TN 1 (11-00)

DI 42548.010 Effectuating Determinations/Decisions after Disability Determination Services/Office of Hearings and Appeals (DDS/OHA) Action

A. Process

Determinations/decisions are effectuated as follows.

1. Title II

Fully and partially favorable title II determinations/decisions are effectuated by the PC.

2. Title XVI

Fully and partially favorable title XVI determinations/decisions are effectuated by the FOs under existing guidelines.

3. Withholding

Normal withholding procedures apply (e.g., Medicare, overpayment, attorney fees, etc.)

4. No benefits payable

If a fully favorable medical determination/decision was issued either because of a subsequent application or a previous Hyatt III reopening, the DDS/OHA adjudicator will complete the Favorable Determination/Decision Worksheet and Transmittal, (see DI 42548.095, Exhibit 14) and forward the folder to the FO for payment verification. If no additional benefits are payable after this review, the FO will prepare and release the notice (see DI 42548.095, Exhibit 13) in SSI and DDS level title II cases. Title II OHA level decisions will be forwarded by the FO to the PC for preparation and release of the “No Benefits Payable Notice” (see DI 42548.010B.1.d.).

5. Systems process

Claims are processed through MCS. MCS processing exclusions require manual adjustment credit and award processing (MADCAP).

B. Procedure

1. Process award

To process awards:

  1. Effectuate A101 or EF101 as prepared by FO.

  2. Route folder in partially favorable DDS determinations in which the class member is automatically entitled to an ALJ hearing (see DI 42548.015) to the servicing FO after payment action. Annotate the route slip “Partially favorable Hyatt reopening, class member automatically entitled to ALJ hearing. Send folder to the OHA servicing office”.

  3. Reopen the Hyatt application and process payment of the retroactive benefits in cases where the Hyatt claim is favorable and a CDR cessation was processed concurrently on a subsequent application. The FO will have already separated the CDR folder for appeal of the cessation.

  4. If OHA prepared the Hyatt III Favorable Determination/Decision Worksheet and Transmittal, (see DI 42548.095, Exhibit 14, and the FO verified payment, no benefits are payable because of the Hyatt III OHA level decision. The PC must:

    • Prepare and release the notice “No Benefits Payable” (see DI 42548.095, Exhibit 13).

    • Release the notice to the claimant, claimant's attorney, if any, class counsel and the Litigation Staff.

    Using the information provided by hearing office on DI 42548.095, Exhibit 14, if the earliest claim(s) filed within the Hyatt III period is not a Hyatt III eligible claim(s), include the following optional language after the first sentence of the notice, DI 42548.095, Exhibit 13: “We did not review your application(s) filed (fill in date of application(s) that are not eligible for Hyatt III review) because (fill in reason claim(s) do not qualify for Hyatt III review.). We reviewed the claim(s) you filed after that date.”

2. Notices

  1. Prepare and release notice to the claimant using DI 42548.095, Exhibit 13, if no benefits are payable or the language provided by DDS on SSA-831-U3 or SSA-865 and work incentive language. See DI 42548.010B.1.d. for optional language that must be included in the notice if the earliest claim filed within the Hyatt III period is not a Hyatt III eligible claim.

  2. Provide claimant, claimant's representative, if any, class counsel and OPB/LS with a copy of the notice.

3. Unfavorable determinations/decisions

On unfavorable determinations where no PC action is required: