Citations:

Section 221(i) of the Act Social Security Act

TN 2 (10-08)

DI 40502.001 Processing Center Instructions for the Continuing Disability Review Mailer Forms SSA-455 and SSA-455-OCR-SM

Policy

DI 40502.001A

Process

DI 40502.001B

Procedure for sending out the mailer

DI 40502.001C

Procedure for FO involvement in the mailer completion process

DI 40502.001D

Procedure for Wilkes-Barre Direct Operations Center (WBDOC) processing

DI 40502.001E

Procedure for Division of Continuing Disability Reviews Support (DCDRS) decision logic and CDR mailer PSC review alerts

DI 40502.001F

Procedure for Processing Center (PC) processing of the mailer

DI 40502.001G

Procedure for PC processing of undeliverable mailers

DI 40502.001H

Procedure for PC processing of nonresponders

DI 40502.001I

Procedure for mailer decision-making and post-decision-making actions by Disability Technician (DT)/Benefit Earnings Technician (BET), and Disability Examiner (DE)/Disability Examiner Consultant (DEC)/Disability Consultant (DC) review instructions

DI 40502.001J

A. Policy

Section 221(i) of the Social Security Act, as amended, requires a periodic continuing eligibility review for disabled beneficiaries at least every three years except where a finding has been made that such disability is permanent. Reviews of cases involving permanent disability are made at such times as the Commissioner determines appropriate. This review is called a continuing disability review (CDR).

Section 1614(a)(3) of the Act provides for periodic review of eligibility for Supplemental Security Income, based on disability or blindness. These reviews are either called CDRs or, in the case of the age-18 reviews, redeterminations.

B. Process

1. Mailer Form SSA-455 Disability Update Report

Form SSA-455 is a self-help mailer designed to solicit key information from disabled beneficiaries about their medical conditions and recent treatment for same. “Recent” usually means within the last two years. The mailer also asks for information about recent education or training, and recent attempts to (return to) work.

2. Who is sent a mailer?

The mailer is usually sent to beneficiaries who, on the basis of statistical analyses called profiling, indicate a low probability of medical improvement where a full CDR was done. This group is sometimes described simply as “LOWs”. In some instances, other groups of beneficiaries may be sent mailers. These groups are variously referred to as “HIGHs” or “MEDIUMs”, to differentiate between the “scores” of those who profile as potentially productive CDRs, or when combined as a group, they may be referred to as “non-LOWs” or “not-LOWs”.

The answers to the questions and remarks on the mailer, and relevant attachments to the form (e.g., medical evidence, work information), are reviewed. The responses may show that the profile has not changed, in which case a full CDR is deferred for LOW profile cases, or a full CDR is initiated for MEDIUM or HIGH (not-LOW) profile cases.

Alternatively, the mailer responses may show that there is reason to conclude that the profile has changed, in which case a full CDR usually results for mailers on LOW profile cases, or a deferral action results in the case of the MEDIUM and HIGH (not-LOW) profile cases.

3. Mailer processing outcomes

When a mailer is completed, there are two possible outcomes depending on the information received. One outcome is a “DO CDR” (mailer to be referred for a full medical CDR) that results in a full medical CDR that occurs in about 2.5% of the completed mailers. The other outcome is to defer doing a full medical CDR, resulting in a mailer deferral action. As part of the deferral action, a new medical reexamination diary is set for up to seven years.

4. Integrity sampling in the mailer process

As a result of integrity sampling, approximately 5% of the mailers received are referred for processing as full medical CDRs despite responses which may otherwise indicate that a deferral action is proper.

5. Mailer processing is not a CDR

The decision to defer a CDR or to refer a mailer case for a CDR is not a CDR; it is not an initial determination subject to administrative review, nor is a new comparison point decision (CPD) established. Although sometimes referred to as CDR mailers, in part, to differentiate them from the other self-mailer forms the Agency uses, the mailer form process is not a CDR. However, the Agency is allowed to count deferral actions as reviews for purposes of annual reporting to Congress on the stewardship of the disability programs. The deferral action represents a way to maintain stewardship without many unnecessary and unproductive full medical reviews that may create anxiety for the beneficiary even when the ultimate outcome is a determination that disability continues. The mailer process is also cost-efficient. Processing a mailer for a deferral action costs approximately $50, as compared to the cost of $750-$800 to make an initial determination on a full medical CDR.

6. The scannable mailer form

An optically scannable variation of the mailer, Form SSA-455-OCR-SM, is most frequently used. The scannable mailers are printed and released by a private contractor according to a schedule prepared by the Division of Continuing Disability Reviews Support (DCDRS). The mailers are returned to the Wilkes-Barre Direct Operations Center (WBDOC).

The WBDOC takes the following actions, as appropriate:

  • processes change-of-address actions;

  • processes name corrections;

  • inputs death information;

  • remails undeliverable mailers (once);

  • controls unsigned forms for signatures;

  • does direct telephone contact (DIRCON) to resolve unanswered questions;

  • analyzes responses and attachments;

  • codes the forms; and

  • scans and keys the returned mailers.

The scannable mailer, Form SSA-455-OCR-SM, is used most of the time, although the standard “hard paper” form may be used by the processing centers (PCs) or field offices (FOs).

7. Question sequencing on the mailer

The sequence of the questions on the two forms is different. They are:

Topic

Form SSA-455

Form SSA-455-OCR-SM

Recent Work

Question 1

Question 1

Health Status (Same, Better, or Worse)

Question 2

Question 4

Discussion with Doctor re: Ability To Work

Question 3

Question 3

Education/Training

Question 4

Question 2

Interest in Vocational Services

Question 5

deleted as of 10/2000

Hospitalizations

Question 6

Question 6

Medical Treatment

Question 7

Question 5

The sequence of questions on Form SSA-455-OCR-SM reflects the most current design and processing policies; however, the older Form SSA-455 may be used.

8. “Scanline” data

The scannable mailer includes barcoded information as well as three lines of scannable data on the front of the mailer, immediately below the telephone number and claim number. These scanlines contain substantial information:

Scanline 1 –

Field 1 – Social Security Number under which the mailer is being controlled

 

Field 2 – Beneficiary Identification Code (BIC) (Title II), or

 

Individual Recipient Identification code (ID) (Title XVI)

 

Field 3 – Year of beneficiary's birth

 

Field 4 – Year of most recent prior CDR

 

Field 5 – Primary and Secondary Diagnosis Codes

Scanline 2 –

Field 1 – Medical Diary Reason/Type

 

Field 2 – Concurrent Entitlement information

 

Field 3 – Profile Type (High, Medium, or Low)

 

Field 4 – Profiling SCORE (9999 is highest)

 

Field 5 – Report Period covered by the mailer

 

Field 6 – Scanning Form Identification Code (SFIC) (describes if it is a first or second request mailer, whether it is Title II, concurrent, or Title XVI-only, and whether the beneficiary prefers a non-English language notice).

 

Field 7 – Servicing Processing Center

 

Field 8 – Servicing State Agency/DDS code

 

Field 9 – Servicing Field Office (FO) Code

Scanline 3 –

Field 1 – Servicing FO City Name

 

Field 2 – Servicing FO State

 

Field 3 – Servicing FO ZIP CODE

9. The vocational rehabilitation services inquiry

The response to question 5 on Form SSA-455 regarding interest in rehabilitation services is always optional and is never considered when deciding whether a full medical review is needed.

