DI 55075.025 Disputes Involving Payment Issues
A. Policy – disputes about a milestone or outcome payment
1. EN disputes
If an EN disputes a milestone or outcome payment decision, SSA will handle the dispute according to the procedures in the EN's contract.
2. State VR agency disputes
SSA does not have contracts with State VR agencies. If a State VR agency serving a beneficiary/recipient as an EN disputes a milestone or payment decision:
The State VR agency must send a written request for reconsideration to the PM within 60 days of receiving the written payment decision notice from SSA.
The PM must review the issue in dispute, make a recommendation, and forward it along with the reconsideration request to SSA.
SSA will review the issue in dispute and the PM's recommendation and issue a written decision.
NOTE: Staff in OESP will issue the SSA written decision. Payment disputes will not be referred to the Dispute Resolution Board.
3. Payment dispute involves an SSA determination about an individual's right to benefits
Determinations that SSA makes about an individual's right to benefits may:
affect an EN's (including a State VR agency's) eligibility for a milestone or outcome payment;
cause a milestone or outcome payment already made to be incorrect, resulting in an overpayment; or
cause a denial of a request for a milestone or outcome payment to be incorrect, resulting in an underpayment.
Although an EN (including a State VR agency) cannot appeal a determination that SSA makes about an individual's right to benefits, the EN (or State VR agency) may furnish any evidence it has that relates to the issues to be decided. Such issues could involve determinations that benefits should be suspended, terminated, continued, denied, or stopped or started on a different date than alleged.
B. Policy – disputes from a State VR agency about a cost-reimbursement payment issue related to a beneficiary/recipient with a ticket
SSA has in place dispute resolution mechanisms for issues involving:
disputes on the amount that SSA pays to a State VR agency for serving a beneficiary/recipient who completes a continuous period of substantial gainful activity (SGA); and
disputes on whether there was a continuous period of SGA and whether the services the State VR agency provided contributed to the continuous period.
OESP is the SSA component that has the lead on these issues and its claims unit makes the initial cost-reimbursement decision.
C. Procedure – handling inquiries about payment disputes
Field components should follow the procedures in DI 55060.001C.2. and DI 55060.001C.3. when a question arises about an EN or a cost reimbursement payment decision.
NOTE: Field components have no direct role in the dispute resolution process involving a payment issue. However, FOs and PCs staff may get involved indirectly if a payment dispute involves a question about a beneficiary's/recipient's right to benefits.