TN 12 (04-12)
DI 81010.150 Processing Claims Appeals of Medical Decisions in Electronic Disability Collect System (EDCS)
A. Mainframe requirements
1. Disability reconsiderations
A mainframe reconsideration request, with the exception of Modernized Claims System (MCS) exclusion appeals, must be created prior to creation of reconsideration cases in EDCS. Reconsideration requests must be printed from the mainframe in order to save the image in the Online Retrieval System (ORS). Reconsiderations that require mainframe input include:
Supplemental Security Income (SSI),
Disability Insurance Benefits (DIB),
Childhood Disability Benefits (CDB), and
Disabled Widow(er)’s Benefits (DWB).
NOTE: For CDB or DWB cases that do not require an MCS application at the initial level; you can create an EDCS appeal only if EDCS was used for the initial filing. See Creating Electronic Disability Collect System (EDCS) Cases - DI 81010.020B.
2. Disability hearings
Create a mainframe hearing request, with the exception of MCS exclusion appeals, before establishing an EDCS hearing level case. Hearing requests must be printed from the mainframe in order to save the image in ORS. Create hearings in EDCS for the following claim types:
When creating an EDCS hearing level case, the associated lower level mainframe claim cases (initial claim and reconsideration) must have a medical denial by the DDS and a denial code must be posted to the Master Beneficiary Record (MBR) or Supplemental Security Record (SSR), or both.
For claims medically denied at the initial claim case level in Prototype States, hearing cases can be established in EDCS even though a reconsideration level appeal does not exist.
NOTE: For CDB or DWB cases that did not require an MCS application at the initial level, create an EDCS appeal only if using EDCS for the initial and reconsideration level filing. For more information on creating an EDCS case, see Creating Electronic Disability Collect System (EDCS) Cases - DI 81010.020B.
3. Appeals Council
A mainframe appeal council request does not need to be created to establish an EDCS AC level case. In order to create a case at the AC level, there must be at least one ALJ Decision on the claim. To create an AC level case, use the case creation screen in EDCS, and follow these steps:
Select Claims Dialog Box,
Complete the required fields,
Select the claim(s) the claimant is appealing,
Enter “Request for Review” date. For more information on the Request for Review date see Requesting Appeals Council (AC) Review, GN 03104.100. This date:
Click on “Create Case” button; and
Fax the “writing” into the CEF after the AC level appeal has been created in EDCS. For more information requests for review see How to Request Review, GN 03104.100A.1.
The FO cannot access the Transfer page. AC cases automatically transfer to the corresponding Office of Appellate Operations (OAO) of jurisdiction. The case downloads to Appeal Review Process System (ARPS) after “Create Case” button is selected.
B. Documenting receipt of an appeal request
There is no requirement for a signature on an appeal request. However, a claimant’s disagreement with a determination or decision by SSA must be in writing. A writing, for appeals purposes, is any documentation, e.g., a letter, facsimile, or submission of additional evidence which clearly implies disagreement with the initial determination. This means an appeal request does not have to be submitted on a prescribed form to be valid, as long as it meets the requirements for a writing. Internet appeals (i3441- Disability Report - Appeal) also meet the requirements for a writing. For more information on appeals see iAppeals - Title II - GN 03101.125 and iAppeals - Title XVI - SI 04005.035.
NOTE: For i3441 cases, use the date the i3441 was finally transmitted to SSA as the appeal date, not the date that it was started. A partial i3441 (never finally submitted) cannot be considered a writing for appeals purposes. The FO acknowledges receipt of all appeal requests, by mailing the notice of appeal generated by the Modernized Claims System (MCS,) and/or Modernized Supplemental Security Income Claims System (MSSICS) and the MCS/MSSICS generated appeal (i.e. Request for Reconsideration (SSA-561) or Request for Hearing by Administrative Law Judge (HA-501)) to the claimant or by returning to the claimant a copy of the appeal form (e.g., a paper SSA-561 or HA-501) if MCS/MSSICS is not used to process the appeal.
1. Appeal request received in the mail - signed or unsigned
A written request submitted by the claimant or other appropriate person on a paper appeal form or other document which clearly shows disagreement with the initial determination or decision, meets the requirement for a writing. For information on Appeals Council Review requirements see:
A signature is not required on the appeal form.
When an appeal is requested on behalf of a claimant, the FO can accept the documentation as an appeal from the claimant. As long as no other names or signatures are shown on the appeal form, and the form appears to have been mailed from the address of record, SSA assumes the request is from the named appellant. For more information on accepting request originating from a claimant or other appropriate person see FO Reconsideration Development of Request for Reconsideration - GN 03102.300 and Preparation of Form SSA-561-U2 (Request for Reconsideration) - GN 03102.225.
