BASIC (04-11)

DI 52520.005 Martinez Cases that Require a Disability Determination Services Determination

There is no need to send title II post-2006 and pre-2007 Martinez relief cases to the disability determination services (DDS) for a medical decision. Title II records do not terminate while in fugitive felon suspension. Instructions for reinstating benefits and processing relief are located in GN 02613.865 through GN 02613.880.

A. Title XVI post-2006 Martinez cases that require a DDS disability determination

The FO will send the following title XVI Martinez cases to the DDS for a disability determination.

1. Reopened technically denied claims

The FO will refer reopened fugitive felon technically denied claims (DS = N25) with the following case characteristics to the DDS for a disability determination:

  • No subsequent claim after an N25 technical denial; or

  • Subsequent claim with a disability determination or decision after an N25 technical denial; or

  • Subsequent non-Martinez technically denied claim; or

  • Title XVI claim with a title II disability denial determination; or decision for the same period or later; or

  • Title XVI claim with a title II disability allowance determination or decision with an established onset date (EOD) later than the title XVI application date of the N25 technically denied claim.

NOTE: The above case characteristics are the most common. However, the FO may refer other types of technically denied claims to the DDS, as appropriate.

2. Previous medical allowance with a subsequent medical denial – request for DDS to vacate subsequent determination

The FO normally reinstates payments on cases with a medical allowance that terminated because of N25 fugitive felon suspension. However, the FO cannot reinstate cases when there is a subsequent medical denial determination. The FO will refer these cases to DDS for a decision to vacate the subsequent medical determination. Once DDS vacates the subsequent medical denial, the FO can reinstate payments.

3. Age 18 disability redetermination

If a child recipient’s benefits terminated because of an unsatisfied felony arrest warrant, the FO cannot reinstate payments from the month after attainment of age 18 to the present until the DDS determines the recipient is disabled as an adult. An age 18 disability determination is required.

The FO will send title XVI post-2006 Martinez childhood disability claims to the DDS to make an adult determination to allow payment past age 18 as a disabled adult.

B. Title XVI pre-2007 Martinez cases that require a DDS disability determination

The previously ineligible fugitive felon recipient may file a new disability application with a protective filing date of April 1, 2009. These claims require a disability determination from the DDS. These claims may have one of the following case characteristics:

  • No subsequent claim filed after 4/2009; or

  • Subsequent claim filed after 4/2009 with a disability determination or decision; or

  • Subsequent technically denied claim filed after 4/2009; or

  • Title XVI claim with a title II disability denial determination or decision for the same period or later; or

  • Title XVI claim with a title II disability allowance determination or decision, with an established onset date later than the title XVI application date of 4/1/2009.

NOTE: The above case characteristics are the most common. However, the FO may refer other types of claims to the DDS, as appropriate.

C. FO process for referring Martinez cases to the DDS

1. Post-2006 Martinez cases

The FO will refer several types of cases to DDS for a disability determination.

a. Initial claims

The FO must determine if it can request a DDS determination for a Martinez case via the Electronic Disability Collect Systems (EDCS). If the initial claim was:

  • technically denied and never had a DDS determination, process the case through EDCS unless an exclusion applies. Follow the instructions for EDCS cases in DI 52520.005C.3. in this section. See list of EDCS exclusions, in DI 81010.030A.

  • technically denied and the claimant filed a subsequent claim that had a DDS determination, the case is an EDCS exclusion. Follow the instructions for non-EDCS cases in DI 52520.005C.4. in this section.

NOTE: If a claim is a Modernized Supplemental Security Income Claim System (MSSICS) exclusion, the FO cannot create the claim in EDCS. See list of MSSICS exclusions in MSOSM MSSICS 001.003.

b. Previous medical allowance with a subsequent medical denial

This group of cases involves records that were medically allowed, then terminated because of fugitive felon suspension (N25), and then had a subsequent filing with a medical denial. For these records, the FO will:

  • Complete a redetermination (RZ) from the earliest N25 fugitive felon suspension through the present; DO NOT place record into current pay and DO NOT release past due payments;

  • Complete a Report of Contact SSA-5002 requesting DDS to vacate the subsequent medical denial determination; and

  • Reactivate and forward the subsequent claim to DDS:

    • For a Certified Electronic Folder (CEF), follow the EDCS procedures in DI 52520.005C.3 in this section. To determine if a folder is a CEF, see DI 81001.005; or

    • For a Modular Disability Folder (MDF), follow the instructions for non-EDCS cases in DI 52520.005C.4.a in this section.

Once you receive the vacated decision on the subsequent claim from DDS, place the record into current pay and release past due payments, based on the installment procedures in SI 02101.020.

c. Age 18 disability determination

An adult DDS determination is required to reinstate payments for former child recipient whose payments terminated because of an unsatisfied felony arrest warrant. The FO will:

  • obtain the medical forms required in DI 11070.030 for age 18 disability redeterminations;

  • complete a redetermination (RZ) from the earliest N25 fugitive felon suspension month through the month of attainment of age 18, to provide Martinez relief for this closed period; and

  • refer the age 18 disability redetermination to DDS.

