TN 48 (11-94)

DI 32594.095 Exhibits

Exhibit 1 - State of New York Case Flag/Alert

Exhibit 2 - State of New York Screening Sheet

Exhibit 3 - State of New York Class Membership Notice

Exhibit 4 - State of New York Non-membership Notice

Exhibit 1 State of New York Case Flag/Alert

 

STATE OF NEW YORK COURT CASE FLAG/ALERT

 

TITLE:        CATEGORY:

 

REVIEW OFFICE     PSC     MFT     DOC     ALERT DATE

 

 

          FUN               NAME

 

      SSN OR HUN          RESP DATE          TOE

 

  FOLDER LOCATION INFORMATION

TITLE     CFL     CFL DATE     ACN     PAYEE ADDRESS

 

 

     SHIP TO ADDRESS:

 

xxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxx

Exhibit 2 State of New York Screening Sheet

SN

STATE OF NEW YORK
(THE EXERCISE TEST CASE) SCREENING SHEET

PLEASE BE AWARE THAT YOU MUST CONSIDER ALL CLAIMS DECIDED DURING THE PERIOD COVERED BY THE COURT ORDER (i.e., June 1, 1980 through February 2, 1994) WHEN MAKING THE CLASS MEMBERSHIP DETERMINATION.

1. SSN          -       -             

     [  ] TITLE II   [   ] TITLE XVI   [  ] CONCURRENT

2. CLAIMANT'S NAME                          

3. BIC         or ID      

     DATE OF SCREENING       -       -     

     MEMBER (J) [  ]  NON-MEMBER (F) [   ]     

  • SCREEN-OUT CODE (04, 05, 06, 07, 08, 11, 12, or 13--enter as appropriate on lines above)

I. CLASS MEMBERSHIP DETERMINATION

4.

Did the claimant file an application for disability benefits under Title II or Title XVI of the Social Security Act? (NOTE: Regardless of the absence of any documentation on the computer, DO NOT screen the claimant out if they have provided evidence of a denial or cessation decision issued between June 1, 1980 and February 2, 1994).

   Yes    No
If yes: Go to 5
If no: Stop here! Check block 04 and follow II below.
 
[  ] 04

5.

Did the claimant live in New York State at the time of any final denial or cessation decision of the Secretary made between June 1, 1980 and February 2, 1994?

   Yes    No
If yes: Go to 6
If no: Stop here! Check block 05 and follow II below.
 
[  ] 05

6.

Did the claimant receive a subsequent fully favorable decision for the earliest alleged onset date for Title II or the earliest application date for Title XVI?

   Yes    No
If yes: Stop here! Check block 06 and follow II below.
If no: Go to 7.
 
[  ] 06

7.

Was the claim(s) finally decided after the date the Agency implementation instructions were issued?

   Yes    No
If yes: Stop here! Check block 07 and follow II below.
If no: Go to 8.
 
[  ] 07

8.

Was the claim(s) decided by a judgment of a district court that became final and unappealable before December 4, 1989?

   Yes    No
If yes: Stop here! Check block 08 and follow II below.
If no: Go to 9.
 
[  ] 08

9.

Is any case a “170” case?
(Generally found by referring to Item 26 on the SSA-831 or Item 34 on the SSA-832/833.)

   Yes    No
If yes: Go to 12.
If no: Go to 10.

10.

Was any claim(s) finally denied or ceased at step 3, (title II widow/widower, or title XVI disabled children) 4 or 5 of the sequential evaluation process (or the equivalent steps of the CDR process) by the New York DDS, by a hearing office servicing the State of New York or by the Appeals Council between 6/1/80 and 12/3/89 inclusive?

   Yes    No
If yes: Go to 12.
If no: Go to 11.

11.

Was any claim(s) finally denied or ceased at step 2, 3, (title II widow/widower, or title XVI disabled children) 4 or 5 of the sequential evaluation process (or the equivalent steps of the CDR process) by the New York DDS, by a hearing office servicing the State of New York or by the Appeals Council between 12/4/89 and 2/2/94?

   Yes    No
If yes: Go to 12.
If no: Stop here! Check block 11 and follow II below.
 
[  ] 11

12.

On any claim(s) did the claimant allege, or is there evidence in file of ischemic heart disease, hypertensive vascular disease, myocardiopathies, rheumatic or syphilitic heart disease?

   Yes    No
If yes: Go to 13.
If no: Stop here! Check block 12 and follow II below.
 
[  ] 12

13.