If the appeal is generated via the mainframe (i.e., MCS and/or MSSICS), the written appeal submitted to the FO does not need to be faxed into the CEF. MCS and/or MSSICS saves the documentation in the Online Retrieval System (ORS). Transcribe verbatim the information from the writing into the MCS and/or MSSICS appeals screens, including the entire reason shown on the form as the reason for the appeal. For concurrent and/or multiple claims, ensure that the identical reason for appeal is entered into MCS and MSSICS when disability is the reason for the appeal. Once the claimant’s writing has been documented and stored in ORS, the paper appeal request can be shredded, whether or not there is a signature on the form.
IMPORTANT: DDS cannot access the ORS to view the reason for the appeal. The field in eView that the DDS can access accommodates 6000 characters, so, if the reason for appeal is not duplicated on the SSA-3441, it is very important for the FO to fully transcribe the reason for the appeal. If the writing is not entirely legible or too extensive to transcribe verbatim, the writing should be faxed into the certified electronic folder for viewing by other components.
For appeals that are not processed through the MCS and/or MSSICS appeal screens, fax the paper appeal into EDCS if one of the claims is established in EDCS and file the appeal request in the Modular Disability Folder (MDF).
2. Appeal request received during face-to-face interview without a separate writing
For situations where a writing by the claimant has not been received in the FO, but a FO employee completes the MCS and/or MSSICS appeal screens during an in-person interview with the claimant, the appeals screen output, documented and stored in ORS, can serve as the writing as long as the claimant is provided a reasonable opportunity to review the print out and agrees that the information is accurate. Agreement is documented by the interviewer’s final processing of the appeal in MCS/MSSICS. If the claimant disagrees with any information on the output, the FO employee must correct the SSA record to document the disagreement and correct the appeal information before final processing. If this process is followed, the requirement in the regulations that a request for an appeal be made in writing is satisfied.
If an MCS and/or MSSICS appeal screen cannot be used to record the appeal, e.g., an EDCS exclusion, a paper appeal form should be completed during the interview and reviewed and agreed to by the claimant prior to storing it in a paper folder or faxing it into the certified electronic folder (for EDCS appeals) or an electronic processing system, or requesting Appeals Council review. A signature is not required.
3. Assertion by claimant that he or she wants to file an appeal during a telephone interview with an SSA representative
Mere oral requests to appeal a determination or decision do not constitute a writing. Therefore, an SSA representative cannot protect an individual’s filing date for an appeal based on an oral request. An appeal request is not received by SSA until a writing is received.
REMINDER: Signature proxy, including attestation does not apply to appeals. Attestation is an act of an employee confirming the agreement of the applicant to sign an application, so it does not apply.
The FO business process for appeals does not normally include telephone appointments since a writing is needed before the appeal is considered filed with SSA. However, there may be situations where a FO employee conducts a telephone appointment for an appeal when a written appeal request (SSA-561, HA-501, HA-520 (Request for Review of Hearing Decision/Order, or SSA-789 (Request for Reconsideration or other writing) has not yet been received. For these interviews, the FO employee cannot use the MCS and/or MSSICS screens to document receipt of an appeal.
Instead, the appeal must be processed in the following manner:
A paper appeal form must be mailed to the claimant for completion, along with any other forms where a signature is required, such as SSA-827s (Authorization to Disclose Information to the Social Security Administration) or an SSA-1696 (Appointment of Representative).
The form must be returned to the FO so the FO can document that a writing has been established.
After the appeal is returned, the FO uses MCS and/or MSSICS to document receipt of the appeal if appropriate. The appeal is not received until the appeal form is returned.
If the appeals period expires within 10 days, advise the individual to submit any written request within the appropriate time limit either by mail, fax, or an in-person office visit, without waiting for the form mailed from the FO.
There is no requirement that the FO document an oral appeal inquiry as there is no protective filing for appeals. For good cause determinations if a writing is not received timely see Claimant Request Reconsideration of a Substantial Gainful Activity (SGA) Cessation - DI 12025.001C. For Hearing requests, the ALJ makes any determination of good cause for late filing.
C. Forms required for filing a reconsideration or a hearing
1. SSA-3441 (Disability Report – Appeal)
Use the SSA-3441 for reconsiderations and hearings for both adult and child claimants. The “Forms Selection” screen in EDCS asks the CR if they want to key an SSA-3441, if the paper form is complete, or 3441 not received.