C. Procedure for sending out the mailer

The mailer, a generic cover notice and instruction insert, and a reply envelope are sent to the beneficiary or representative payee. An initial mailer or “first-request” form is sent. If it is not returned and receipted within a specific time frame, a “second-request” mailer is sent. If the second mailer is not returned and receipted within a specific time frame, a nonresponder alert is generated.

The mailer is completed by the beneficiary or representative payee and returned to the WBDOC (Form SSA-455-OCR-SM), or to the PC or FO (Form SSA-455).

D. Procedure for FO involvement in the mailer completion process

FO personnel may assist in the completion of this form if the beneficiary requests help or the PC requests assistance.

The FO forwards signed SSA-455-OCR-SMs to the WBDOC for processing. The mailing address for the WBDOC is provided at the top of the front side of Form SSA-455-OCR-SM. Note that Title II and Title XVI mailers have different Post Office Box numbers.

The FO forwards “hard paper” SSA-455s to the servicing PC for processing.

E. Procedure for Wilkes-Barre Direct Operations Center (WBDOC) processing

1. Handling undeliverables

The WBDOC reviews and processes most scannable mailers, including mailers returned by the United States Postal Service (USPS) as undeliverable. When this happens, the WBDOC has procedures to attempt re-delivery.

Second-request mailers that are returned as undeliverable after a re-mailing attempt are held until 150 days from the send request has passed, when the “UNDELIVERABLE” mailer automatically updates as “NONRESPONDER” to the DCF. Subsequently, those mailers are securely destroyed.

2. Preliminary screening for signatures, damaged forms, name or address changes, reports of death, or allegations of fraudulent activity

  • Some mailers are received unsigned, in which case the WBDOC establishes controls to obtain a signature.

  • Signed mailers sometimes have unanswered questions; the WBDOC uses the DIRCON process and the mail to secure missing responses.

  • Some mailers are returned with a report of death or are so damaged as to not be optically scannable. A name change, a change of address to a foreign country, or fraudulent activity may also be reported. When any of these events happen, the mailer is referred to the servicing PC or FO for necessary action.

  • The WBDOC updates the Master Beneficiary Record (MBR) for name corrections (but not name changes), change of address (with or without a corresponding change of telephone number), and reports of death for Title II cases, and refers such reports on Title XVI cases to the servicing field offices (FOs) for action.

3. WBDOC mailer analysis, coding, scanning, and keying

Upon completion of the preliminary actions, the WBDOC performs a detailed analysis of the mailer responses, including remarks and any attachments that are received with the mailers. Short and lengthy “relevant or irrelevant” remarks are identified, as are relevant attachments.

a. The mailer electronic data file

The fronts of most mailers are optically scanned and the data are entered into the electronic data file that is created for each scannable mailer.

All mailers require some keying, including responses on the back of the form (questions 5 and 6) and relevant short remarks of 30 words or 200 characters or less. All keyed data becomes part of the data file for that mailer.

Also included in the data file are the scanline data, the responses to the questions, and a set of three codes (called ANY CODES?) that are used to identify if irrelevant or relevant short or lengthy relevant remarks or attachments are present.

b. The “ANY CODES?” coding process

The first two of the three “ANY CODES?” codes are used to identify the subject matter of the relevant submissions (e.g., work, medical, both work and medical, or miscellaneous). They can also be used to identify the submission of irrelevant remarks. The first two codes are also used to identify cases in which translation is required.

The third of the three “ANY CODES?” codes are used to alert the PC when other program issues are raised (e.g., a change of name; the need to develop for a representative payee; or receipt of, or a change in the amount of, workers’ compensation).

4. Sorting mailers in the WBDOC

Another critical element of WBDOC processing involves sorting the processed mailers by Title (Title II, concurrent, or Title XVI-only), by PC jurisdiction, and by whether the mailer is considered “actionable” or “nonactionable”.

a. PC jurisdiction

Jurisdiction for the mailer follows the Agency's jurisdiction rules.

PC-8 has jurisdiction for foreign claims. Beneficiaries under the jurisdiction of PC-8 are excluded from selection for the first of the mailers. However, a change of jurisdiction to PC-8 after the first mailer has been sent may not be detected, and the PCs may encounter second mailers or nonresponder alerts involving what has become a foreign claim.

OCO/PC-7 has jurisdiction for all domestic Title II-only and concurrent Title II/Title XVI disabled worker claims and claims for auxiliaries of disabled workers. Jurisdiction of these cases changes from OCO/PC 7 to PC 1, 2, 3, 4, 5, or 6 when the disabled wage earner attains age 54 (or dies).

NOTE: Beginning May 2009, the jurisdiction of these cases changes from OCO/PC7 to PC 1, 2, 3, 4, 5, or 6 when the disabled wage earner attains age 54 (or dies).

PCs 1 through 6 have jurisdiction for all Title XVI-only cases, and for all Title II and concurrent Title II/Title XVI claims not under the jurisdiction of PC 7 or PC 8 (as explained previously). The first three numbers of the Social Security Number (SSN) determine PC 1 through 6 jurisdiction.

See Also:

GN 01050.055 – Determining Processing Center Jurisdiction

GN 01070.245 – Processing Center SSN Jurisdiction

b. Actionable and nonactionable mailers

In addition to being sorted by Title and PC jurisdiction, mailers are sorted based on whether they are “actionable” or “nonactionable”.

Actionable mailers are those that always require PC review. The PC reviewer always needs to review the actual mailer (and attachments) to complete the mailer processing. Actionable mailers include those:

  • with relevant remarks in excess of the 30 word/200 character limit in the electronic data file;

  • with relevant attachments, including, but not limited to, medical evidence, and work and earnings information;

  • signed by a doctor (or a nurse), or by a staff member of a nursing home, skilled nursing facility, or residential care facility;

  • requiring translation;

  • with a code of “Y” in position 3 of the Any Codes? codes, which indicates another program issue has been raised (e.g., a name change, need to develop for a representative payee, or a request to waive recovery of an overpayment);

  • with a “YES” response to question 1.a. (Have you worked?) or in response to question 1.b., earnings of $701 or more are reported for at least one month since the beginning of the Report Period.

If question 1.b. is blank or if no earnings are reported; and if question 1.a. is answered “Yes”, is not answered, or is answered BOTH “Yes” and “NO”; and DIRCON does not resolve these inconsistencies, the mailer is actionable.

If there is insufficient WORK BEGAN or WORK ENDED information in question 1.b. to determine when the earnings occurred, but the reported MONTHLY EARNINGS in 1.b. are $701 or more in any of the three entries, the mailer is actionable.

NOTE: If only work and earnings prior to the report period are described, the mailer is not considered an actionable mailer.

Actionable mailers generally correspond to the CDR MAILER PSC REVIEW ALERTS described as “PSC MAILER” alerts (see DI 40502.001F.3.b. in this section). Do not work these cases using the facsimile provided by DCDRS. Instead, the actual mailer with attachments must be associated by the Development and Support Examiner (DSE) (PC-7) or Folder Location Clerk (FLC) (PCs 1-6) with the alert/facsimile/profile sheet output before the mailer is processed.

Nonactionable mailers may contain relevant remarks, but they are short enough that they can be entered into the electronic data file for that mailer. This means that you can use the facsimile of the mailer generated by DCDRS to process the case (see DI 40502.001F.3. in this section).

Nonactionable mailers correspond to the CDR MAILER PSC REVIEW ALERTS described as “MISCELLANEOUS” alerts (see DI 40502.001F.3.d. in this section).

Nonactionable mailers do not have any of the characteristics specified in this section at DI 40502.001E.4.b., that require review of the actual documentation.