On any claim(s) does the medical evidence in file include the results of an exercise test (e.g., treadmill, bicycle, arm ergometry)?

   Yes    No
If yes: Follow III below.
If no: Stop here! Check block 13 and follow II below.
 
[  ] 13

II. Non-members or members who have already received relief

  • If you checked block 04, 05, 06, 07, 08, 11, 12 or 13 the claimant is not entitled to relief as a class member. Check “non-member” (F) in item 3 and fill in the screen-out code (04, 05, 06, 07, 08, 11, 12 or 13). Proceed to IV.

III. Class members

  • If you have no blocks checked, the claimant is entitled to relief as a class member. Check “member” (J) in Item 3. Proceed to IV.

IV. Dates

  • On the lines below, please enter the date(s) of all final decisions considered in the screening process, and indicate the administrative level at which the final decision was made (i.e., DDS, ALJ, AC). Also record the dates of any determinations after the date Agency implementation instructions were issued that you considered in the screening process, and indicate the administrative level at which the determination was made (i.e., DDS, ALJ, or AC).

            

            

            

            

            

            

V. Screener identification

  • (NOTE: BEFORE SIGNING, PLEASE COMPLETE ITEM 3.)

            

Print name, phone number and component

            

 

Signature

 

State of New York (SONY) Screening Sheet Instructions (DI 42594.015B.2.)

 

  1. Consider all Title II and XVI claims (denials/cessations) finally decided during the period June 1, 1980 to February 2, 1994, inclusive.

    NOTE: If ALJ, AC or Federal court made last decision in SONY time period, send the case to OHA for screening.

  2. Review the SONY alert, related queries (FACT, SSIRD, etc.) and claim file(s).

    When the claim file has been destroyed or declared lost, determine if the case may be screened out solely on the basis of information shown on the queries. EXAMPLE 1. SSIRD shows Title XVI claim(s) denied for excess income and resources; FACT shows Title II claim(s) denied because insured status not met at any point, or alleged onset date occurred more than one year after insured status last met (disallowance code 90). Check block 11. EXAMPLE 2. SSIRD shows a Title XVI claim that was denied initially but subsequently allowed at the reconsideration or ALJ level with no change in date of eligibility: Check block 6. Any case which cannot be conclusively screened out on the basis of the queries must be sent to the FO for reconstruction.

  3. Complete Questions 1 - 3 and Part I of the screening sheet as follows:

Question 1.

Enter the SSN under which the claim was filed and check Title II, Title XVI or Concurrent.

Question 2.

Enter claimant's name.

Question 3.

  1. Enter BIC (Title II) or ID (Title XVI)

    • Concurrent Title II and XVI claims --- Enter the BIC or ID for the claim that was a medical-vocational denial. If both claims were medical-vocational denials, always enter the BIC.

    • Concurrent DIB and DWB or CDB claims --- Enter the BIC for the claim that was a medical-vocational denial. If both claims were medical-vocational denials, always enter the DIB claim BIC.

    • Multiple claims filed at different times---When all claims are screened out, enter the BIC or ID of the earliest claim screened. When at least one claim has been screened in, enter the BIC or ID of the earliest claim that makes the responder a class member.

  2. Enter date case screened.

  3. Check class membership determination block.

    • Check block J when one or more claims are screened in for DDS/OHA review.

    • Check block F and enter screen out code of the earliest claim screened when none of the claims is screened in for DDS/OHA review.

Question 4.

  1. Determine if claimant filed an application for Title II or Title XVI disability insurance benefits.

  2. The absence of FACT or SSIRD information does not necessarily mean the claimant did not file an application. When both the FACT and SSIRD queries show no record, obtain a numident query to determine if the claimant has a cross-reference SSN. If the numident does not disclose a possible Title II or XVI claim number send claimant the SSN verification notice (See DI 42594.015A.1.b. and DI 42594.095 Exhibit 2), if the FO has not already done so.

  3. If the FO has previously verified the claim number and there is no evidence of a disability application, check block 4; check block F and fill in the screen out code in Question 3; sign the screening sheet.

Question 5.

  1. Screen for residency as of the date of the final determination or decision, not date of application. (The date of the final determination/decision is the date the notice is received by the claimant. The date of receipt is presumed to be the fifth day following the date of the notice.)

  2. If date of the final decision was between June 1, 1980 and February 2, 1994, inclusive, go to question 6.

  3. If the answer to Question 5 is no for all decisions, check block 5; check block F and fill in the screen out code in Question 3; sign the screening sheet.

Question 6.

