BASIC (03-13)

DI 52522.001 Title XVI Clark Cases that Require a Disability Determination Services Determination

There is no need to send title II Clark relief cases to the disability determination services (DDS) for a medical decision. Title II records do not terminate while in parole or probation violation (PPV) suspension. Instructions for reinstating benefits and processing title II relief are located in GN 02615.100 through GN 02615.185.

A. Title XVI Clark cases that require a DDS disability determination

By order of the U.S. District Court for the Southern District of New York, we are required to reinstate payments:

  • if on October 24, 2006 or later, we suspended or denied benefits and payments or, made an initial determination of an overpayment based solely on the existence of a PPV warrant; or,

  • if on October 24, 2006 or later, there was a pending administrative appeal of any such determination.

The field office (FO) will send the following title XVI Clark cases to the DDS for a disability determination.

1. Reopened technically denied claims

The FO should refer reopened PPV technically denied claims (DS = N25) with one of the following case characteristics to the DDS for a disability determination:

  • No subsequent claim after an N25 technical denial;

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

  • Subsequent non-Clark technically denied claim;

  • Title XVI claim with a title II disability denial determination; 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: This list is not all inclusive.

2. Previous medical allowance with a subsequent medical denial determination

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

3. Age 18 title XVI disability determination

We require an (age 18) adult disability determination. If a child recipient’s benefits terminated because of a PPV warrant, the FO will reinstate payments from the N25 PPV suspension month and continuing until:

  • the DDS determines the recipient is disabled as an adult; or

  • the DDS medically denies the case.

If the DDS medically denies the case, the FO should follow normal processing procedures including payment continuation, if requested timely. The FO will send title XVI Clark childhood disability claims to the DDS to make an adult disability determination to allow payment past age 18 as a disabled adult.

B. FO process for referring title XVI Clark cases to the DDS

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

1. Initial claims

The FO must determine if it can request a DDS determination for a Clark 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 52522.001C 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 52522.001D 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.

2. Previous medical allowance with a subsequent medical denial

This group of cases involves records that the DDS medically allowed, then terminated because of PPV suspension, and then had a subsequent filing with a medical denial. For these records, the FO should:

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

  2. Complete an SSA-5002 (Report of Contact) requesting DDS to vacate the subsequent medical denial determination; and

  3. Reactivate and forward the subsequent claim to DDS:

    • For a Certified Electronic Folder (CEF), follow the EDCS procedures in DI 52522.001C in this subsection. 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 52522.001D in this section.

When 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.

3. Age 18 adult disability redetermination

An adult DDS determination is required to reinstate payments for former child recipient whose payments terminated because of a PPV warrant. The FO should:

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

  • complete a redetermination (RZ) from the earliest N25 PPV suspension month through the present; and

  • refer the age 18 disability redetermination to DDS.

C. EDCS referrals for title XVI Clark cases

Prepare the EDCS Routing Form according to DI 81001.045 and complete the following four actions:

1. Add EDCS court case flag

Add a court case flag in EDCS according to DI 81010.080. In the remarks section of the flag enter Clark Court Order and one of the following case characteristics:

  • No subsequent claim after an N25 technical denial;

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

  • Subsequent non-Clark technically denied claim;

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

  • 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;

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

  • Age 18 adult disability redetermination; or

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

2. Complete an SSA-5002 to explain that you need a disability determination

Explain to DDS on an SSA-5002 that you need a disability determination for the period from ­­­­­­­­­­­­__________ to_______. For example: “Clark case – disability determination needed from MM/DD/YYYY (protective filing date) to the present.” If requesting the DDS to vacate a subsequent medical determination, explain why you are requesting the DDS to vacate the prior decision. For more information see Storing Non-Medical Evidence in the Electronic Folder (EF) in DI 81010.135.

3. Transfer the case to the DDS

Transfer the case to the DDS via EDCS according to DI 81010.020.

4. Send prior folders to the DDS

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.

D. Non-EDCS referrals for title XVI Clark cases

If the FO cannot use EDCS to send a Clark case to the DDS, create a paper Modular Disability Folder (MDF) as described in DI 81010.030C. After creating the MDF complete the following three actions.

1. Attach a paper Clark court order flag

Attach a paper Clark Court Order flag, located in DI 52522.001E in this section, to the front of the MDF. Complete the recipient’s information and indicate the case characteristics.

2. Complete an SSA-5002 to explain that you need a disability determination

Explain to the DDS on an SSA-5002 that you need a disability determination for the period from ­­­­­­­­­­­­__________ to_______. For example: “Clark case – disability determination needed from MM/DD/YYYY (month before subsequent claim’s protective filing date). Subsequent claim filed MM/DD/YYYY (protective filing date) and a favorable (or unfavorable) determination made on MM/DD/YYYY (date of previous DDS determination).” If requesting DDS to vacate a subsequent medical determination, explain why you are requesting the DDS to vacate the decision. Attach SSA-5002 to the blue section of the MDF and place on top.

3. Attach any prior or subsequent paper folders

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

E. Exhibit of Clark court order flag

Clark Court Order Case Flag

Recipient Name: ­­­­_____________________________

Recipient SSN: _____________________________

Type of Clark Relief (select one):

Protective Filing Date: ­­­­­­­­­­­­­­­­_________________________

_______ No subsequent claim after an N25 technical denial

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

_______ Subsequent non-Clark technically denied claim

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

_______ 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

_______ FO can reinstate benefits-vacate subsequent medical denial determination

______ Age 18 Disability Redetermination

______ Other (please explain): ________________________________________________


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0452522001
DI 52522.001 - Title XVI Clark Cases that Require a Disability Determination Services Determination - 05/06/2013
Batch run: 05/06/2013
Rev:05/06/2013