Nonactionable mailers are held in the WBDOC for a specified period of time and are then securely destroyed.

5. Delivery of mailers from the WBDOC to the PCs

After sorting by PC jurisdiction and Title (II or XVI), WBDOC images the actionable mailers without attachments and passes them to the National Computer Center (NCC). The NCC downloads the images into each PC’s Paperless Processing Control system; the images appear as “SSA455PF ProngFile” on the “Completed” side of paperless, awaiting association with the electronic data file.

The actionable mailers with attachments are boxed in special boxes that include a shipping label addressed uniquely for each PC, indicating that the contents are actionable CDR mailers and are either Title II or Title XVI mailers. The boxes are delivered by mail to the PCs.

6. Transmission of the mailers electronic data file and confirmation files

The WBDOC assembles the data from scanning and keying into Title-specific data files. Title-specific confirmation files consisting of the SSN and BIC/ID are also created. All files are transmitted to the Agency's National Computer Center (NCC). During periods of high workloads, these assembled files are transmitted daily, and multiple daily transmissions are possible.

The NCC receives, prepares, and routes the confirmation file data to the appropriate program for updating the Disability Control File (DCF). Receipt of the confirmation data clears the second-mailer/nonresponder control.

The NCC receives and prepares the data files for DCDRS to retrieve and process through DCDRS's decision logic.

F. Procedure for Division of Continuing Disability Reviews Support (DCDRS) decision logic and CDR mailer PSC review alerts

1. Decision logic

DCDRS retrieves the data files prepared by the NCC on the basis of receipt of data files from the WBDOC. The data are processed by DCDRS through a decision logic program. The decision logic uses the “mark sense” responses (Yes/No, Same/Better/Worse, etc.) to questions 1.a., 2, 3, 4, 5.a., and 6.a., the ANY CODES? codes, as well as the data used to select the cases for mailer processing, to decide what is the next appropriate action.

a. Decision logic outcomes

The logic provides front-end screening of all returned mailers. Mailers in which a clear decision can be made to do a full CDR or to defer a CDR are processed to completion by DCDRS. Approximately 80% of mailer electronic data files received by DCDRS can be processed directly to a deferral or DO CDR action. The rest require PC Review.

b. DCDRS decision logic inputs

DCDRS makes the appropriate input to update the DCF to reflect the results of decision logic processing.

Mailers for which the decision logic cannot make a clear decision are forwarded to the PCs for review. Mailers are most often referred to the PC for additional review following WBDOC and Central Office processing. This workload is typically called “PC Review”, and involves approximately 20% of all mailers received in the WBDOC.

2. “Hard-paper” mailers

A significant additional workload consists of hard paper forms initiated by and returned to the PC. These forms are not scannable and cannot be processed to a data file by the WBDOC. Because no electronic data file exists for these mailers, they cannot be processed through DCDRS decision logic and must be reviewed manually. No CDR MAILER PSC review alerts are generated for these cases.

3. CDR MAILER PSC REVIEW Alerts

For each case requiring PC Review, DCDRS provides electronic files containing:

  1. an output CDR MAILER PSC REVIEW ALERT sheet, which includes the following information:

    • the alert generation run date;

    • the disabled individual's name and claim number;

    • whether the mailer is Title II-only, concurrent Title II/Title XVI, or Title XVI-only;

    • PCACS (Title II-only or concurrent Title II/Title XVI cases) or SSICCS (Title XVI-only) data, including folder location and date-in-location information;

    • servicing FO, State and DDS codes, FO city and state name; and

    • the case-specific alert message/recommended processing instructions;

  2. an electronic facsimile of the completed, scanned mailer; and

  3. a profile sheet that includes much of the data used to profile the case, including

    • name,

    • account number,

    • application date,

    • date of entitlement,

    • date of onset of disability,

    • diagnoses codes,

    • impairment data,

    • medical diary type as calculated by DCDRS (the OD-CALC MDR: field),

    • profile category (Low, Medium, or High),

    • recent earnings information, and

    • initial claim and prior CDR data.

a. The two types of alerts

Two types of alerts are generated;

  • PSC MAILER alerts, and

  • MISCELLANEOUS alerts.

b. PSC MAILER alerts

Alerts with the secondary title of “PSC MAILER” are generated when the actual mailer and any attachments must be used with the alert, facsimile, and profile sheet for mailer processing.

c. Alert messages in PSC MAILER alerts

One of seven messages is included on the alert. The messages specify who should review the case next. The possible messages are:

  1. TRANSLATION NEEDED. AFTER TRANSLATION AND REVIEW, THE DE/DEC/DC SHOULD CONSIDER THE RECOMMENDED DECISION, WHICH IS TO REFER THE CASE FOR A MEDICAL CDR. IF THE DE/DEC/DC CONCURS WITH THE RECOMMENDED DECISION, REFER THE CASE TO THE FO USING A SSA-5526-U2-OP2.

  2. TRANSLATION NEEDED. AFTER TRANSLATION AND REVIEW, THE DE/DEC/DC SHOULD CONSIDER THE AUTOMATED RECOMMENDED DECISION, WHICH IS TO REDIARY THE CASE. IF THE DE/DEC/DC CONCURS WITH THE AUTOMATED RECOMMENDED DECISION, REDIARY THE CASE AND DO NOT REFER TO THE FO.

  3. BET/DT REVIEW NEEDED. IF THE BET/DT DETERMINES THERE IS NO WORK ISSUE, AND NO OTHER ISSUE REQUIRING REVIEW BY A DE/DEC/DC, REFER THE CASE TO THE FO FOR A MEDICAL CDR USING A SSA-5526-U2-OP2.

  4. BET/DT REVIEW NEEDED. IF THE BET/DT DETERMINES THERE IS NO WORK ISSUE, AND NO OTHER ISSUE REQUIRING REVIEW BY A DE/DEC/DC, REDIARY THE CASE. DO NOT REFER THE CASE FOR A MEDICAL CDR AT THIS TIME.

  5. DE/DEC/DC REVIEW OF REMARKS/ATTACHMENTS NEEDED. IF THE DE/DEC/DC FINDS THAT THE REMARKS/ATTACHMENTS ARE NOT MATERIAL, FOLDER REVIEW IS NOT REQUIRED. IN THAT CASE, THE DE/DEC/DC SHOULD FOLLOW THE AUTOMATED RECOMMENDED DECISION TO REDIARY THE CASE AND NOT REFER THE CASE FOR A CDR AT THIS TIME.

  6. DE/DEC/DC REVIEW NEEDED. IF THE DE/DEC/DC FINDS THAT THE REMARKS/ATTACHMENTS ARE MATERIAL OR THAT FOLDER REVIEW IS REQUIRED, THE DE/DEC/DC SHOULD CONSIDER THE AUTOMATED RECOMMENDED DECISION WHICH IS TO REFER THE CASE FOR A MEDICAL CDR. IF THE DE/DEC/DC CONCURS WITH THE RECOMMENDED DECISION, REFER THE CASE TO THE FO USING A SSA-5526-U2-OP2.

  7. DE/DEC/DC REVIEW NEEDED. IF THE DE/DEC/DC FINDS THAT THE REMARKS/ATTACHMENTS ARE NOT MATERIAL, OR THAT FOLDER REVIEW IS REQUIRED, THE DE/DEC/DC SHOULD CONSIDER THE AUTOMATED RECOMMENDED DECISION WHICH IS TO REDIARY THE CASE. IF THE DE/DEC/DC CONCURS WITH THE RECOMMENDED DECISION, REDIARY THE CASE AND DO NOT REFER TO THE FO.

