PROGRAM OPERATIONS MANUAL SYSTEMPart DI – Disability InsuranceChapter 265 – Initial Case ProcessingSubchapter 30 – Personalized Disability ExplanationsTransmittal No. 4, 01/23/2019
This is a QAT. These revisions do not change or introduce new policy.
Summary of Changes
DI 26530.005 Cases Requiring a Personalized Disability Explanation
Alphabet D-2 was revised and added alphabet D-3.
The following notices require a personalized disability explanation:
Initial title II and title XVI medical and medical/vocational denials;
Initial title II and title XVI Substantial Gainful Activity (SGA) denials;
Initial title II and title XVI closed period allowances; and
Unfavorable onset date allowances
Closed period allowances in which the onset and cessation dates are the same as those alleged;
Title XVI cases in which onset is alleged prior to the protective filing month, but established during the protective filing month, or during the month of filing if there is no protective filing.
DWB or Childhood Disability Beneficiary (CDB) claims in which the onset is set later than alleged but which allows payment or entitlement to Medicare for the disabled at the earliest date based on the retroactivity of the application, number holder's date of death or first month of entitlement.
DIB claims when the Alleged Onset Date (AOD) is earlier than the date insured status is first met (for MQGE claims, see DI 25501.280A.2.);
DIB claims in which the period of disability ends due to attainment of full retirement age (FRA). In these cases, the disability benefits are converted to retirement benefits.
Any adverse title II reopening determination in which a written, personalized disability explanation of the adverse action is not provided under due process (see DI 27536.000);
Title II or XVI reopenings which are less than fully favorable.
Title XVI multicategory cases: If a currently entitled SSI beneficiary files to establish entitlement under a second category and the subsequent claim is denied, the DDS will prepare and release the personalized notice outlined in DI 26535.021.
A personalized notice is not necessary when an individual files a disability claim alleging a visual impairment and the DDS makes a fully favorable determination based on another impairment since the determination is not totally or partially unfavorable.