Effective Dates: 4/15/2022 - Present

Identification Number:
DI 31001 TN 16
Intended Audience:
Originating Office:ORDP ODP
Title:Representation of Claimants
Type:POMS Transmittals
Program:All Programs
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM
Part DI – Disability Insurance
Chapter 310 – Representation of Claimants and Inquiries
Subchapter 01 – Representation of Claimants
Transmittal No. 16, 04/15/2022

Originating Component

ODP

Effective Date

Upon Receipt

Background

The Office of Disability Policy is revising this POMS section to accommodate longstanding Disability Determination Services (DDS) business processes.

Summary of Changes

DI 31001.010 Disability Determination Services (DDS) Responsibilities When an Appointed Representative is Involved

We updated this POMS section to:

  • •

    Clarify that DDS sends correspondence to the claimant with a copy to the representative,

  • •

    Add cross-references to GN 03910.050B for the Field Office and HALLEX I-1-1-20.E for the Office of Hearing Operations,

  • •

    Add documentation requirements for cases processed in the Disability Case Processing System, and

  • •

    Make minor language clarifications.

DI 31001.010 Disability Determination Services (DDS) Responsibilities When an Appointed Representative is Involved

A. Events that end a representative's appointment

See GN 03910.060B for the actions that end the appointment of a representative and his or her authority.

NOTE: If a claimant files a new disability claim, he or she must complete a new written notice of appointment (e.g., Form SSA-1696 (Claimant's Appointment of a Representative) or any other writing) and submit it to the Field Office (FO). See GN 03910.060E for information on appointment of representative in subsequent disability applications.

B. Contacting represented claimants

A represented claimant may continue to participate in the development of his or her claim, through the appointed representative or directly with SSA or the DDS.

1. Claimant initiates contact

If a represented claimant contacts SSA or the DDS, SSA or the DDS may discuss his or her specific issue. A represented claimant does not need permission from the appointed representative to contact SSA or the DDS or SSA directly.

2. SSA or DDS initiates contact

If the claimant appoints a representative, generally the DDS initiates all contacts connected to that claim through, or with the permission of, the appointed representative. See GN 03910.050 for information about when to contact represented claimants directly.

In scenarios with multiple appointed representatives and it is not clear who is currently appointed or who is the principal representative, see GN 03910.040C for information on when multiple representatives are appointed.

EXAMPLE: The claimant appointed two representatives at different times and the representatives do not appear to be working together. In this instance, SSA will contact the claimant directly to clarify the situation.

C. Potential issues

Representation issues may arise while the case is at the DDS. While the FO is responsible to accept appointments and address fee-related issues, the DDS is responsible to help representatives comply with our program rules.

1. Appointed representative requests SSA or the DDS to communicate directly with the claimant regarding a specific issue

If the representative requests that we communicate directly with the claimant regarding a specific issue:

  • •

    Prepare an SSA-5002 (Report of Contact), Electronic Claims Analysis Tool (eCAT) Claims Communication, or Disability Case Processing System (DCPS) Case Note to document that the DDS will deal directly with the claimant on the specific issue;

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    Include the SSA-5002, eCAT Claims Communication, or DCPS Case Note in the file. For paper cases, send a copy to the FO;

  • •

    Post a message in eView to notify the FO of the representative’s request.

2. Represented claimant requests SSA or the DDS to communicate directly with him or her regarding a specific issue

If a represented claimant requests that we communicate directly with him or her regarding a particular issue:

  • •

    Prepare an SSA-5002 describing the claimant’s desire to communicate directly with the DDS on that specific issue;

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    Include the SSA-5002 in the electronic folder. For paper cases, send a copy to the FO;

  • •

    Post a message in eView to notify the FO of the claimant’s request.

IMPORTANT: A represented claimant’s request to communicate directly with him or her regarding a specific issue is not the same as revoking the appointment of representation. Remind the claimant that the representative will continues to have access to the file, which may include information regarding the issue that he or she identified.

3. Appointed representative contacts the DDS

If the representative contacts the DDS, subsequent actions taken depend on whether the DDS issued the Personalized Disability Explanation (PDE). To determine the PDE’s date of issue, see DI 81020.130D.

a. Before PDE issuance and case is pending at the DDS

When an appointed representative contacts the DDS to discuss his or her client’s case before PDE issuance and the case is at the DDS, provide the following information that is relevant to the contact:

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    Identify sources of medical information.

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    Indicate development undertaken or outstanding.

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    Clarify the need for a development request, if necessary.

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    Advise the representative of his or her right to both review or receive copies of material in the claimant's file.

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    Do not disclose information about the disability claim determination to an appointed representative until claim processing is complete.

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    Prepare an SSA-5002 or document the nature of the appointed representative’s request in an eCAT Claims Communication or a DCPS Case Note, and the actions taken to comply with the request.

b. When the case is no longer at the DDS

When an appointed representative contacts the DDS to discuss his or her client’s case after PDE issuance and the case is no longer at the DDS, inform the inquirer that the DDS forwarded the claim to another office, and take the following action(s):

  • •

    Forward the inquiry to the office with jurisdiction of the claim for a response;

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    Advise the inquirer to contact the servicing FO if he or she has further questions about the claim; and either

  • •

    Add an alert to the electronic folder for electronic claims according to the instructions in DI 81020.080; or

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    Complete an SSA-408 (Route Slip) for paper claims and annotate with the comment: “Inquiry – Action Needed.”