In order of priority, the alert states that BET/DT review is required when translation is needed (examples 1 and 2).

Next in priority, the alert states that BET/DT review is needed if the response to question 1 (work activity) is positive or if a code of “1” (or, in certain cases, “3”), was input in response to the “Remarks” and/or “Attachments” boxes in the “ANY CODES” query (alert message examples 3 and 4).

DE/DEC/DC review is required for all other PC review mailers (alert message examples 5 through 7).

The output alert sheet includes an “automated recommended final action” that reflects the decision the DCDRS decision logic would have made to defer/rediary or refer the case for a CDR. The reason PC Review is required is that the DCDRS decision logic action is made without consideration of what is in the relevant remarks and/or attachments. Review of the attachments or other information may warrant an action other than that suggested by the “automated recommended final action”. For this reason the PC reviewer must always consider the automated recommended final action but never think he or she must follow it.

d. MISCELLANEOUS alerts

The secondary title of MISCELLANEOUS alerts tells the DSE/FLC that the alert/facsimile/profile sheet attachment is sufficient for folderless processing of the case. Corresponding to mailers processed by the WBDOC as nonactionable, the actual mailer is not needed for processing nor does the mailer require subsequent forwarding for retention in the electronic or paper claim folder.

e. Alert messages on MISCELLANEOUS alerts

One of two messages is shown:

  1. DE/DEC/DC REVIEW NEEDED. SIGNIFICANT RESPONSES AND/OR RELEVANT REMARKS/ATTACHMENTS ARE PRESENT. IF THE DE/DEC/DC FINDS THAT THE RESPONSES AND/OR REMARKS/ATTACHMENTS ARE MATERIAL OR THAT FOLDER REVIEW IS REQUIRED, THE DE/DEC/DC SHOULD TAKE APPROPRIATE ACTION. IN DECIDING THAT ACTION, THE DE/DEC/DC SHOULD ALWAYS CONSIDER THE AUTOMATED RECOMMENDED DECISION WHICH IS TO REDIARY THE CASE. IF THE DE/DEC/DC CONCURS WITH THE AUTOMATED RECOMMENDED DECISION, DO NOT REFER THE CASE FOR A CDR.

  2. DE/DEC/DC REVIEW NEEDED. SIGNIFICANT RESPONSES AND/OR RELEVANT REMARKS/ATTACHMENTS ARE PRESENT. IF THE DE/DEC/DC FINDS THAT THE RESPONSES AND/OR REMARKS/ATTACHMENTS ARE MATERIAL OR THAT FOLDER REVIEW IS REQUIRED, THE DE/DEC/DC SHOULD CONSIDER THE AUTOMATED RECOMMENDED DECISION WHICH IS TO REFER THE CASE FOR A MEDICAL CDR. IF THE DE/DEC/DC CONCURS WITH THE RECOMMENDED DECISION, REFER THE CASE TO THE FO USING A SSA-5526-U2-OP2.

G. Procedure for Processing Center (PC) processing of the mailer

1. Folderless processing

The review performed in the PC is almost always a folderless process. The PC considers both the beneficiary's responses on the mailer, any other documents that may have been submitted (e.g., a medical report), the contents of the profile sheet (DI 40502.095, Exhibit 1), and any online information to determine if a CDR is appropriate.

Rarely, it may be necessary to obtain the claim folder. In the early years of the CDR mailer PC review process, it was necessary to provide information to DCDRS when a folder review was done. It is no longer necessary to report to DCDRS when a folder review is done.

2. Sorting actionable mailers

Actionable mailers received from the WBDOC are sorted in anticipation of receipt of the decision logic alert/facsimile/profile sheet output.

3. Receipt of the alert, mailer facsimile, and profile sheet

For each mailer received for PC Review, an alert, a facsimile of the mailer, and a profile sheet are generated (see DI 40502.095, Exhibit 1).

The facsimile of the mailer includes questions and answers and any relevant remarks of less than 30 words or 200 characters. In many cases, you can use this facsimile in place of associating and reviewing the actual mailer. However, a portion of the mailers received at the WBDOC have lengthy relevant remarks, work information, relevant attachments, and/or require translation. They are identified as “actionable” mailers in the WBDOC.

The WBDOC images the actionable mailers without attachments and passes them to the NCC. The NCC downloads the images into each PC’s Paperless Processing Control system; the images appear as “SSA455PFProngfile” on the “Completed” side of the paperless, awaiting association with the electronic data file.

The actionable mailers with attachments are boxed in special boxes and are shipped to the PCs in specially labeled containers. A useful facsimile cannot be generated for these cases. Instead, processing actionable mailers require review of the profile sheet and paper alert before processing.

The profile sheet contains much of the data used by DCDRS to identify and profile the case, including the disabled individual's:

  • name,

  • account number,

  • application date,

  • date of entitlement,

  • date of onset of disability,

  • diagnoses codes,

  • impairment data,

  • medical diary type as calculated by DCDRS (the OD-CALC MDR: field),

  • profile category (Low, Medium or High),

  • recent earnings information, and

  • initial claim and prior CDR data.

Every mailer case is classified as a High, Medium, or Low profile. The word High, Medium, or Low is printed on the profile sheet. An “H”, “M”, or “L” is also provided in the third field of the second scanline on the front of the mailer or the facsimile.

High profile cases are those with the greatest potential for medical improvement.

Low profiles are those with the least potential for medical improvement.

4. Review of the alert

Review the alert to determine the next action.

a. PSC MAILER alerts

For PSC MAILER alerts, one of seven messages is included on the PSC MAILER alert. The seven messages are listed in this section at DI 40502.001F.3.c.

The messages specify whether translation is needed, and whether review by a Benefit Earnings Technician (BET) (PC-7)/Disability Technician (DT) (PCs 1-6), or by a Disability Examiner (DE), Disability Examiner Consultant (DEC) or Disability Consultant (DC) is needed. Each message also includes a recommended final action.

In those PSCs that do not scan actionable mailers into paperless, receipt of a PSC MAILER alert tells the DSE/Folder Location Clerk (FLC) of the need to associate an actionable mailer with the electronically generated output before the next action is done. The documents are put in a holder and referred for review based on the specific alert message.

Work activity is reported - The alert states that BET/DT review is needed if the response to question 1 (work activity) is positive or if a code of “1” (or, in certain cases, “3”) was input in response to the “Remarks” and/or “Attachments” boxes in the “ANY CODES?” query.

Translation is needed - BET/DT review is required when translation is needed. The BET/DT refers the holder or paperless action control record (ACR) to the appropriate translator.

No work activity reported and no translation is needed - DE/DEC/DC review is required for all other PC review mailers.

b. MISCELLANEOUS alerts

For MISCELLANEOUS alerts, only one of two messages is generated. Both state that review by a DE/DEC/DC is needed, but differ as to the recommended action. The two messages are listed in this section at DI 40502.001F.3.e.

c. The automated recommended final action

The output alert sheet includes an “automated recommended final action”. It reflects the action the DCDRS decision logic would have made (to defer and rediary, or refer the case for a CDR) without consideration of relevant remarks on the form or relevant information submitted as attachments to the form.

NOTE: Review of the mailer, remarks on the form, and any attachments, and/or information obtained from other sources (e.g., the DCF) may warrant an action different from the “automated recommended final action”. The recommended automated decision is provided as a guide but is not binding on the PC reviewer.

