DI 42010.020 Effectuating Favorable ALJ Decisions - Onset in Period Covered by Current Application
Cross refer to DI 42010.230.
A. General instructions
Favorable decisions received from an ALJ will be effectuated and certified at once. If an error in the decision is discovered which prevents effectuation, follow the instructions in DI 42010.070 and DI 42010.060 for referring the matter to OHO's attention. If the decision contains a typographical or clerical error, follow the instructions in DI 42010.075.
Complete the determination Form SSA-831-U5 as shown below:
Do not complete items 1, 2, 8, 10, 13, 14, 19, 21, 22, 23, 30 through 33, and 35.
(Filing Date), enter the date established by the ALJ decision.
NOTE: See DI 42010.025 for the filing date to be used and action to be taken when the ALJ reopens or does not reopen a prior determination. Where an earlier protective filing date is reflected by the file, and it is material, the award will be processed using the more advantageous protective filing date.
(SSN), enter the NH's Social Security number.
(Name and Address of Claimant), enter the name and address as shown on the hearing decision.
(NH's Name), complete for CDB and DWB claims involving a DIB NH.
(Type Claim), extract from the prior SSA-831-U5.
(Date of Birth), extract from the file.
(Remarks), in concurrent cases, enter “Concurrent Title II/Title XVI.”
(District-Branch Office Address), enter the information from the prior SSA-831-U5 if the claimant's address has not changed. If the address has changed, show the city, State, zip code and DO-BO code of the new DO/BO (obtained from the Service Area Directory of District Offices).
(Disability Began), enter the exact date of onset as specified by the ALJ (if no date of onset was specified by the ALJ, refer the case to OHO under the instructions in DI 42010.070). When a closed period of disability is established, check Item 15B and enter the date (month/day/year) the disability ceased. When a closed and open period of disability are involved in a single application, prepare two SSA-831-U5's, one for each period of disability.
Items 16A and 16B (Primary and Secondary Diagnosis)
In item 16A enter the primary diagnosis on all determinations (allowances and denials) using DI 27015.000 as a guide. In the first space, following, enter the applicable body system code number from the following list, and in the second space the “International Classification of Diseases 9th Revision Clinical Modification” Code Number (ICD-9-CM). Follow the instructions in the “ICD-9-CM Coding Handbook for the Social Security Disability Program User's Manual” to locate the most appropriate code.
A list of the body systems follows:
|02||Special Senses and Speech|
|10||Congenital Disorders That Affect Multiple Body Systems|
|14||Immune System Disorders|
| ||In Item 16B, for both allowances and denials, determine and enter the secondary diagnosis (i.e., the most significant diagnosis following in severity the primary diagnosis). In the space provided, enter the ICD-9-CM code number applicable to the secondary diagnosis. Entry of a secondary diagnosis is required in all cases where one exists. Thus, if there is no secondary diagnosis, write “None” in the space provided for that diagnosis.|
|Item 17||(Diary), complete per instructions in DI 26510.020. Follow instructions in DI 26525.000 for determining when a medical improvement expected (MIE) diary is needed.|
|Item 18||(Case of Blindness as Defined in Section 1614(a)(2)(216(i)), check block “A” or “B” as appropriate (DI 24000.000 and DI 26000.000.)|
|Item 20||(Vocational Background), complete this item in DIB, freeze, and CDB cases. This block should reflect vocational background data regarding the beneficiary/recipient's customary occupation or, if not determined, the longest full-time occupation in the 15-year period prior to current adjudication. Show both the individual's occupation and the industry. Enter the 2 digit occupation code from DI 40105.005C., Exhibit 3, most closely approximating the determined occupation. Follow this code with a dash and then enter the appropriate 2 digit industry code from DI 40105.005C., Exhibit 4, most closely approximating the determined industry. If a CDB has never had an occupation enter “None.” If there is no vocational information in the file, and it is not needed, enter “unknown.”|
|Item 24||(MOB Code), secure from the prior SSA-831-U5.|
|Item 25||(Revised Det.), place a check in the block.|
|Item 25A||(Adjudicative Level), check appropriate block|
|Item 26||(List No), The revised SSA-831-U5 provides spaces for up to six listing numbers in item 26, thus eliminating use of item 34 for entry of other listing codes. Complete per instructions in DI 26510.070.|
|Item 27||(Rationale), enter the following statement only: “Decision of Administrative Law Judge (Name of ALJ) on (Date of Decision).”|
| ||A box has been added to item 27 to indicate whether an Appendix 2 Vocational Rule has been met. In the space following, cite the rule, e.g., “202.03.” (See DI 25020.000 for processing instructions.)|
|Item 28||(Period of Disability/Etc.), complete this item in a DIB “open period” or “closed period” allowance.|
