When processing an award at the appeals level, ALJ, AC, and Courts, check for current
WC/PDB payment information. Review the folder (paper or electronic), the MCS screens,
and NDRed to determine if a request for proofs was already done or to check that proof
may already be in file.
IMPORTANT NOTE: To expedite case processing, technicians should utilize concurrent development efforts
by contacting both the beneficiary or their representative, the WC payer, insurance
carrier, or WC attorney to obtain simultaneously all available sources of WC/PDB proof.
There is no need to wait until you have exhausted one resource of WC/PDB information
before contacting another. This means calling the NH directly, calling their attorney,
calling the WC attorney, and calling the WC carrier simultaneously. In addition, you
may need to get permission from the beneficiary in order to receive any information
from another party. When contacting a beneficiary, advise them which other parties
you will be contacting for WC/PDB proof. Always verify the WC/PDB amount prior to
adjudication to avoid payment errors. Use direct contact (DIRCON) procedures to all
available WC resources in GN 01070.305 through GN 01070.335 to obtain allegations of WC/PDB payments, or to find out what proof is readily available
from WC/PDB resources. Make two contact attempts per resource and document all calls
each time, whether the contact was successful or unsuccessful or if the outcome resulted
in a voicemail message.
Take the appropriate actions based on the situation, as follows:
a. The WC/PDB claim is still under appeal
Obtain an SSA-795 repayment statement, if not already in file, and an expected decision
date per DI 52140.001F.
Annotate MCS or ICF as appropriate, with any new WC/PDB claim information that you
Adjudicate the claim; and
Establish a diary control to follow-up on the status of the appeal. For PCACS diaries,
provide contact names, telephone numbers and any necessary WC/PDB claim information
in the narrative portion of the diary.
b. Worker has proof of WC/PDB
Ask the NH to fax the proof directly to you or take it to their local FO as soon as
hold the case no longer than five business days before follow-up.
c. Worker does not have acceptable proof or you are unable to contact him or her by phone
Check eView and Claims File User Interface (CFUI) to determine if the FO already obtained
a signed SSA-1709 for authorization to obtain WC/PDB proof.
Simultaneously attempt to contact the WC carrier, PDB payer, or the WC/PDB attorney
Request that the carrier or third party resource submit WC/PDB proof to SSA by faxing
it directly to you or mailing it to the applicable PC address.
For more information on developing WC/PDB proof, see Verification/Proof of WC/PDB
in DI 52145.001F. and Obtaining Verification/Proof from Outside Sources in DI 52145.005.
d. You cannot obtain proof within 10 business days
Adjudicate the claim using the current allegation of WC/PDB payments. If you do not
have an alleged rate, use the State WC maximum at the time of the WC/PDB injury or
Include MADCAP paragraph WCPR27 in the award notice or use dictated language that
asks the beneficiary to provide proof of WC/PDB.
If the beneficiary has an attorney or non-attorney representative, send neutral language
paragraphs in GN 03940.075.
Establish a 30-day diary to follow up on the response to our request for proof.
If no response is received, continue development on a post-adjudicative basis.
e. Discrepant WC/PDB answers
If the work-related question is answered "yes" but the filing question is answered
1. Obtain an explanation from the NH or employer.
2. Determine if a claim will be filed if the NH has not filed a WC claim.
3. Document MCS RPOC screen or the EF with the responses.