5. PC review decision making

Following translation, cases with reports of work and earnings are referred to the BET/DT for resolution (see DI 40502.001I.2.c.). Most of these mailers, and all other mailers not requiring BET/DT review, are referred to a DE/DEC/DC, who conducts a review of the responses to the six questions, any remarks, and attachments.

Use the following information to determine whether to refer the case for a full medical CDR:

  • the beneficiary's responses and the documentation that may be submitted with the mailer;

  • online data (e.g., a DCF query response, MBR query response, Supplemental Security Record (SSR) query responses, Summary Earnings Query (SEQY) and Detailed Earnings Query (DEQY) response), and

  • the information contained on the profile sheet.

If you make a DO CDR action, refer the case to the FO to notify the beneficiary and the representative payee, if any, that a CDR is being initiated.

After the review is completed, update the Disability Control File (DCF) to reflect the result of the review.

If a full medical CDR is deferred, input of the deferral action causes an automated notice to be generated and mailed to the beneficiary (or representative payee) and the case is rediaried for later review (see DI 40502.001J.3. in this section).

Use the medical diary reason (MDR/MR) at the time of selection to reset the medical reexamination diary date. The MDR/MR is an alpha for MIE diary types, 3 for MIP diaries, 5 or 7 for MINE diaries. It is usually provided in field 1 of scanline 2 on the front of the mailer or the facsimile, and is also on the profile sheet in the OD-CALC MDR: field.

If no code is provided in the scanline or on the profile sheet, query the DCF and use the MEDICAL RE-EXAM REASON provided on the most current QMID screen.

For Title XVI cases, if no information is posted to the most recent QMID screen, querying the MG segment of the SSR may provide a diary reason. NOTE: If no code is provided anywhere, use the default MDR/MR value of “3”.

a. DO CDR/Full Medical CDR referral action

In Title II cases, if a full medical CDR is needed, update the mailer in DCF to DO CDR and transfer the CDR to the FO. The FO can request the folder if needed.

In Title XVI cases, if a full medical CDR is needed, update the mailer in DCF to DO CDR and transfer the CDR to the FO. The FO can request the folder if needed.

b. FO action upon receipt of the DO CDR referral

Upon receipt of the claims folder, examine the folder to determine if it should be discontinued under the “screen out” criteria provided in DI 13005.020.

If it is not screened out/discontinued, determine if it can be processed under the MINE or MINE-equivalent procedures (see DI 13005.022).

If it can be processed under the MINE or MINE-equivalent procedures, refer it to the servicing DDS for processing under DI 28040.000.

If it cannot be processed under the MINE or MINE-equivalent procedures, notify the beneficiary and representative payee, if any, that a CDR is being initiated and conduct a CDR interview.

6. DCF input for processed mailers

When a mailer is sent, the DCF is annotated with a “001 EVENT”. The QCDR screen of the DCF shows a date followed by “T2 INITIAL MAILER SENT”, “T2/16 INITIAL MAILER SENT”, or “T16 INITIAL MAILER SENT” in the EVENT column.

When the next mailer selection is done (currently, every four months for Title II-only and concurrent Title II/Title XVI cases, and every six months for Title XVI-only cases), any case with “001/T16 INITIAL MAILER SENT” as the most recent event, and that event is more than 90 days old, is selected to receive a second-request mailer. When selected for a second-request mailer, a date and an event of “T2 SECOND MAILER SENT”, “T2/16 SECOND MAILER SENT”, or”T16 SECOND MAILER SENT” is posted to the DCF QCDR screen. At the same selection, cases with the most recent posted event of “SECOND MAILER SENT”, and that event that is more than 150 days old, are alerted as nonresponders and an event code of “T2 NONRESPONDER REVIEW”, “T2/16 NONRESPONDER REVIEW”, or”T16 NONRESPONDER REVIEW” is posted to the DCF QCDR screen.

When a case is pending PC Review, an event of “T2 PC MAILER REVIEW”, or T2/16 PC MAILER REVIEW”, or”T16 PC MAILER REVIEW” is posted to the DCF.

Periodically, if the PC MAILER REVIEW is not cleared, the system generates and posts a “T2 PC MAILER FOLLOW-UP”, or “T2/16 PC MAILER FOLLOW-UP”, or “T16 PC REVIEW FOLLOW-UP” alert event.

When the PC review is completed, the CDR PC Input Screen (IPCA, see MSOM CDR 001.005) in the DCF is selected and one of the following event types is selected:

IPCA SCREEN EVENT TYPE

FULL CDR NEEDED

RESPONSE TO VR INQUIRY?

2 = INITIATE CDR

Yes

No/No Response

3 = INITIATE CDR-VR REQUESTED

Yes

Yes

4 = DEFER CDR

No

No/No Response

5 = DEFER CDR-VR REQUESTED

No

Yes

7. Integrity sampling and “flipped” cases

Each year, a small, but statistically sufficient, random sample of cases that have been reviewed by the PC are selected for integrity sampling. Regardless of the action decided and input by the PC reviewer, the case is referred to the FO for a full medical CDR.

Integrity sampling is controlled on the DCF. It occurs after the PC reviewer makes a deferral or DO CDR input, and, when necessary, inputs a subsequent DO CDR action and alerts the case to the FO for a CDR. As a result, the flip process is essentially invisible to the PC reviewer.

Integrity sampling is done to provide real world outcomes that allow the Agency to monitor the accuracy of the statistical analyses (profiling) that identify which cases are appropriate for CDR mailer processing. The integrity sample is not intended, and is too small, to measure the accuracy of an individual PC reviewer's decision-making.

Because of the small size of the integrity sample, and because integrity sampling is essential to permit accurate auditing of the mailer process, it is critical that no one with access to the DCF take any action to change a “flipped” case back to a deferral.

8. PCACS/SSICCS Input

Update PCACS to show folder movement and clear any mailer action control record for Title II cases. In the unusual Title XVI case in which the claims folder has been obtained, input an NDDSQ SSA-4648 to reflect referral of the claims folder to the field office or storage site.

H. Procedure for PC processing of undeliverable mailers

1. Types of undeliverable mailers - general

As discussed in this section at DI 40502.001E., most undeliverable mailers are processed in WBDOC. However, the PC mailroom may receive undeliverable hard paper SSA-455s from the processes described in DI 40502.001I. and/or DI 40502.001J. in this section. In these cases, the mailroom or DPB remails all undeliverables (see Title II Undeliverable Mail – COA GN 02605.055).

2. Processing undeliverable mailers

Establish a workload control for undeliverable mailers by making an input to the DCF and by selecting EVENT TYPE “UNDELIVERABLE” (currently event type “7”) on the IPCA screen (see MSOM CDR 001.005).

Query the MBR and/or SSR for a current address.

If no new address is available for the mailer, make an input to the DCF by selecting EVENT TYPE “REVIEW NONRESPONDER” (currently event type “6”) on the IPCA screen, and then process as a nonresponder per DI 40502.001I. in this section.

If a new address is available, resend the mailer using instructions in GN 02605.055.

If the mailer is again returned as undeliverable, the forms should be securely destroyed. After 150 days from the send request the “UNDELIVERABLE” mailer will automatically update as “NONRESPONDER” to the DCF.

I. Procedure for PC processing of nonresponders

PC personnel receive systems notification (a nonresponder alert) when the beneficiary fails to respond to the initial and follow-up mailing. Handle these as follows:

  • Attempt direct telephone contact (DIRCON) to complete form SSA-455. Follow the PC DIRCON procedures in GN 01070.305 and GN 01070.315.

