on the Title XVI portion of the concurrent claim, but additional development is needed regarding onset date relative to DLI, prescribed period in a widow/er claim or age 22 in childhood disability claim in the Title II claim, corrective action is taken after effectuation of the Title XVI determination.

a. Concurrent initial claims

In concurrent Title II/Title XVI initial claims with a medical documentation deficiency involving onset, the review component will send both folders and an SSA-1774-U5 to the adjudicating component and will fax the Title XVI SSA-831-C3/U3 to the FO to effectuate payment on the Title XVI claim. See GN 04440.207A.2.

EXCEPTION: Concurrent Title II/Title XVI initial claims involving unresolved capability issues, or cases in which the beneficiary has a DAA condition and is incapable of managing his/her benefits. These cases follow the same routing procedure as for concurrent Title II/Title XVI reconsideration claims as described in DI 30005.216D.1.b.

b. Concurrent reconsideration/initial exception claims

In concurrent Title II/Title XVI reconsideration claims and concurrent Title II/Title XVI initial claims that are an exception to the initial claims routing, the review component will send an SSA-1774-U5 and supporting documentation to the adjudicating component and send both claims folders to the FO to effectuate payment on the Title XVI claim. See GN 04440.207A.3.

2. DDS procedure – concurrent initial cases

Upon receipt of the folders and SSA-1774-U5 deficiency transmittal and folders:

  • Take the action requested in the SSA-1774-U5.

  • Return the corrected case to the review component.

3. DDS procedure – concurrent reconsideration/initial cases

Upon receipt of the SSA-1774-U5 and supporting documentation:

  • Take the action requested in the SSA-1774-U5.

  • Request the folders from the FO if onset development is completed before the folders are received in the adjudicati