For more information about handling inquiries when the case is no longer at the DDS, see DI 31005.005.

4. Document the claims folder

Take the following actions to document the claims folder:

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    Retain copies of all correspondence between the representative, SSA, and the DDS in the claims folder;

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    Document correspondence with the representative in the claims folder. Place the documentation in the eCAT Claims Communications or DCPS Case Notes section of the Disability Determination Explanation (DDE), or on an SSA-5002. This documentation is important to evaluate fee.

5. The DDS receives appointed representative information or fee-related documents by mail or via fax

If the DDS receives representative information or fee related documents by mail or fax, the DDS returns the document to the sender following instructions in DI 31001.001B.1.

6. Evidence furnished by appointed representative

A claimant must inform us about or submit all evidence known to him or her that relates to whether or not he or she is blind or disabled. An appointed representative must act with reasonable diligence and promptness to help obtain all information or evidence that the claimant must submit and promptly forward the information or evidence to us for consideration. Appointed representatives must submit or inform SSA of all known evidence regardless of the perceived effect the evidence has on the outcome of the disability determination (i.e. whether the evidence helps or hurts the case). For examples of violations of this requirement, see GN 03970.010.

The DDS is responsible for appropriate, necessary, and correct development of all known evidence that relates to whether the claimant is blind or disabled.

Treat evidence provided by a representative as if the claimant provided it. Consider this evidence as part of the total record on which you base the determination.

7. Notices and correspondence

Send all notices and correspondence to both the claimant and the appointed representative, as follows:

  • •

    Send requests for developmental evidence or action (e.g., work history or disability reports, questionnaires, medical deferment, call-in letters) to the claimant and a copy to the representative.

  • •

    Send requests to attend a consultative examination (CE) or a disability hearing to the claimant and a copy to the representative.

  • •

    Send determination notices to the claimant and a copy to the representative.

NOTE: Sending requests to attend a CE or other requests for evidence or action to both the claimant and the representative ensures that both parties are made aware the requests.

For notices and correspondence specific to the FO, see GN 03910.050B. For notices and correspondence specific to the Office of Hearing Operations (OHO), see HALLEX I-1-1-20.E.

8. Representative uncooperative

If a representative is uncooperative, such as encouraging the claimant to not cooperate with SSA or DDS’ request for evidence, proceed with adjudication of the claim, and making direct contact with any source the representative submitted evidence from.

  • •

    Use normal follow-up procedures and diaries described throughout DI 22505.000.

    Do not delay the case beyond the time ordinarily allowed a claimant acting on his or her own behalf. Instead, adjudicate the case on the evidence in the record.

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    Use normal “failure to cooperate” procedures found if either the claimant or the representative is uncooperative (see DI 23007.000).

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    Refer representatives who routinely fail to cooperate to the regional office (RO). Proceedings may begin to suspend or disqualify a representative from acting as a representative if the representative violated his or her affirmative duties or engaged in prohibited conduct.

9. Make a determination

If the claim has insufficient evidence to make a disability determination, deny the claim. For information on collecting and evaluating evidence, see DI 11010.530.

D. Make a referral for appointed representative misconduct

When an employee interacts with an appointed representative who:

  • •

    Precludes us from obtaining information or evidence that the claimant must inform us about or submit;

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    Violates his or her affirmative duties; or

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    Engages in prohibited conduct.

The DDS must refer the representative to the Office of the General Counsel (OGC) for further investigation.

For referral instructions, see DI 31001.010D, DI 31001.010E, and GN 03970.017.

For definitions of affirmative duties and prohibited conduct, see GN 03970.010.

1. The DDS actions regarding referral for appointed representative misconduct

Prepare form SSA-166 (Report of Representative Misconduct) to refer suspected appointed representative misconduct to OGC for possible investigation and sanctions. Do not store any referral development in the claim folder. Do not include a copy of the completed Form SSA-166 in the claim folder.

Email the completed Report of Representative Misconduct form to the appropriate regional center for disability (CD), center for program support (CPS), or specified regional contact below:

||SEA ARC MOS

||CHI ARC MOS CD

||KC CDP

||PHI MOS CTR Disability and Programs

||DA DP

||BOS Center for Disability

||SF MOS CDPS

||DEN CFD

||NY CDPS

||ATL MOS CDPS

Continue to adjudicate the claim after you send the referral to the regional contact.

Open the “Alerts/Messages” section in an affected claimant’s electronic case file and create a new message entitled, “OGC Referral - Representative Misconduct.” Do not enter an expiration date, which helps avoid premature and automatic deletion of the alert or message. If the potential violation involves evidence in the case file (or a lack of evidence), provide relevant details in the message. This information should not be accessible to non-SSA or DDS employees. If you take further action, or the regional contact or OGC declines to pursue potential sanctions, document the message.