  • Make 2 DIRCON attempts; do not count busy signals as attempts. Document the results on form SSA-5002 or other appropriate documentation.

  • If DIRCON is successful, process the mailer to a deferral or DO CDR action per DI 40502.001J.3. (deferral) or DI 40502.001J.4. (DO CDR).

If a folder review was done (e.g., to review work activity information in the folder), and a deferral action follows, return the claim folder(s) to storage with appropriate PCACS/SSICCS input(s).

If DIRCON is unsuccessful because the individual cannot be located or is located but refuses to cooperate, process the case as a “DO CDR” to the servicing field office per DI 40502.001J.4.

Update the DCF by following these steps:

  1. Select the IPCA screen;

  2. Select item #2 “INITIATE CDR”; the IPCB screen appears;

  3. Enter the Detailed Office/Organization Resource System (DOORS) location of the servicing FO in the “TRANSFER CASE OFFICE RESPONSIBLE FOR THE NEXT ACTION” field;

  4. Enter “Y” next to REMARKS; and

  5. Enter a message that the mailer is being sent to the FO.

In addition to the instructions in DI 40502.001J.4., annotate in the special message field on the MBR (CIP M), or the CDR Remarks Input Screen (IRMK) by selecting “Y” in the Remarks section of the CDR PC Input Screen B (IPCB, see MSOM CDR 001.006) of the DCF, that the beneficiary was a non-responder and the case is being referred to the FO to initiate a full CDR per DI 13005.000. Avoid using the DCF codes that indicate a whereabouts unknown or failure to cooperate suspension/cessation action has been taken.

REMEMBER: The mailer is not a CDR. Consequently, an inability to locate an individual to complete a mailer, or an individual's refusal to provide responses to questions on the mailer is not a basis for a cessation or suspension action under the whereabouts unknown or failure to cooperate provisions of the CDR process (DI 40525.001). It is, however, a basis to refer the case to a FO to initiate a CDR.

J. Procedure for mailer decision-making and post-decision-making actions by Disability Technician (DT)/Benefit Earnings Technician (BET), and Disability Examiner (DE)/Disability Examiner Consultant (DEC)/Disability Consultant (DC) review instructions

1. Unanswered questions/unresolved issues

Follow the entire process explained herein.

If a full medical CDR is not indicated based on the responses supplied by the beneficiary, make direct telephone contact (DIRCON) to complete unanswered questions or to clarify unresolved issues.

Do not use DIRCON if the responses or other information provided indicate that a full CDR is needed.

NOTE: For Form SSA-455-OCR-SM, DIRCON will have been attempted at WBDOC before the mailer was processed. For these mailers, a question(s) that remains unanswered at the time of PC review reflects a previous unsuccessful DIRCON attempt in WBDOC.

When DIRCON is required, follow the DIRCON procedures in GN 01070.305 and GN 01070.315. Make two DIRCON attempts; do not count busy signals as attempts. Document the results on Form SSA-5002.

Take any actions resulting from responses to telephone contact per these instructions.

2. Folderless review of responses

a. Sequence of questions

The following instructions are designed for the sequence of the questions as they appear on the SSA-455-OCR-SM. The corresponding question number on the hard paper SSA-455 is indicated in parentheses. This is because it is expected that most mailers requiring PC Review will be the scannable mailer, Form SSA-455-OCR-SM.

b. DSE/FLC and BET/DT alert review for necessary mailer association and screening for translations

In those PSCs that do not scan the 455s into paperless, the DSE/FLC reviews the alert/facsimile/profile sheet packages and identifies PSC MAILER alert packages. The actual mailer and any attachments are associated with PSC MAILER alert packages. Each mailer package is placed in a holder.

The BET/DT screens for alerts with messages indicating that translation is needed, and refers the assembled holder or paperless ACR for translation.

c. BET/DT review of Question 1

The BET/DT develops the work on mailer alerts with a BET/DT remark/message, and the DE/DEC/DC develops the work on any alerts with a DE/DEC/DC remark/message.

DCDRS decision logic uses the same criteria used by the WBDOC to determine if the response(s) to question 1 are actionable (DI 40502.001E.4.b.). DCDRS alerts the following cases for BET/DT review:

  • all mailers with a “YES” response to question 1.a. (Have you worked?) AND/OR

  • in response to question 1.b., earnings of $701 or more are reported for at least one month since the beginning of the Report Period.

If question 1.a. is answered “Yes” (or is not answered or is answered BOTH Yes and NO, and DIRCON does not resolve these situations), but question 1.b. is blank/no earnings are reported, the mailer is actionable.

If there is insufficient WORK BEGAN and/or WORK ENDED information in question 1.b. to determine when the earnings occurred, but the reported MONTHLY EARNINGS in 1.b. are $701 or more in any of the three entries, the mailer is actionable.

NOTE: If only work and earnings prior to the report period are described, the mailer is not considered an actionable mailer.

DCDRS decision logic also alerts “nonactionable” mailers for PC review when it detects a code of “1” in position 1 or 2 of the ANY CODES? codes. These cases can be worked from the facsimile.

Local procedures may have the DE/DEC/DC refer cases involving work and earnings for BET/DT review.

The BET/DT procedures, as described herein, are generalized and may not precisely describe the local process.

NOTE: Under no circumstances should the BET/DT “NAN” the mailer after review of question 1. Either an earnings investigation or referral to a DE/DEC/DC is required.

Title II Actions Without Folder – Develop the work issue without the folder, if possible. Take the following actions based on receipt of a BET/DT REVIEW alert:

  • Folderless Actions – Check the T2 WORK and EARNINGS Segments of the DCF. If alleged work falls within the dates of the work information posted to the T2 WORK and/or EARNINGS segments of the DCF annotate the mailer with “WORK ON THE DCF”

  • Prepare an SSA-559 routing the holder/paperless ACR to the DE/DEC/DC for completion of the PC review.

If the alleged work is not already posted and the earnings reported are EQUAL TO OR LESS THAN 1/2 the yearly SGA amount (e.g., for 2008, equal to or less than $217 weekly, or $940 monthly, or $11,280 annually), do not develop the work issues at this time. Instead, prepare an SSA-559 to refer the case to the DE/DEC/DC to process the mailer.

Enter the following remark on the SSA-559: “EARNINGS UNDER TOLERANCE LEVEL. RETURN TO BET/DT AFTER DE/DEC/DC REVIEW.”

When the mailer processing is completed, return those cases not referred by the DE/DEC/DC to the FO for a CDR, and not selected for a CDR as integrity sample cases, to the BET/DT to complete the development of the unposted earnings in accordance with DI 40510.000.

If the alleged work is not already posted and the earnings reported EXCEED 1/2 the yearly SGA amount (e.g., for 2008, more than $217 weekly, or $940 monthly, or $11,280 annually), develop the work issues per DI 40510.000, update the DCF to show an earnings investigation is being initiated, and enter a Special Message on the IRMK screen of the DCF that states:

“WHEN WORK DEVELOPMENT IS COMPLETE, REVIEW MAILER TO DETERMINE IF FULL MEDICAL CDR IS NECESSARY, AND REPLACE WORK AND EARNINGS INVESTIGATION WITH APPROPRIATE IPCA EVENT CODE”.

Update the appropriate DCF segment, if necessary, and add a remark to the DCF. After the work issue is resolved, refer to the DE/DEC/DC for completion of the PC mailer review.

