TN 1 (06-05)

HI 03010.040 Information/Evidence and Closeout

A. Introduction

After a subsidy application is filed, SSA may need additional information if the application is not complete. Also, SSA may need evidence to support an allegation which differs from SSA's matched data.

An individual is ineligible for the subsidy if he/she fails to provide the requested information or evidence within the 15-day specified time period.

B. Policy

1. SSA responsibilities

SSA must:

  1. Obtain the necessary information/evidence to determine an individual's eligibility.

  2. Offer assistance to individuals and their personal representatives in obtaining information/evidence needed to determine the individual's eligibility. The offer must be made during the initial contact with the individual and all subsequent contacts that involve requests for additional information/evidence.

2. Claimant/Personal representative responsibility

The individual or personal representative is responsible for:

  1. Answering all application questions to the best of his/her knowledge.

  2. Providing the necessary information, documents, or evidence to prove that the eligibility requirements for the subsidy are met.

3. Evidentiary standards for the subsidy

The evidentiary standards in GN 00301.000 do not apply to subsidy cases (except as explained in HI 03020.030D.1. regarding verification of alleged higher IRWE or BWE). For subsidy purposes only:

  • SSA will only request documentary evidence if an individual's explanation of a discrepancy between the application or redetermination form and data obtained from other Federal agencies does not seem reasonable in the CR's judgment. Most issues or discrepancies should be resolved by a phone call and documented in MAPS as described in HI 03035.006, HI 03035.010, HI 03035.020 and HI 03035.030.

  • If the CR believes that documentary evidence is required, original documents are not required. We will accept photocopies or FAXed documents.

Do not retain any paper documents. Annotate MAPS to indicate the evidence received. Do not annotate subsidy documentation on the Shared Process EVID screen

EXCEPTION: If an issue affects Title II or XVI as well as the subsidy, follow the evidentiary rules in GN 00301.000 to document the Title II or XVI case.

C. Procedure - obtaining information/evidence

1. General

Take these steps when obtaining information/evidence:

  • Request information/evidence directly from the individual or personal representative.

  • Explain what information/evidence is needed and why.

  • Advise that we will attempt to obtain the information/evidence by phone and, if unsuccessful, we will send a notice stating that the information/evidence must be provided within 15 days after the date of the notice.

  • Explain that timely cooperation in providing the information/evidence is important.

  • Assist in obtaining necessary information/evidence if the individual has difficulty obtaining it himself. The extent of SSA's assistance in obtaining information/evidence is determined on a case by case basis.

2. WBDOC exception processing

If an SSA-1020-OCR is received with required questions unanswered, inconsistent answers (e.g., both “Yes” and “No” blocks are checked for the same question for the same person), or illegible answers, WBDOC will attempt to contact the individual to obtain the answer.

WBDOC employees will make two telephone attempts to obtain the information. If those attempts are unsuccessful, WBDOC will send a written request (HI 03010.040F). The notice is generated from the MAPS Exception screen and will ask each question on the SSA-1020 for which a response is needed. If the individual calls the 800 number after receiving the WBDOC notice, transfer the call to the Workload Support Unit (WSU) to obtain the information requested by WBDOC. If the individual contacts the FO after receiving the notice, a CR should obtain the information.

Document the results of the contact on the MAPS Exception Screen. If the individual does not respond to the letter within 15 days plus 5 days mail time, the WBDOC will annotate Failure to Cooperate per MSOM INTRANETMAPS 006.007. This will generate the pre-decisional notice and, if no timely response is received, the formal denial notice with appeal rights (see HI 03035.050).

3. FO exception processing

If a FO or WSU completes a MAPS application but the applicant is unable to answer one or more questions at the time of the interview or if a case with unanswered questions is transferred from the WBDOC to the FO, the FO/WSU will attempt two phone contacts to obtain the information. Document the results of the contact on the MAPS Exception Screen.

If those attempts are unsuccessful, send a written request (HI 03010.040G). The notice is generated from the MAPS Exception screen and will ask each question on the SSA-1020 for which a response is needed. See HI 03010.038C.17. for signature requirements for partially completed MAPS claims.

Document the responses in MAPS per HI 03010.040D. If no response is received within 15 days plus 5 days mail time after the notice is sent, annotate Failure to Cooperate per MSOM INTRANETMAPS 006.007 . This will generate the pre-decisional notice and, if no timely response is received, the formal denial notice with appeal rights (see HI 03035.050).

4. FO evidence requests

If a case is sent to the FO for verification as described in HI 03035.006, HI 03035.010, HI 03035.020 or HI 03035.030, contact the individual per those sections to resolve the issue(s).

