Identification Number:
DI 13015 TN 10
Intended Audience:See Transmittal Sheet
Originating Office:ORDP ODP
Title:Special CDR Issues
Type:POMS Transmittals
Program:All Programs
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM
Part DI – Disability Insurance
Chapter 130 – Continuing Disability
Subchapter 15 – Special CDR Issues
Transmittal No. 10, 01/31/2020

Audience

PSC: BA, CA, CS, DE, DEC, DTE, ICDS, IES, ISRA, PETE, RECONR, SCPS, TSA, TST;
OCO-OEIO: BET, BIES, CR, ERE, FCR, FDE, PETL, RECONE, RECONR;
OCO-ODO: BET, BTE, CR, CST, CT, CTE, CTE TE, DE, DEC, DS, PAS, PETE, PETL, RCOVTA, RECONE, RECONR, RECOVR;
ODD-DDS: DHU, REF;
FO/TSC: AWIC, CS, CS TII, CS TXVI, CSR, CTE, DRT, FR, OA, OS, RR, TA, TSC-CSR, WIL;

Originating Component

ODP

Effective Date

Upon Receipt

Background

This is a Quick Action Transmittal. These revisions do not change or introduce new policy or procedure.

Summary of Changes

DI 13015.001 Failure to Cooperate-Insufficient Evidence Decision (FTC) Policy for Continuing Disability Reviews (CDRs) - Field Office

Added clarifying language to when the streamline FTC process does not apply with relevant references.

DI 13015.001 Failure to Cooperate-Insufficient Evidence Decision (FTC) Policy for Continuing Disability Reviews (CDRs) - Field Office

This subchapter provides policy guidance to field offices (FOs) when the beneficiary or recipient does not provide information requested during a CDR.

A. FTC CDR policy

FTC during a CDR occurs when:

  • there is a question about whether a beneficiary or recipient continues to be disabled

  • he or she fails to provide the requested information or evidence within the specified period, and

  • the FO followed the development steps in DI 13005.025 Field Office (FO) Actions to Initiate a Continuing Disability Review (CDR) and DI 13005.030 Field Office (FO) Personal Contacts and Exceptions.

B. FTC- medical CDR

1. Streamlined FTC process- FO

The streamlined FTC process, implemented for medical CDRs on January 27, 2007, enables the FO to suspend Title II and Title XVI benefits when the beneficiary or recipient does not respond to our requests for information or evidence. This streamlined process does not apply in disability cessation appeals. See FO appeal procedures in DI 12026.025E.4 and DI 12010.005. When the streamlined process applies:

  • The FO suspends benefits or payments, and does not refer the case to the disability determination services (DDS) for a medical determination.

  • If the beneficiary or recipient cooperates and provides the requested information for the CDR within the 12 months, and there are no other outstanding factors to resolve, the FO can reinstate benefits and continue the medical CDR process. The FO then forwards the CDR to the DDS for a medical determination. This does not apply if the record has terminated. For FTC cases that have terminated, obtain an appeal if within the appeal period or obtain a new application.

  • If benefits or payments remain in suspense for 12 months, eligibility terminates effective the 13th month.

Note: Statutory benefit continuation (SBC) does not apply per DI 12027.015 Cases Excluded from Statutory Benefit Continuation (SBC).

2. FTC DDS or Program Service Center (PSC) requests FO assistance

The DDS or PSC may request FO assistance in obtaining the individual's cooperation, or in conducting the medical CDR interview. For more information, see DI 13015.025 Field Office Assistance in a Medical Continuing Disability Review (CDR) and Failure to Cooperate- Insufficient Evidence Decision (FTC) or Whereabouts Unknown (WU) Cases.

3. Exception to streamlined CDR FTC process

The streamlined CDR process does not apply to medical CDRs for extended Medicare cases. For information on extended Medicare entitlement see DI 28055.001B. If the beneficiary does not cooperate with the FO's requests for information or evidence for this type of CDR, refer to DI 13015.005D.

C. Overview of streamlined CDR FTC process

1. Beneficiary or recipient fails to provide requested information to the FO

  • The FO makes a FTC determination and records it on the Disability Control File (DCF) after following the development steps in DI 13005.025 and DI 13005.030.

  • The DCF FTC input places benefits in non-payment status (LAF S0 for Title II/ PS N20 for Title XVI).

  • The suspension notice automatically generates when the transaction is processed.

If the beneficiary subsequently cooperates and provides the requested information during the 12-month suspension period, reinstate benefits for any previous months for which they are otherwise payable if all other factors of entitlement are met. The beneficiary does not file an appeal to have benefits reinstated.

If the beneficiary does not cooperate during the 12-month suspension period, benefits automatically terminate effective the 13th month. No benefit continuation will be offered.

Note: For FO FTC procedures refer to DI 13015.005 Failure to Cooperate-Insufficient Evidence Decision (FTC) Suspension Procedures for Continuing Disability Reviews (CDR)- Field Office (FO).

2. Suspension month

We will suspend benefits effective with the first month that does not cause an overpayment. Note: For Title II claims, we will also suspend benefits to any auxiliaries on the record.

3. Termination month

After 12 months of suspension, we will terminate eligibility effective with the 13th month if the individual did not comply with our request for necessary information or evidence. No DDS medical determination is necessary to terminate benefits.

Example: After all contact attempts have been unsuccessful, the beneficiary does not respond by the final closeout date of 04/25/2018. The FO records the FTC determination on the DCF; benefits are suspended effective 06/2018 (the first month that does not cause an overpayment). If the beneficiary does not cooperate during the period of suspense, benefits terminate effective the 13th month (06/2019).


DI 13015 TN 10 - Special CDR Issues - 1/31/2020