Title II Actions with Folder – Determine whether the alleged work and earnings have already been resolved. If resolved, annotate the mailer holder/paperless ARC with, “WORK RESOLVED”, and prepare an SSA-559 referring the case to the DE/DEC/DC to complete the PC mailer review.

If the alleged work is not already posted and the earnings reported are EQUAL TO OR LESS THAN 1/2 the yearly SGA, do not develop the work issues at this time. Instead, prepare an SSA-559 to refer the case to the DE/DEC/DC for processing of the mailer. Enter the following remark on the SSA-559:

“EARNINGS UNDER TOLERANCE LEVEL. RETURN TO BET/DT AFTER DE/DEC/DC REVIEW.”

When the mailer processing is completed, return those cases not referred by the DE/DEC/DC to the FO for a CDR, and not selected for a CDR as integrity sample cases, to the BET/DT to complete the development of the unposted earnings in accordance with DI 40510.000.

If the alleged work is not already posted and the earnings reported EXCEED 1/2 the yearly SGA amount, develop the work issues per DI 40510.000, update the DCF to show that an earnings investigation is being initiated, and enter a Special Message on the DCF's IRMK screen that states:

“WHEN WORK DEVELOPMENT IS COMPLETE, REVIEW MAILER TO DETERMINE IF FULL MEDICAL CDR IS NECESSARY, AND REPLACE WORK AND EARNINGS INVESTIGATION WITH APPROPRIATE IPCA EVENTCODE”.

Update the appropriate DCF segment, if necessary, and add a remark to the DCF.

After the work issue is resolved, refer to the DE/DEC/DC for completion of the PC mailer review.

Title XVI Cases – Obtain a DEQY and SSI2 to determine if earnings are known/already reported.

If earnings are known, annotate the mailer with, “EARNINGS KNOWN”, and prepare an SSA-559 referring the holder/paperless ACR to a DE/DEC/DC for completion of the PC mailer review.

If earnings are not known/previously reported, do not apply the Title II earnings tolerance. Make a photocopy of the mailer/facsimile and any relevant attachment (e.g., pay stubs, copies of W-2's), and refer to the servicing FO to develop/adjust for the work and earnings.

Annotate the mailer, the photocopy, and the DCF's IRMK remarks screen with, “UNKNOWN EARNINGS REFERRED TO FO”.

Complete the clerical and DE/DEC/DC review. On the copy of the mailer referred to the FO, advise the FO that no referral to PC-7 is necessary.

d. DE/DEC/DC review and decision-making

The DE/DEC/DC reviews all responses and any remarks or attachments, and weighs the significance of missing responses to determine if a deferral or a full CDR is appropriate.

Following are some guidelines for decision making when reviewing questions 1 through 6.

It is also important to consider the profile. Check field 3 of scanline 2 of the mailer or facsimile for an H (High), M (Medium), or L (Low), or check the profile sheet for the word High, Medium, or Low.

When there is conflict between the codes, give the highest priority to the code on the mailer or facsimile.

If the case is being worked from a hard paper SSA-455, or for some other reason a profile code is not provided, query the DCF for the profile code.

The profile ranking should be factored into the DE/DEC/DC decision, as should the automated recommended decision on the alert. The DE/DEC/DC is not required to follow the suggested outcome; however, profiling has been shown to be accurate in assessing the likelihood of medical improvement. This means that for Low cases, there must be compelling information to refer a case for a CDR, while for Medium and High profile cases, there must be compelling information to warrant a deferral action.

Consider the following instructions when reviewing the mailer responses:

  • SSA-455-OCR-SM, Question 1 (SSA-455, Question 1)--Have you worked for someone or been self-employed?

If the answer to question 1 (1) is:

Your action is:

YES

All Profiles (High, Medium, or Low)–If the BET/DT reports WORK ON THE MBR or WORK RESOLVED or EARNINGS UNDER TOLERANCE (Title II), or EARNINGS KNOWN or UNKNOWN EARNINGS REFERRED TO FO (Title XVI), go to question 2, but consider the automated recommended decision, and whether work activity suggests possible medical improvement.

NO

All Profiles (High, Medium, or Low)-Go to question 2

NO RESPONSE

All Profiles-Go to question 2

SSA-455-OCR-SM, Question 2 (SSA-455, Question 4)--Have you attended any school or work training program(s)?

If the answer to question 2(4) is:

Your action is:

YES

High or Medium-DO CDR unless the response to question 5 or 6 (7 or 6 on SSA-455) is “YES”, or the reviewer has other information indicating medical improvement is very unlikely.

If the response to 5 or 6 is “YES”, weigh all information, especially responses to questions 1, 3, and 4.

Low-Go to question 3

NO

All Profiles-Go to question 3

NO RESPONSE

All Profiles-Go to question 3

SSA-455-OCR-SM, Question 3 (SSA-455, Question 3)--Have you discussed work with your doctor…?

If the answer to question 3 (3) is:

Your action is

HAVE NOT DISCUSSED

All Profiles-Go to question 4

CANNOT WORK

All Profiles-Go to question 4

CAN WORK

High or Medium-DO CDR unless theDE/DEC/DC review raises doubt about the response (consider DIRCON to resolve).

Low-Go to question 4

NO RESPONSE

All Profiles – Go to question 4

SSA-455-OCR-SM, Question 4 (SSA-455, Question 2)--Describe your health now as compared to…?

If the answer to question 4 (2) is:

Your action is:

BETTER

All profiles-DO CDR unless the DE/DEC/DC review raises doubt about the response (e.g., is “better”, but information shows a severe mental impairment continues, or that inpatient care or residency in an institution continues, or is “worse” but reports recent work activity after bypass grafting).

Consider DIRCON to resolve.

SAME

High or Medium-DO CDR unless the review raises the same types of doubts about medical improvement as discussed for a response of “better”.

Low-Go to questions 5 and 6.

WORSE

All Profiles-Go to questions 5 and 6.

NO RESPONSE

All Profiles-Go to questions 5 and 6

The following chart lists instructions for responses to questions 5 and 6 of the SSA-455-OCR-SM (questions 7 and 6 on the SSA-455). These questions both inquire as to different types of recent medical treatment. The DE/DEC/DC may find it efficient to consider the responses together.

SSA-455-OCR-SM, Question 5 (SSA-455, Question 7)--Have you gone to a doctor or clinic...?

If the answer to 5 is:

Your action on all profiles is:

YES

Check the profile sheet for information about the prior decision. Knowledge can be gained from the following:

  • Date of birth

  • Date of onset

  • Date of initial decision

  • Date of latest decision

  • Reg basis code

  • Vocational rule met

  • Diaries set

  • Blindness

Assess the importance of ongoing medical treatment, or its absence, to the status of the condition. Read carefully the “how often” and “reason for visit” narratives and draw any conclusions.

Consider any remarks or attachments that might address whether medical improvement is or is not indicated.

Consider whether a telephone call to the beneficiary or representative payee will provide further details.

For LOWS, recommend a DO CDR only if the narrative/telephone call response(s) indicates there is possible medical improvement.

For HIGHS/MEDIUMS, take a DO CDR action unless the narrative/telephone call response(s) indicates no likelihood of medical improvement.

NO

All Profiles-If not explained on the form, obtain by DIRCON to the beneficiary or representative payee the reason(s) for the lack of ongoing treatment, especially if impairment codes are:

  • 4140 (angina)

  • 4430(arterial)

  • 5710 (liver)

  • 5840 (renal)

  • 2500 (diabetes)

These impairments usually require continuous medical intervention.