| ||1. Since insured status and an effective application are requirements for a period of disability, check blocks “A” and “C”, then enter in “C” the date on which all requirements for entitlement are first met.|
| ||2. If the earnings requirement is met after the onset date established by the ALJ decision, complete Block “C” showing the first day of the quarter in which insured status is met. Show an asterisk *after Block “C” and in item 34 enter the following explanatory remark, “*, date insured status is first met.” Prepare an SSA-567 referring the file after payment to a reconsideration examiner for preparation of a memorandum to OHO requesting the ALJ to amend his/her decision based on the date insured status is first met.|
| ||3. If disability is found to be continuing, check Block “D.”|
| ||4. If disability is found to have ceased, check Block “E” and enter the year with the last day of the second month following the cessation date in item 15B.|
| ||5. If a second period of disability is being established, the first period of disability (and benefit entitlement) will continue through the last day of the second month following cessation of disability; a second period can begin no earlier than the first day thereafter. If the established onset date shown in item 15 falls within this 2-month period, Block “C” should be completed with the first day of the month after the prior period of disability.|
| ||A disability ceases June 15, 1978, and the corresponding period of disability ends August 31, 1978. It is determined that the claimant is entitled to a second period of disability based on an onset of August 8, 1978. In this situation, Block C should show the second period of disability as beginning on September 1, 1978. Also, include this remark in item 34, “Dates in items 15 and 28 differ—new period of disability established after cessation.”|
|Item 29||(Ltr. Para. No), enter “C13” for ALJ and AC decisions and any other appropriate paragraphs. (See NL 00601.010 for award notices and NL 00705.030 and NL 00708.100 for closed period of disability awards.)|
| ||1. Enter “This revises the determination of (date of reconsideration SSA-831-U5).” Cross refer the reconsideration determination by entering a remark on that SSA-831-U5, “See revised determination of (date of current SSA-831-U5).”|
| ||3. Enter any other applicable remarks regarding capability, earnings discrepancies, WC, no waiting period, multiple SSN's etc.|
|Items 34A and 34B||(Multiple Impairments Considered) Check block A in item 34 in all cases where multiple impairments were considered in the determination, and the combination of nonsevere impairments results in a determination of a severe impairment. Check block B if the combination of nonsevere impairments results in a determination of a nonsevere impairment. (See DI 24505.005).|
NOTE: Those DDS in States currently affected by court decisions prohibiting the use of the nonsevere concept; e.g., Illinois (Johnson case), New York (Dixon case), Alaska, American Samoa, Arizona, California, Guam, Hawaii, Idaho, Montana, Nevada, Northern Marianas, Oregon, and Washington (Smith case), should follow existing instructions with respect to the nonsevere concept, and they SHOULD NOT complete either block 34A or B.
|Item 36||(Revised Det. Codes)|
| ||If the prior decision was a denial, enter “D.” If the prior decision was an allowance enter “A.” Following this: If a prior application is reopened enter “9.” If a prior application is not reopened enter “5.”|
|Item 37||(SSA Representative) (Section) will show the signature and modular processing branch of the individual preparing the form.|
| ||The SSA adjudicator or reviewer should sign in item 37 and in the “SSA CODE” block, identify his/her component by entering the appropriate code from the following list:|
|7||ODO (other than DAP)||18||DQB-Denver|
|9||ODO-DAP||20||Administrative Law Judge|
|Item 38||(Date), enter date form is prepared. If the file includes an authorization to secure award or an authorization to release notice of determination to United Mine Workers Fund, place the authorization on top of all the material inside the folder on the right and enter appropriate remarks on the determination.|
NOTE: It is important that a claimant's representative (attorney or other designated party) receive a copy of the award notice. Where an attorney is involved, follow procedures in GN 03940 000.
| ||File the ALJ decision on the left side of the folder below any control card. Assemble the determination in accordance with current instructions and process the file as necessary. Notify the DDS of favorable ALJ decisions.|
B. Future month of entitlement cases
If a decision is received in which the ALJ has established an onset which will result in a future month of entitlement, prepare the SSA-831-U5 and enter “S” in Item 29. Instruct the typist to use Form SSA-L30-C1 and enter “C13” for ALJ and AC cases when typing the award. A conditional award will be prepared to effectuate the decision.
C. DIB-DWB or DIB-CDB (RSI N/H) cases
Items 1., 2., and 3. below pertain to DIB cases within ODO's jurisdiction. If ODO should receive a DIB file which is the PSC's jurisdiction both the DIB-DWB or DIB-CDB (RSI NH) files should be forwarded to the PSC/DRS for effectuation.