Attempt two phone contacts to obtain the information. If those attempts are unsuccessful, send a written request (HI 03010.040H.) from the MAPS verification screens.

Document the response in MAPS per HI 03010.040D. If no response is received within 15 days, annotate Failure to Cooperate per MSOM INTRANETMAPS 006.005 . This will generate the pre-decisional notice and, if no timely response is received, the formal denial notice with appeal rights (see HI 03035.050).

D. Procedure - what to do when information or evidence is received

The subsidy application is a fully electronic process. No paper will be maintained.

Record answers to application questions or verification issues on MAPS screens per MSOM INTRANETMAPS 006.003 MAPS Report of Contact (DWRC).

See HI 03035.007 for documentation requirements. Do not use the EVID screen in the Shared Process.

E. Procedure - denying an application

1. Documentation

a. Document

Document the basis for failure to cooperate.

  • Create a new report of contact for each attempt to contact the applicant by phone. The two phone calls should be made at different times of the day to increase the chances of making contact. Use the Comments section of the Report of Contact to document the results of your attempts.

  • If the phone attempts do not successfully resolve the issue, send the Information Request Notice or Evidence Request Notice per HI 03010.040C. A copy of these notices will be stored on ORS.

  • The Report of Contact history in the Developmental Worksheet will display each report of contact created for the application.

b. Annotate the Report of Contact screen on MAPS

Annotate the Report of Contact screen on MAPS with the questions that were not answered or for which there were conflicting responses. The Evidence Summary portion of the verification screen lists the evidence that was requested.

2. Appeals

Follow the procedures in HI 03040.001 through HI 03040.400 if there was no response to the pre-decisional notice and the claimant contacts SSA within the 60-day appeals period following the receipt of the denial notice.

F. Exhibit - WBDOC exception processing letter

This notice is used by WBDOC per HI 03010.040C.2. when requesting information needed to process a subsidy application.

Social Security Administration

Medicare Prescription Drug Assistance

Application Development

Mr. Frank Johnson

111 Bird Rd. Telephone: 410-222-7777

Randallstown, Md. 21133 Date: 11/05/04

Social Security Number:

123-00-6789

This is a very important letter and could affect whether you get extra help to pay for your prescription drugs. Please read carefully. If there is anything you do not understand, please get in touch with us right away.

What You Need To Do

We need more information to decide if you are eligible for this extra help. Therefore, it is important that you mail the following information.

The office address is at the top of this letter.

  • Please enter the value (money amounts) of bank accounts, (checking, savings, and certificates of deposit) that either you (or your spouse if living together) or both of you own in the space below.

__ None $_________

If We Do Not Hear From You

We may deny your Application for Help with Medicare Prescription Drug Plan Costs if you do not respond to this request or contact us by ________ to tell us why.

If You Have Any Questions

If you have any questions or need help, please call us at the telephone number at the top of this letter and ask for_________________________.

Manager

Enclosure

Postage Paid Return Envelope

G. Exhibit - FO exception processing letter

This notice is used by the FO per HI 03010.040C.3. when requesting information needed to process a subsidy application.

Social Security Administration

Medicare Prescription Drug Assistance

Application Development

Office Address: PO Box 1041

Randallstown

Md. 21218

Mr. Frank Johnson Office Hours: 8:00 a.m. - 4:00 p.m.

111 Bird Rd. Telephone: 410-222-7777

Randallstown Md. 21133 Date: 12/05/04

Social Security Number

123-00-6789

This is a very important letter and could affect whether you get extra help to pay for your prescription drugs. Please read carefully. If there is anything you do not understand, please get in touch with us right away.

What You Need To Do

We need more information to decide if you are eligible for this extra help. Therefore, it is important that you mail or bring in the following information.

The office address is at the top of this letter.

  • Please enter the value (money amounts) of bank accounts, (checking, savings, and certificates of deposit) that either you or your spouse (if living together) or both of you own in the space below.

__ None $_________

If We Do Not Hear From You

We may deny your application for help with Medicare Prescription Drug Plan Costs if you do not respond to this request or contact us by ________to tell us why.

If You Have Any Questions

If you have any questions or need help, please call us at the telephone number at the top of this letter and ask for _________________________.

Manager

Enclosure

Postage Paid Return Envelope

H. Exhibit - FO request for information or evidence

This notice is used by the FO per HI 03010.040C.4. when requesting evidence needed to process a subsidy application.

Social Security Administration

Medicare Prescription Drug Assistance

Application Development

Office address: 343 West Road

Burbank, MD 21217

Office Hour