DI 81010.143 Processing Medical Reactivations
Medical Reactivation changes a claim that is in “closed,” “transferred,” or “manually cleared” status in the electronic folder to pending or active again. A claim is Medically Reactivated in eView so that the prior medical decision can be reopened. The policy regarding reopening and revision has not changed. Follow the existing reopening policies and procedures, DI 27501.005 - Reopening and Revisions, General; DI 27505.001 - Time limits and other conditions for Reopening a Final Determination or Decision; DI 28500.000 - CDR Reopening.
A. When to Do a Medical Reactivation
Medical Reactivation may be used when there are no open claims pending in Electronic Disability Collect System (EDCS)/eView and:
Trailer mail is received that affects the final decision;
The Field Office (FO) detects an error on the SSA-831 such as an incorrect regulation basis code, onset date, etc. and verifies with the Disability Determination Service (DDS), Disability Processing Branch (DPB) or Flexible Disability Unit (FDU) that the claim should be reopened;
The FO revises pertinent factors in the case such as the insured status dates or provides a statutory blind date last insured, etc. and verifies with the DDS, DPB or FDU that the claim should be reopened;
The DDS, DPB or FDU makes a favorable decision with evidence that is readily available, but needs to develop for an earlier onset.
B. Who Can Do a Medical Reactivation
Use of the Medical Reactivation utility is controlled by position and security profile:
In the FO, a Claims Representative (CR) or other designated user with the proper security profile can medically reactivate claims in the most recently closed Certified Electronic Folder (CEF) where the final medical decision was made by a DDS, DPB or FDU;
In Office of Quality Performance (OQP), Disability Quality Branch (DQB) team leaders and program experts can medically reactivate claims in the most recently closed CEF where the final medical decision was made by a DDS, DPB, FDU or OQP;
DDSs, DPBs and the FDU are able to designate specific individuals who can medically reactivate cases. The DDS and DPB must request that functional profile P73680P be assigned to the individual(s) by their Regional Center for Security and Integrity. The FDU must request that functional profile P73680P be assigned to the individual(s) by the Office of Central Operations (OCO) Center for Security and Integrity.
In the Hearing Office (HO) designated user with the proper security profile can medically reactivate claims in the most recently closed Certified Electronic Folder (CEF).
C. How to Do a Medical Reactivation
Medical Reactivation is done using eView. To reactivate a claim:
Enter the SSN on the Case Selection screen and select the claim to reactivate.
REMINDER: The claim must be in the most recent CEF case and have a status of “closed,” “transferred,” or “manually cleared.” Reactivation only works when there are no pending cases in eView;
Lock the claim using “Edit (Lock Case)” in eView;
REMINDER: Cases automatically open in eView for viewing only (i.e. in “unlocked” mode). To edit a case in eView, the case must first be “locked.” For more information on locking and unlocking a case in eView see DI 81001.040 Editing a Certified Electronic Folder (CEF) in eView.
Click on the Case Status/History tab;
Click “Reactivate” on the Case Status/History screen. The Reactivate Claim screen will display claims available for reactivation;
Select the claim to reactivate;
Key the reason why a Medical Reactivation is needed. For example, Developing for an earlier onset date, FO modified the date last insured, or Incorrect Regulation Basis Code on 831 dated xx/xx/xx, SGA establishes a different onset date, etc.
NOTE: The FO must contact the DDS, DPB or FDU before they send a Medical Reactivation to the DDS, DPB or FDU. The DDS, DPB or FDU must agree with the FO to medically reactivate the claim.
Medical Reactivation is only permitted on a claim with a medical determination in the most recently closed CEF case. A case is defined as all of the claims filed/adjudicated at the same time. For example:
John Smith has two disability cases and both are CEFs.
Since Medical Reactivation can only be performed on the claims in the most recently closed CEF, the user can only medically reactivate the claims in Case 2, the case that was closed in April 2007. Either the DI or DIB claim, or both, can be medically reactivated. Claims that were closed in March 2006 cannot be medically reactivated because they are not part of the most recently closed CEF case.
NOTE: Claims that were technically denied by the FO cannot be medically reactivated. Instead, FOs will use the Technical Reactivation utility in EDCS per DI 81010.110.
D. How to Cancel a Medical Reactivation
If a claim is medically reactivated by mistake, users have the ability to cancel the medical reactivation.
FO users must cancel the medical reactivation using EDCS by going to the “Claims Actions” tab and choosing “Cancel Reactivation”. The FO cannot cancel a Medical Reactivation through eView.
DDS, DPB or FDU users receipt the claim and close it as a “No Decision” and select the reason “Mistakenly Reactivated in their case processing system.”
E. How to Process a Medical Reactivation - FO Actions
Once a claim is medically reactivated, it can be:
Transferred to the appropriate case processing component;
NOTE: Before Medically Reactivating a claim and sending it to the DDS, DPB or FDU, the FO should call the DDS, DPB or FDU to ensure they agree that the reopening is appropriate;
Adjudicated by the FO with a FO determination;
Cancelled by the Claims Representative; or
Retained in the FO for additional development.
When a new DDS, DPB or FDU determination is made on the medically reactivated claim, a special designation is displayed on the EDCS Actions Page. Under the column “Reopen,” a red flag appears noting that the claim has been medically reactivated, and the “Issue” column features the statement “DDS, DPB or FDU Determination Added” similar to an initial claim. The FO will take actions necessary to effectuate the determination.