1. DIB allowed—DWB or CDB (RSI NH) denied
Effectuate the DIB as indicated in “A” or “B” above. Since unfavorable ALJ decisions are sent to OHO pending expiration of the appeal period, the DWB or CDB file should not be with the DIB file. After determining the exact location of the DWB or CDB file, send a photocopy of the DIB SSA-831-U5 and the DIB award determination for association with the DWB or CDB file. If the DWB or CDB file is in OHO's Central Office, send the photocopies to: OHO, Arlington, VA., Attn: Docket and Files. When forwarding the photocopies, show the name and Social Security number of the NH on whose record the DWB or CDB claim was filed.
2. Both DIB and DWB allowed
Prepare an SSA-831-U5 for both the DIB and DWB and cross-refer by use of photocopies. Effectuate payment of the DIB award and place a photocopy of the DIB SSA-101-U3 in the DWB folder. Forward the DWB folder (and the survivor's folder if attached) to the PSC for effectuation of the DWB award.
3. Both DIB and CDB (RSI N/H) allowed
Prepare an SSA-831-U5 for both the DIB and CDB and cross-refer by use of photocopies. Effectuate payment of both awards.
D. CDB cases on another SSN
In cases where an ALJ has issued a favorable decision on a CDB claim and the claimant may be entitled as a CDB on another SSN, follow the instructions below for adoption of the determination on the second claim.
1. Both claims are Title II CDB claims
A favorable ALJ decision on one title II CDB claim may be adopted on another CDB claim on a different SSN. Prepare the SSA-831-U5 on the second claim, and enter in item 34 (Remarks) of each SSA-831-U5: “See SSA-831-U5 dated , SSN .” Prepare a photocopy of each SSA-831-U5 and place it in the other folder. Also modify paragraph C13 as follows: “this supersedes our previous determination on SSN , and is in accordance with the decision of the administrative law judge and AC.”
2. Title II CDB and Title XVI child claims
If an ALJ has made a favorable decision on either a title II or title XVI claim, adoption of the decision on the claim under the other title will depend on the status of that claim. (See DI 27515.000.) An SSA-831-U5 is necessary for each claim if the determination is adopted.
E. Effectuation of favorable ALJ decisions—Title II—Title XVI claims involving drug addiction or alcoholism (DA/A)
Title XVI payments must be paid through a representative payee in those cases where a disabled individual is medically determined to be a drug addict or an alcoholic. The requirement that a representative payee be appointed applies only to title XVI allowances. Therefore, disregard any statements contained in an ALJ decision, imposing restriction of payments on title II claims in concurrent title II/title XVI entitlement cases. A 1-year mandatory medical reexamination diary must be established on all DA/A cases.
F. SSI folders/SSI material that ODO receives in error after favorable ALJ decisions
Although SSI only cases or the SSI portion of concurrent cases are not under the jurisdiction of ODO, hearing offices sometimes route the SSI folder or SSI material to ODO in error. ODO should immediately send the SSI folder or SSI material to the proper DRS. The SSI folder or material should be specially flagged as relating to a favorable ALJ decision in need of effectuation. A copy of the ALJ decision should be included with the forwarded material. The addresses of the SSI effectuating components can be obtained from internal operating instructions.
G. Effectuating reversals of cessations
Complete only the blocks of an SSA-833-U5 as shown below and route the case for reinstatement of benefits under cover of an SSA-559
Where the instructions require the checking of certain blocks on the forms, comply with these requests by entering an “X” in each designated block.
1. Item 1A - Social Security number
Enter the social security number (SSN) of the primary beneficiary/recipient. In CDB or DWB cases, show wage earner's SSN. To the right of the SSN in title II claims, enter the beneficiary identification code (BIC) shown under the BIC caption on the latest award document in the claims folder for the disabled beneficiary; e.g., “A” for disabled title II wage earner.
NOTE: If disabled wage earner's BIC is shown as “HA”, enter only “A” on the SSA-833-U5. Also, enter any numerical suffix following a designated BIC; e.g., C1 (CDB), enter both “C” and “1”.
2. Item 1B - Type of claim/case
Title II categories:
DIB - disabled beneficiary (wage earner)
FZ - disability freeze (wage earner)
DWB - disabled widow/widower beneficiary
CDB - childhood disability beneficiary
ESRD - end-stage renal disease
3. Item 1C - Other entitlement
Check as appropriate. In concurrent cases, the title II determination will have the entry “title XVI” checked. On title II claims, check the title II block if there is other title II involvement (e.g., HA-CDB, HA-DWB, etc.) and enter the SSN, upon which other entitlement is based in item 24 “Remarks”, e.g., DWB SSN 123-00-6789.
4. Items 2 and 3 - Name of payee or disabled or blind individual and address
The following information should be taken from the latest determination in file (right or left side), unless more recent information is known.
Block A - enter representative payee's name, if any, including the term “for,” “on behalf of,” or “guardian of.”