  1. Review the file(s) and queries (e.g., FACT, SSIRD) to determine if benefits were subsequently allowed or continued. If yes,

    • in title II cases, check the subsequent award/continuation for first month of entitlement.

    • in title XVI cases, check the subsequent award/continuation for the first month of eligibility.

  2. Identify the earliest SONY claim/termination. Determine the earliest month benefits could have been paid based on the SONY alleged onset and the SONY application or termination date.

  3. Compare the earliest possible SONY benefit date with the subsequent award or continuation dates. If the dates are the same and the allowance or continuation was fully favorable (not a closed period allowance), Check block F and fill in the screen out code in Question 3; sign the screening sheet.

    • In title II cases, if full retroactive benefits were not paid, also check to see if the later award established an onset that would allow payment back to the first possible month under the SONY claim. If the earliest possible onset was established, but full retroactive benefits were not paid,

      -- Change the application date on the later SSA-831/832/833 to reflect the SONY application date, enter SONY Court Case, retroactive benefits due based on earlier application, and sign and date the form. If ODIO or the PSC is screening the case, send the case to a CA for processing for title II or to the FO for title XVI. Follow DI 42594.015B.7. if the DDS is screening the case, send the case to the FO for processing and follow DI 32594.035D for notice language.

Question 7.

  1. Screen for date of final determination or decision, not date of application.

  2. If the date of the final decision was between June 1, 1980 and February 2, 1994, inclusive, go to question 8.

  3. If the answer to Question 7 is yes for all applications, check block 7; check block F and fill in the screen out code in Question 3; sign the screening sheet.

Question 8.

  1. Screen to determine if the judgment of the district court was actually appealed or if the district court issued a final, i.e., unappealed, decision on the SONY application(s) on or before October 5, 1989.

    NOTE: The period within which an appeal of a district court decision may be filed is 60 days from the date of entry of judgment. Therefore, a district court decision entered on October 2, 1989 became final and unappealable on December 2, 1989 the 61st day after entry of judgment if no appeal was filed.

  2. If the answer to question 8 is yes and no other claims qualify for SONY DDS/OHA review, check block 8; check block F and fill in the screen out code in Question 3; sign the screening sheet.

Question 9.

  1. Review Item 26 on the SSA-831 or Item 34 on the SSA-832/833 to determine if this case was listed under code “170”.

  2. If the answer to Question 9 is yes, skip questions 10 - 11 and continue with Question 12.

  3. If the answer to Question 9 is no, Question 10 must be answered.

Question 10.

  1. Review the file(s) and queries (e.g. FACT, SSIRD) to determine whether claimant received a denial/cessation decision on any claim(s), between June 1, 1980 and February 2, 1994, inclusive, by NYDDS, hearing office servicing NY residents or the Appeals Council at steps 3, 4, or 5 of the sequential evaluation process. (look for basis denial codes for title II of E1, E2, E3, E4, G1, G2, H1, H2, J1, J2, K1, K2, L1, L2, M5, M6; for Title XVI N31, N32, N34, N35, N36, N37, N39, N40, N42, N43, N45, N46, N47, N51 on the SSA-831. In a CDR case, read the rationale to determine the reason for the cessation on the SSA-832/833. In a DHU or ALJ case, read the decision to determine the basis for the denial or cessation.

  2. If the answer to Question 10 is no, you must answer Question 11.

  3. If the answer to Question 10 is yes, skip Question 11 and continue with Question 12.

Question 11.

  1. Review the file(s) and queries (e.g. FACT, SSIRD) to determine whether claimant received a denial/cessation decision on any claim(s), between December 4, 1989 and February 2, 1994, inclusive, by NYDDS, hearing office servicing NY residents or the Appeals Council at steps 2, 3, 4, or 5 of the sequential evaluation process. (look for basis denial codes for title II of E1, E2, E3, E4, F1, F2, G1, G2, H1, H2, J1, J2, K1, K2, L1, L2, M5, M6; for Title XVI, N30, N31, N32, N34, N35, N36, N37, N39, N40, N41, N42, N43, N45, N46, N47, N51 on the SSA-831. In a CDR case, read the rationale to determine the reason for the cessation on the SSA-832/833. In a DHU or ALJ case, read the decision to determine the basis for the denial or cessation.

  2. If the answer to Question 11 is yes, you must answer Question 12.

  3. If the answer to Question 11 is no, check block 11; check block F and fill in the screen out code in Question 3; sign the screening sheet.

Question 12.