If the CR selects KEY, EDCS displays the 3441 and 3367 (Disability Report – Field Office) for completion. For details on completing the 3441 in EDCS, see Processing Claims Appeals of Medical Decisions in Electronic Disability Collect System (EDCS) - DI 81010.150D.
If the CR selects PAPER, EDCS displays only the 3367 for completion.
For instructions to complete the paper SSA-3441, see SSA-3441-BK (Disability Report – Appeal) - DI 12095.030C.
If the CR selects 3441 Not Received, EDCS does not require the CR to complete the questions on the 3441 form or obtain management override for case transfer. For instructions for 3441 Not Received, see Processing Claims Appeals of Medical Decisions in Electronic Disability Collect System (EDCS) – DI 81010.150E.
NOTE: In request for Appeals Council review cases, an SSA-3441, SSA-3367, SSA-3881 Questionnaire for Children Claiming SSI Benefits), or SSA-827 does not need to be obtained.
REMINDER: For reconsiderations or hearings filed on Supplemental Security Income Disabled Child (SSIDC) claims, the SSA-3881 is required. For more information see Processing Claims Appeals of Medical Decisions in Electronic Disability Collect System (EDCS) - DI 81010.150C.4.
2. SSA-3367 (Disability Report – Field Office)
The SSA-3367 must be completed for reconsiderations of the initial claim and escalated claims. If the reconsideration or hearing case includes an escalated claim, make sure the Prior Filing information is complete per Processing Disability Claims at Different Levels of Appeal, Title II and Title XVI – Common Issue Cases - DI 12045.010B.1.
NOTE: Although the SSA-3367 appears in the path for a hearing, it is not required for transfer to ODAR.
3. SSA-827 (Authorization to Disclose Information to the Social Security Administration)
For reconsideration and hearing appeals, see Field Office Instructions for Obtaining Form SSA-827 DI 11005.057.
NOTE: EDCS defaults to print one SSA-827. You can over key the default number if more forms are needed.
NOTE: Effective August 2012, adults who complete an i3441 on their own behalf have the option to electronically sign and submit Form SSA-827. If the IU electronically signs Form SSA-827, the IU does not need to print, sign, and mail or bring Form SSA-827 to the FO. For more information about the electronic signature process for Form SSA-827, see DI 11005.056.
4. SSA-3881 (Questionnaire for Children Claiming SSI Benefits)
Since the SSA-3441 is used for both adult and child claims, it does not include specific questions that are normally asked on the SSA-3820, such as schools and additional sources. Complete an SSA-3881 in all childhood reconsideration and hearing cases.
To complete the SSA-3881 in Electronic Disability (eDib) Cases:
Access and complete the SSA-3881 via eForms in Electronic Disability Collect System (EDCS); and
Save the eForm electronically to the Certified Electronic Folder (CEF) following instructions in eForms - DI 81010.115.
NOTE: If the case is a CEF Exclusion, print the completed eForm and store it in the paper Modular Disability Folder (MDF). For more information on EDCS exclusions see Certified Electronic Folder (CEF) Exclusions and Limitations - DI 81010.030).
5. Other documents requiring signatures
Fax other documents into the CEF that require signatures following instructions in Faxing Documents into the Certified Electronic Folder (CEF) Using Barcodes - DI 81010.090. Both the front and back of two sided forms must be faxed into the CEF.
Examples of Documents requiring signatures include:
Attorney Fee Agreements, and
Good Cause documentation (per Good Cause for Extending Time Limit – GN 03101.020).
NOTE: Do not fax the instructional pages (pages 1-3) of the SSA-1696 (revised 05-2008) into the CEF.
D. Completing the 3441 (Disability Report Form) for appeal in EDCS
Use the SSA-3441 for reconsiderations and hearings for both adult and children claims. The “Date of Last Disability Report” field automatically pre-fills with the date the lower-level case was initiated in EDCS.
If the claimant, representative, or third party completed an Internet Disability Report (IDR) Appeal (i3441), see Receiving the i3441 (Internet Disability Report – Appeals) - DI 81007.050 for instructions.
1. Data from prior case level
After establishing the 3441 in EDCS, it links to the prior level case. This allows certain data to be copied from the prior level case into the 3441. Copy the following types of data:
EDCS displays the toggle link “Show information from prior level(s).” To copy an item from a previous level, select the desired item in the “available for copy” box. Not all fields for the item selected can be copied into the current case. Information that may have changed is left blank after copying the data and must be completed by the interviewer. This information includes the following medical source fields:
NOTE: If there is no information available from a prior level for the user to copy, the claimant may not have provided any information for the prior level, or the case may be an exclusion from electronic processing. For information on copying from a prior level, see Creating Electronic Disability Collect System (EDCS) Cases - DI 81010.020C.2. If the case is an electronic exclusion, CEF Exclusions and Limitations - DI 81010.030 provides instructions for processing.