NOTE: If there is a representative payee, see instructions for completion of item 29 of these instructions.
Block B - enter the name of the disabled or blind individual. Print the first three letters of the surname in capital letters in the block (e.g., JOHnson). On title II cases, if the individual named is a CDB or DWB, enter the wage earner's name in item 3 of the SSA-833-U5.
Block C (SSA-833-U5) - enter the latest mailing address for the recipient or the disabled/blind individual, or, if applicable, the representative payee. The address should always include the zip code. Do not show the bank address if direct deposit is involved. In any case where the beneficiary/recipient filed on his or her own behalf and is deceased, line out the address entry and enter “beneficiary/recipient deceased.”
NOTE: If the most current address is different from the one shown in the folder, promptly request an address change.
5. Item 4 - Date of birth
Show a 6-digit figure (e.g, 01/03/59).
6. Item 5 - Date disability began
Date shown on prior SSA'833-U5 or original SSA-831-U5.
7. Item 6 - DO/BO address
Enter a complete DO/BO address and zip code.
8. Item 7 - DO/BO and DDS code
Show DO/BO code only. (The DDS code applies only to DDS jurisdiction cases.)
9. Item 8 - Adjudicative level
Check the appropriate block.
10. Item 9 - Determination findings — Title II SSA-833-U5—Blocks 9A-9J
Always check the disability block.
Block A - Check if appropriate.
Block B - If the decision revises a cessation date previously established, check block “B” and enter the new cessation date established by the ALJ.
Block C - Check this block to indicate termination of disability. The month of termination is the second month after the month in which cessation occurs, e.g., ceased in 12/77, terminated 02/78. Use a 4-digit figure to show both the cessation and termination dates (MM/YY).
Blocks D, E, F, G and H must be completed to reflect EPE based on the cessation date established by the ALJ.
11. Item 11 - Reason for cessation
Enter the appropriate code from the list in DI 13095.105. Codes from these lists also apply to EPE cases where benefits are stopped (suspended) during an EPE.
12. Item 12 - Reason for continuance
Enter appropriate code from the lists in DI 13095.115. The medical listing number is completed only in medical determinations. Codes from these lists also apply to EPE cases where benefits are reinstated during an EPE.
13. Item 20 - Why review was made (WRM)
Enter the appropriate code from DI 13095.135.
14. Items 21 And 22 - Primary and secondary diagnosis
Extract the information (including both secondary and primary diagnoses as well as body system and ICD codes) from the most recent SSA-831-U5, SSA-832-U5, or SSA-833-U5 in the file. It may be necessary to leave this item blank in a title XVI conversion case. Similarly leave only those items blank for which corresponding data are not included on previous determinations.
15. Item 23 - Diary
The DO/BO will not complete this item (ODO/PSC-DRS and INTPSC).
16. Item 24 - Remarks
Enter any of the following remarks, if applicable. More than one remark may be entered. (The following list is not all inclusive.)
In title II cessations, show the SSN of a CDB or DWB.
Enter “This revises the determination of (date of recon SSA-833-U5) .” Cross refer the reconsideration determination entering a remark on that SSA-833-U5, “See revised determination of (date of current SSA-833-U5) .” Also show “Based on decision of (ALJ—name of ALJ, date of decision) .”
Use a clarifying remark to explain any apparent inconsistency.
17. Item 29 - LTR/PAR no — Enter C13 In ALJ and AC decisions
If the beneficiary/recipient is legally competent and has a representative payee, the notice should be addressed and sent to the beneficiary/recipient at his/her mailing address, not to the representative payee.
18. Items 31 through 33
The DO will leave these items blank. ODO, PSC-DRS, and INTPSC will complete and date, as appropriate, being careful to fully identify the component, in Item 32, by entering the appropriate code from the following list:
07 ODO (other than DAP)
13 DQB-Kansas City
14 DQB-San Francisco
15 DQB-New York
20 Administrative Law Judge
21 Appeals Council
19. Item 34 - List number
Certain adjudicative situations are listed to provide information for program purposes or for future call up of cases if legislative or policy changes occur which may have a bearing on particular cases. For example, if the individual has a permanent impairment, ODO, PSC-DRS, and INTPSC will enter the related listing code.
20. Item 35 - Folder sent to
Designate where the folder is being routed. For example, if case is routed to the Program Service Center, show “NEPSC, MATPSC, SEPSC, GLPSC, MAMPSC, or WNPSC”, as appropriate. If disability examiner action is required, route the case first to the DRS, e.g., NEPSC-DRS, MATPSC-DRS, etc.
The routing designation is for external routing only; i.e., if an ODO examiner routes to a benefit authorizer within ODO, no entry would be made. However, if he/she routed the folder to a PSC, he/she would enter that PSC.