Recommend a full medical CDR only if the DIRCON response indicates there is possible medical improvement.

NO RESPONSE

All Profiles-Go to question 6.

SSA-455-OCR-SM, Question 6 (SSA-455, Question 6)--Have you been hospitalized or had any surgery...?

If the answer to 6 is:

Your action for all profiles is:

YES

All Profiles-Review dates and the narrative. Check the profile sheet to determine the impairment(s) involved.

Assess the effects of hospitalization/surgery on the impairments.

Release for DO CDR only if the narrative indicates there is possible medical improvement. Otherwise, DEFER.

NO

All Profiles-DEFER if response to question 5 was “Yes” and there is no indication of possible medical improvement.

NO RESPONSE

All Profiles-DO CDR if question 5 is also answered “No” or there is no response to question 5, and nothing in remarks or on an attachment indicates there has been recent treatment or provides a credible reason for an absence of treatment.

NOTE: Regarding versions of the SSA-455-OCR-SM with question 7 (SSA-455, Question 5), or a VR? inquiry below the signature line -- Do not consider this response.

3. Processing deferrals and resetting diaries in deferral actions

a. Deferring mailers

Call up the IPCA screen on the DCF and select event 4 “DEFER CDR”.

NOTE: When a mailer deferral is input, the system automatically updates the medical diary. The new diary is calculated based on the old medical data in the DCF. If the medical data in the DCF (on the left-hand side of the QMID) is blank or zeros, the system has nothing with which to calculate the new diary. The medical data cannot be manually updated via 15=MODIFY MEDICAL DATA because the systems requirements were written to prevent user input in these situations.

Enter the pertinent medical information in the REMARK screen. Do not open a new CDR path (using the DRES) and then close it in order to enter the medical data because this creates a new history screen indicating a full medical review was processed (which it wasn’t) and results in inaccurate management information (MI).

NOTE: In those Title II or concurrent Title II-XVI cases in which unresolved earnings equal to or less than 1/2 of the yearly SGA amount were reported (EARNINGS UNDER TOLERANCE LEVEL), the DE/DEC/DC refers the case to the BET/DT for investigation of earnings per DI 40502.001J.2.c.

b. Diary types and dates

The profile sheet, the MEDICAL RE-EXAM REASON section on the Query Medical Information Data (QMID) screen on the DCF, the MR entry on the SSR, and the first field in the second scanline on the scannable form SSA-455-OCR-SM contain this information. There may be multiple QMID screens; typically, the most recent iteration is used.

In the event the diary types do not agree, use the diary type on the profile sheet in the OD-CALC MDR: field. The diary type on the profile sheet reflects the most accurate on-line information regarding the diary type that was set at the CPD.

The DCF QMID, SSR MR, and scanline information may be less accurate as a result of missing or intervening systems entries, but should be used if no value is provided on the profile sheet or the mailer.

In the event that no MDR/MR is provided on any database, use the default MDR/MR of “3”.

The following diary types and corresponding duration apply:

  • MIE = reset for 18 months;

  • MIP = reset for 3 years;

  • MINE = reset for 7 years.

Some MINE cases have 5-year diaries. Reset these MINE diaries for 5 years.

Do not reset or attempt to substantively change the diary type using current instructions in DI 26525.000.

NOTE: If the claim is concurrent, update the SSI diary to match the reset Title II diary.

c. The CDR mailers deferral notice

Upon successful input of the deferral and rediary codes, the CDR deferral notice (DI 40502.095, Exhibit 2) is generated by the system. Note that mailer deferral notices returned by the USPS as undeliverable do not require further delivery attempts. Instead, they are securely destroyed.

d. Disposing of mailers, facsimiles, attachments, alerts, and profile sheets

All facsimiles of mailer, alerts, and profile sheets are securely destroyed.

Refer original mailers and attachments that describe work activity and/or earnings, or are considered medical evidence (e.g., copies of hospital records, a note from a doctor, a mailer signed by an official of a treatment facility) to the claims folder location. If the folder is paper (e.g., Megasite, Caves, WBFSO, DDS, FO, ODAR), fax the material into NDRed and send the paper for drop-filing. If eView exists for the record, fax the material into DMA and destroy the paper documentation.

Special situations (e.g., one of the attachments is a request for class action membership, the remarks on the mailer describe misuse of funds by a representative payee, an SS-5 and supporting documentation for a name change were included in the attachments, or documentation affecting felony payment suspension) may dictate that the original mailer and/or attachment(s) should be referred to another component for additional post-entitlement action or for drop-filing.

All other original mailers and attachments (e.g., those forwarded to the PC from the WBDOC because translation was necessary) are securely destroyed.

4. Full medical “DO CDR” CDR actions

a. Referring a Title II-only or the Title II portion of a concurrent case for a full medical CDR

  1. Select the IPCA screen to update the DCF .

  2. Select item #2 “INITIATE CDR”; the IPCB screen appears.

  3. Enter the Detailed Office/Organization Resource System (DOORS) location of the servicing FO in the “TRANSFER CASE OFFICE RESPONSIBLE FOR THE NEXT ACTION” field.

  4. Enter “Y” next to REMARKS and enter a message that the mailer is being sent to the FO.

  5. Provide any other pertinent instructions or remarks in the special message field on the MBR (CIP M) or in the DCF Remarks or notepad. When appropriate, identify the need to investigate earnings if the BET/DT did not resolve unknown earnings because the reported earnings did not exceed 1/2 of the yearly SGA.

  6. Fax the documentation in NDRed or eView.

b. Referring a Title XVI-only case for a full medical CDR

Do not request the claim folder. The FO will obtain it.

  1. Update the DCF by first selecting the IPCA screen.

  2. Select item #2 “INITIATE CDR”; the IPCB screen appears.

  3. Enter the Detailed Office/Organization Resource System (DOORS) location of the servicing FO in the “TRANSFER CASE OFFICE RESPONSIBLE FOR THE NEXT ACTION” field.

  4. Enter “Y” next to REMARKS and enter a message that the mailer is being sent to the FO by mail. Include any other pertinent instructions or remarks, including reference to any unresolved work and earnings (see DI 40502.001J.2.c.).

  5. Annotate the CDR mailer with the CDR Mailer Decision Code, the DT or DS' name and Title, and the current date.

  6. Fax the documentation into NDRed or eView.

NOTE: In the unusual situation where the Title XVI claims folder has been obtained, file the mailer (the actual form or the facsimile, if it was used to process the case), the profile sheet, and any attachments in the right side of the claims folder.

c. CDT coding on the SSA-5526-U2-OP2

The PC's supply of the SSA-5526-U2-OP2 may not have pre-printed Continuing Disability Review Type (CDT) codes for mailer cases that were initiated after fiscal year (FY) 1999. For DO CDR actions involving mailers initiated FY 2000 or later, print the appropriate CDT code in the CDT section of the SSA-5526-U2-OP2, if necessary.

The possible CDT codes are:

  • 40 – CDR mailer released in FY 2000

  • 41 – CDR mailer released in FY 2001

  • 42 – CDR mailer released in FY 2002

  • 43 – CDR mailer released in FY 2003

  • 44 – CDR mailer released in FY 2004 or later

A complete list of CDT codes is in SM 06001.120B.11.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0440502001
DI 40502.001 - Processing Center Instructions for the Continuing Disability Review Mailer Forms SSA-455 and SSA-455-OCR-SM - 09/22/2016
Batch run: 09/22/2016
Rev:09/22/2016