2. Data copied from prior case level
When data is copied from a prior case level: Insert an introductory sentence here:
The item that was copied to the current appeal level returns it to the “available for copy” section when deleted.
If you delete a new item that was added to the current appeal level it is deleted from the case.
Copying a medication or a test also copies the source for that medication or test.
NOTE: Copying medical test information from a school in a child’ claim does not copy the source (school) information from the initial level.
Selecting “No” to a medication or test lead question and attempting to select a medication or test from the “available for copy” list causes an alert message to appear.
“Key fields” cannot be changed once a source is copied. For example, if a medication is copied to the current level, the medication name cannot be changed.
If a source from a prior level has a change of address or telephone number, copy the source to the current level case and update the information.
E. SSA-3441 (Disability Report – Appeal) not received
Claimants may file a request for reconsideration or hearing but refuse or fail to provide the necessary forms and/or additional evidence to support the request. Follow instructions in FO Reconsideration Development of Request for Reconsideration - GN 03102.300 for requesting evidence.
If an SSA-3441 is not received and the appeal can be processed in EDCS select the “3441 not received” option on the Form(s) Selection page. The CR is required to document the attempts made to obtain the 3441 on the “Transfer” screen before sending the case to the Disability Determination Services (DDS) or Office of Disability Adjudication and Review (ODAR) for review.
1. Documenting attempts to obtain a SSA-3441
After entering the reconsideration or hearing on the mainframe, complete the following steps on the “Transfer” screen to document your attempt(s) to obtain a 3441:
Select “I am transferring this case with no SSA-3441”;
Enter the date of the letter mailed to the claimant attempting to collect the 3441;
NOTE: When transferring the case to ODAR you are not required to enter the date of the letter mailed to the claimant attempting to collect the 3441.
Enter any additional information relevant to your attempt(s) to obtain the 3441; and
Transfer the case to DDS or ODAR.
2. Case Documentation when the 3441 is not received
EDCS adds an alert titled “5002: 3441 not received” along with the description, “See Case Documents tab for detailed information”. Under the Case Documents tab in eView a SSA-5002 documenting the reason for appeal and your attempt to obtain the 3441 is added.
3. Receiving the SSA-3441 after EDCS transfer
If an SSA-3441 is received after the FO transfers the case to DDS/ODAR:
Add a message to the CEF, without an expiration date, showing “Claimant 3441 received MM/DD/YY faxed into CEF.” See Alerts, Flags, and Messages in the Electronic Disability Collect System (EDCS) - DI 81010.080.
F. Receiving a pending case alert in EDCS when a reconsideration or hearing is filed
EDCS only allows one pending case at a time. An alert message appears if there is a case pending while attempting to load an appeal into EDCS. If a pending case alert is received, choose one of the following options:
1. Update the existing pending case
Use the re-propagation function on the EDCS case section screen to re-propagate all mainframe data into the pending EDCS case, including any new mainframe claims. See Data Repropagation in Electronic Disability Collect System (EDCS) - DI 81010.045.
NOTE: Use this option when the Field Office (FO) has Claims Representatives (CRs) who are specialized by Title II or XVI, and only defined the claim for one Title on the mainframe when first creating the EDCS case.
2. Close the existing pending case prior to creating a new case
Manually clear a pending EDCS case only when a prior EDCS case was:
Never transferred to the DDS for a medical determination; AND
Not appropriately closed (e.g., a technical denial on the mainframe that was not given an FO Determination in EDCS); or
Not transferred in EDCS and the existing data may no longer be accurate
3. Delete the existing pending case and create a new case
For instructions and requirements for deleting an EDCS case, refer to Deleting and Manually Clearing Electronic Disability Collect System (EDCS) Cases - DI 81010.105.
Use this option only to start a new EDCS case (e.g., if a case was established at an incorrect case level). An EDCS case cannot be deleted if:
If Internet Disability Report (IDR) data existed for a deleted case, the data propagates into EDCS if another EDCS case is created unless the Internet Disability Report is purged (7 months from the first Internet Disability Report for the i3368 and 90 days for the i3820 and i3441).
NOTE: An alert message does not appear when establishing a reconsideration or hearing appeal in EDCS on a subsequent application when there is an Appeals Council level appeal pending on a prior claim.