  1. Review the file(s) for evidence of ischemic heart disease, hypertensive vascular disease, myocardiopathies, rheumatic or syphilitic heart disease. There are many pieces of evidence in file that can provide allegations/evidence of cardiovascular disease. The following are some common sources but are not intended to be all inclusive:

    • Items 16A and 16B of any prior SSA-831 for the primary and secondary diagnosis, body system, and code number (see DI 26510.015).

    • Items 21 and 32 of any prior SSA-832/833 for the primary and secondary diagnosis, body system, and code number (see DI 28084.035).

    • Any prior SSA-3820 (Medical History Disability Report for Widows, Widowers, Surviving Divorced Spouses).

    • SSA-3441 Reconsideration Disability Report (it updates information previously obtained or identifies additional impairments).

    • SSA-3368 (Disability Report) Item D lists disabilities alleged.

    • The disability application may provide an allegation of a cardiovascular impairment.

    • Reports of the results of various tests such as TET, echocardiogram, cardiac catheterization, Doppler exercise test, radionuclide studies, resting electrocardiogram.

    • Reports from sources such as treating physician, consultative examination, hospital emergency room, or inpatient hospitalization.

    • Reports of contact prepared by the DDS based on conversations with the claimant or a treating/consulting physician.

    • Any decision issued by an ALJ or the AC.

      NOTE: If an exercise test (see Question 13) was done in conjunction with a cardiovascular diagnosis, such as hypertension, congenital heart disease, etc., not mentioned above, answer Question 12 “yes”. (After consultation with a physician, the screener will resolve any doubt about the cardiovascular nature of a diagnosis or alleged impairment in favor of a “yes” response.)

  2. If the answer to Question 12 is yes, you must answer Question 13.

  3. If the answer to Question 12 is no, check block 12; check block F and fill in the screen out code in Question 3; sign the screening sheet.

Question 13.

  1. Review the file(s) for a report on the results of an exercise test (e.g. treadmill (TET), bicycle, arm ergometry, etc.) and/or the tracings.

    NOTE: After consultation with a physician, the screener will resolve any doubt about whether the evidence includes results of cardiac exercise testing in favor of a “yes” response.

  2. If the answer to Question 13 is yes, the claimant is entitled to relief as a class member. Follow the instructions at III on the screening sheet.

  3. If the answer to Question 13 is no, check block 13; check block F and enter the screen out code in Question 3.

  1. Complete Part IV of the screening sheet by entering the dates and administrative review level (initial, recon, ALJ or AC) of all final determinations/decisions issued during the period June 1, 1980 to February 2, 1994, inclusive, that were considered during the screening process; as well as the dates and administrative review level of all final determinations/decisions issued after February 2, 1994.

  2. Complete Part V, “Screener Identification”.

    Place a copy of the completed screening sheet in the claim folder and send a copy to:

    ODIO
    Attn: State of New York Coordinator
    P.O. Box 17369
    Baltimore MD 21298-0050

Exhibit 3 State of New York Class Membership Notice

 

THE STATE OF NEW YORK v. SULLIVAN
(THE EXERCISE TEST CASE) CLASS MEMBER NOTICE

Date:
Claim Number:

  1. We are writing to let you know that we have decided you are entitled to a new decision because of the State of New York v. Sullivan case (the exercise test case).

  2. We will contact you when we start reviewing your claim and ask you if you have additional evidence.

    You will be told where to send any additional evidence at that time.

  3. If you have a legal representative you should show this notice to that person. If you would like to obtain a legal representative, you may call:

    1. Legal Services, which will refer you for free assistance if you are financially eligible.

      1. In the New York city area: Legal Services for New York City at (212) 431-7200 OR The Legal Aid Society at (212) 577-3300.

      2. In the rest of New York state: Greater Upstate Law Project, at 1-800-724-0490.

    2. The National Organization of Social Security Claimant's Representatives will refer you to an attorney who will charge a fee for representation, call 1-800-431-2804.

  4. If you have other questions, you may also contact the Social Security Administration at 1-800-772-1213. If you visit a Social Security office, please bring this letter with you. It will help us answer your questions.

     

Si usted no entiende esta carta, llavela a la oficina de Seguro Social arriba mencionada para que se la expliquen.

Exhibit 4 State of New York Non-Membership Notice

 

STATE OF NEW YORK V. SULLIVAN (The Exercise Test Case)

 

Date:
Claim Number:

 

THIS NOTICE IS ABOUT YOUR SOCIAL SECURITY/SSI BENEFITS.
PLEASE READ IT CAREFULLY!