If the age 18 disability redetermination is favorable, the FO must complete another RZ from the month after attainment of age 18 through the present before reinstating benefits.

2. Pre-2007 Martinez cases

The FO will only refer initial claims with a protective filing date of 4/1/2009. The FO must determine if it can request a DDS determination for a Martinez case via EDCS. If there is:

  • no subsequent claim filed after 4/2009, process the case through EDCS unless an exclusion applies. See list of EDCS exclusions in DI 81010.030A.

  • a subsequent claim filed after 4/2009 that had a DDS determination, the case is an EDCS exclusion. Follow the instructions for non-EDCS cases in DI 52520.005C.4. in this section.

NOTE: If a claim is a Modernized Supplemental Security Income Claim System (MSSICS) exclusion, the FO cannot create the claim in EDCS. See list of MSSICS exclusions in MSOM MSSICS 001.003.

3. EDCS referrals

Follow the instructions in DI 81001.045 to prepare the EDCS Routing Form and include the following:

  1. Add a Court Case flag in the Flag – View Details/Edit Tab. In the remarks box of the flag, identify the case as a post-2006 or pre-2007 Martinez settlement case and indicate the case characteristics in the remarks box of the flag. Example: “Post-2006 Martinez Case – no subsequent claim”

    Post-2006 Martinez case characteristics:

    • No subsequent claim after an N25 technical denial; or

    • Subsequent claim with a disability determination or decision after an N25 technical denial; or

    • Subsequent non-Martinez technically denied claim; or

    • Title XVI claim with a title II disability denial determination or decision for the same period or later; or

    • Title XVI claim with a title II allowance determination or decision with an established onset date later than the title XVI application date of the N25 technically denied claim; or

    • FO can reinstate benefits-vacate subsequent medical denial determination; or

    • Age 18 disability redetermination; or

    • Other (explain reason for referral for disability determination if not one of the items listed above).

    Pre-2007 Martinez case characteristics:

    • No subsequent claim filed after 4/2009; or

    • Subsequent claim filed after 4/2009 with a disability determination or decision; or

    • Subsequent technically denied claim filed after 4/2009; or

    • Title XVI claim with a title II disability denial determination or decision for the same period or later; or

    • Title XVI claim with a title II disability allowance determination or decision with an established onset date later than the title XVI application date of 4/1/2009; or

    • Other (explain reason for referral for disability determination if not one of the items listed above).

  2. Explain to DDS on an SSA-5002 (Report of Contact) that you need a disability determination for the period from ­­­­­­­­­­­­__________ to_______. If requesting DDS to vacate a subsequent medical determination, explain why you are requesting that the DDS vacate the prior decision. See DI 81010.135 Storing Non-Medical Evidence in the Electronic Folder (EF). EXAMPLE: “Post-2006 Martinez claim- a disability determination is needed from MM/DD/YYYY (protective filing date) to the present”.

  3. Transfer the case to the DDS via EDCS using the instructions in DI 81010.020.

  4. Send any prior paper folders or electronic folders to the DDS to associate with this claim. For converting CEF cases to paper, see DI 81010.030C.

4. Non-EDCS referrals

If the FO cannot use EDCS to send a Martinez case to the DDS, create a paper Modular Disability Folder (MDF) as described in DI 71005.005. Include the following:

a. Add the Martinez Court Flag, located in DI 52520.005E in this section, to the front of the MDF. Indicate on the flag whether the claim is a post-2006 or pre-2007 Martinez claim with the proper case characteristics.

The case characteristics for post-2006 and pre-2007 Martinez relief are located in DI 52520.005C.3.a in this section.

b. Explain to the DDS on an SSA-5002 (Report of Contact) that you need a disability determination for the period from ­­­­­­­­­­­­__________ to_______. If requesting DDS to vacate a subsequent medical determination, explain why you are requesting that DDS vacate the decision. Attach SSA-5002 to the blue section of the MDF and place on top.

EXAMPLE: “Post-2006 Martinez claim - a disability determination is needed from MM/DD/YYYY (protective filing date) to MM/DD/YYYY (month before subsequent claim’s protective filing date). Subsequent claim filed MM/DD/YYYY (protective filing date) and a favorable/unfavorable (select one) determination was made MM/DD/YYYY (date of previous DDS determination)”.

c. Attach any prior and subsequent paper folders to this claim before transferring to the DDS.

D. Exhibit - Martinez settlement flag

Martinez Court Case

Recipient/Claimant Name: ­­­­_____________________________

Recipient/Claimant SSN: _____________________________

Type of Title XVI Martinez Relief (select one):

Post-2006--Protective Filing Date:­­­­­­­­­­­­­­­­_________________________

_______ No subsequent claim after an