TN 4 (03-09)

DI 81020.117 Processing Medical Reactivations

A. Definition of 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. Medical Reactivation is only permitted on a claim with a medical determination in the most recently closed Certified Electronic Folder (CEF) case. A case is defined as all of the claims filed/adjudicated at the same time.

B. Identifying possible Medical Reactivation

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 in:

  • DI 27501.005 – Reopening and Revising a Determination or Decision

  • DI 27505.001 – Reopenings and Revisions: Pertinent Definitions and Related Policy

  • DI 28500.000 – Reopenings and Revision of CDR Determinations

NOTE: Use of Medical Reactivation is controlled by position and security profile. FOs, DDSs, Data Processing Branches (DPBs) and Federal Division Unit (FDU) are able to designate specific individuals who medically reactivate cases. The DDS and DPB must request that functional profile P73680P is assigned to the individual(s) by the Regional Center for Security and Integrity. The FDU must request that functional profile P73680P is assigned to the individual(s) by the Office of Central Operations (OCO) Center for Security and Integrity.

Medical Reactivation may be used when there are no open claims pending in EDCS or eView and:

  • Trailer mail is received that affects the final decision.

  • The FO detects an error on the 831 such as an incorrect regulation basis code, onset date, etc. and verifies with the DDS, DPB or 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.

C. Reactivating claim

When there are no current pending or open claims for the same person in EDCS or eView, claims in the most recently closed Certified Electronic Folder (CEF) with a medical determination can be Medically Reactivated.

1. Medical Reactivation using eView

To reactivate a claim:

  • Access eView,

  • Enter the SSN on the Case Selection screen and select the claim to reactivate;

    NOTE: Remember 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;

  • 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, and

  • 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.

2. A claim is Medically Reactivated by mistake

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; and

  • 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.

D. Processing Medical Reactivations in the DDS

1. Case receipt

The DDS, DPB, or FDU receives an EFI download and the claim appears in the EFI download queue. There is no paper associated with the medically reactivated claim.