  1. WE HAVE DETERMINED THAT YOU ARE NOT ENTITLED TO RECEIVE A NEW DECISION IN THE STATE OF NEW YORK V. SULLIVAN COURT CASE (THE EXERCISE TEST CASE).

    You asked us to review your case under the terms of the exercise test case, or under another of the New York court cases (i.e., Stieberger, Dixon, and/or Hill), or we identified you as a potential State of New York class member through some other means. We have looked at your case and decided that you are not entitled to relief as a State of New York class member. The reason you are not entitled to relief is checked below. (If we are also looking at your claim in connection with other New York court cases, (Stieberger, Dixon, and/or Hill), you will be getting separate notice(s) regarding class membership in those cases).

  2. WHY YOU WILL NOT RECEIVE A NEW DECISION

    YOU ARE NOT ENTITLED TO RELIEF AS A STATE OF NEW YORK CLASS MEMBER BECAUSE:

1.

[  ]

You were not issued a decision by the New York Disability Determination Service (DDS) or the Office of Hearings and Appeals, for New York state, denying or ceasing disability benefits on or after June 1, 1980 and February 2, 1994.

2.

[  ]

You did not live in the state of New York at the time your claim for disability benefits was finally denied or ceased.

3.

[  ]

Your claim did not involve in any way the problems of heart disease or a heart condition.

4.

[  ]

There were no exercise test results in your file.

5.

[  ]

Your benefits were denied or ceased for some reason other than your medical condition. That reason was

            

            

6.

[  ]

You have received a subsequent fully favorable decision awarding you either Title II benefits based on the earliest date that you said you were disabled, or Title XVI disability benefits based on the earliest date on which you applied. We will be in touch with you if you are owed any additional retroactive benefits.

7.

[  ]

Other

            

            

            

We looked at the decision(s) dated:

            

  1. WE ARE NOT DECIDING WHETHER YOU ARE DISABLED

    It is important for you to know that we are not deciding whether you are or were disabled. We are deciding only that we will not make a new decision, based on the exercise test case, on your past claim(s) for disability benefits.

  2. WHAT YOU MAY DO IF YOU DISAGREE WITH THIS DETERMINATION

    1. You may write Legal Services for the Elderly, one of the offices that represented the plaintiff class in this action. Their address is:

      Legal Services for the Elderly
      130 W. 42nd St., 17th Fl.
      New York, NY 10036
      ATTN: The Exercise Test Case

      If it is difficult for you to write, you may call Legal Services For The Elderly at: (212) 391-0120.

    2. If you prefer, you may send your written disagreement directly to:

      OFFICE OF THE GENERAL COUNSEL
      DEPARTMENT OF HEALTH AND HUMAN SERVICES
      RM. 639 ALTMEYER BLDG.
      6401 SECURITY BLVD.
      BALTIMORE, MD 21235
      ATTN: THE EXERCISE TEST CASE

    3. You may also contact the Social Security Administration. To locate your local Social Security office, call 1-800-772-1213. If you visit a Social Security office, please bring this letter with you. It will help us answer your questions.

  3. IF YOU HAVE A LEGAL REPRESENTATIVE OR WOULD LIKE TO OBTAIN ONE

    If you have a legal representative, you should show this notice to that person. If you would like to obtain a legal representative, you may call:

    1. Legal Services, which will refer you for free assistance if you are financially eligible.

      1. In the New York city area call:
        Legal Services for New York City at (212) 431-7200 OR The Legal Aid Society at (212) 577-3300.

      2. In the rest of New York state call: Greater Upstate Law Project, at 1-800-724-0490.

    2. The National Organization of Social Security Claimant's Representatives will refer you to an attorney who will charge a fee for representation, call 1-800-431-2804.

  4. YOU ALSO HAVE THE RIGHT TO FILE A NEW APPLICATION FOR BENEFITS. FILING A NEW APPLICATION IS NOT THE SAME AS CHALLENGING OUR CLASS MEMBERSHIP DECISION, AND OBTAINING A NEW DECISION ON A PAST APPLICATION.

  5. IF YOU HAVE OTHER QUESTIONS

    You may also contact the Social Security Administration at 1-800-772-1213. If you visit a Social Security office, please bring this letter with you. It will help us answer your questions.

     

Si usted habla español y no entiende esta carta, favor de llevarla a la oficina de Seguro Social arriba mencionada para que se la expliquen.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0432594095
DI 32594.095 - Exhibits - 11/18/2015
Batch run: 11/18/2015
Rev:11/18/2015