2. Regional office actions regarding referral for appointed representative misconduct

Regional offices (RO) review the DDS referrals about appointed representative misconduct and determine whether to forward those referrals to OGC for further consideration. The RO forwards a referral to their regional OGC, and sends a copy of the referral to SSA headquarters at Representative.Referrals@ssa.gov.

The regional office contact maintains records of:

  • •

    Referrals they receive; and

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    Referrals they forward to OGC and a copy of the referral to headquarters.

3. OGC actions regarding referral for appointed representative misconduct

OGC reviews the referral about appointed representative misconduct and takes appropriate action. Such action may include closing the case with a finding of no misconduct, informal resolution or initiating proceedings to suspend or disqualify the individual from acting as an appointed representative. OGC may contact the referring office or region for more information or assistance. The regional OGC maintains records of:

  • •

    Referrals they receive; and

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    Statuses of all representative referrals received.

4. Referrals for appointed representative misconduct versus referrals for possible fraud or similar fault

Some non-fee violations may also qualify as criminal violations. If so, complete separate referrals. If the evidence suggests both appointed representative misconduct and possible fraud or similar fault, complete a form SSA-166 (Report of Representative Misconduct), and submit a referral through the Allegation Referral Intake System (ARIS) for possible fraud or similar fault.

For more information about referrals for possible fraud or similar fault, see GN 03970.016 and DI 23025.000.

5. How to track the status of your referral for appointed representative misconduct

DDS management may contact your regional contact to track the status of a referral. Regional contacts contact OGC for status updates on a case-by-case basis or in accordance with their office policies. OGC informs the referring component when they resolve a case.

E. DDS instructions to complete form SSA-166 (Report of Appointed Representative Misconduct)

Use form SSA-166 (Report of Representative Misconduct) when you suspect that an appointed representative violated the rules of conduct and standards of responsibility for representatives or otherwise inhibited case development.

Do not use form SSA-166 to make referrals for possible fraud or similar fault. Use ARIS to make referrals for possible fraud or similar fault to the Office of the Inspector General (OIG).

1. Section A – Origin of Referral

Check the DDS box to indicate that the referral for representative misconduct originated in a DDS.

Provide the DDS location or site code and address. To obtain a code or address, go to the DDS Community>>Disability Contacts page, and select the DDS Telephone Directory.

Provide the name, title, work phone number, and work email address for the technician making the referral and for an alternate contact, likely a supervisor or other DDS designated contact.

2. Section B – Representative Identification Information

Provide identifying information for the appointed representative. Include the appointed representative’s name, applicable firm or company, telephone number, address, and the representative identification (Rep ID), if the representative is registered, or Social Security number, where applicable and available.

3. Section C – Reason for Referral

If the referral stems from a specific claim for benefits, provide the name and Social Security number of the claimant or Number Holder.

List the date of the incidents. For example, list the dates of conversations and written communications where an appointed representative informed the DDS that the representative and representative’s client would not provide necessary information to the DDS for adjudication of a disability claim.

a. Applicable situations

Check all appropriate boxes to indicate the situations that apply to the referral. Options include:

  1. (1) 

    The representative failed to provide prompt and responsive answers to requests and communications from you, pertaining to the processing of a pending claim. Examples include:

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      Filling out forms,

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      Providing medical sources,

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      Providing medical evidence,

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      Authorizing SSA or the DDS to obtain a claimant’s treatment records,

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      Replying to notices,

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      Returning telephone calls or other communications, or

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      Reason for a delay in processing the claim.

  2. (2) 

    The representative informed you that the representative or the claimant would not provide you with requested information or action.

  3. (3) 

    The representative provided you with incomplete evidence, such as an incomplete or altered medical record, or a form with substantive information missing.

  4. (4) 

    To the best of your knowledge, the representative, in any way:

    • •

      Submitted false or misleading documents;

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      Tried to conceal, delete, or alter evidence; or

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      Provided misleading, inaccurate, or untrue information.

  5. (5) 

    The representative instructed a claimant not to attend a scheduled CE or obstructed your ability to schedule a CE for a claimant.

  6. (6) 

    A represented claimant informed you that his or her representative told him or her not to provide certain evidence, answer questions, or take certain requested actions.

  7. (7) 

    A represented claimant informed you that his or her representative has not assisted in complying with requests for information or evidence, in a manner you find unreasonable.

  8. (8) 

    The representative threatened, attempted to coerce, or intimidated you or anyone in your office.

  9. (9) 

    To your knowledge, the representative engaged in other unethical behavior or behavior inconsistent with the rules of conduct and standards of responsibility for representatives. For more information, see GN 03970.010 Rules of Conduct and Standards of Responsibility for Representatives.

  10. (10) 

    The representative engaged in other behavior or inactivity that you believe warrants a referral to OGC.

b. Detailed explanation of the referral for appointed representative misconduct

In the blank space at the end of form SSA-166 (Report of Representative Misconduct), explain the situation(s) that led to the referral and provide details. In your statement, use the format of who, what, when, where, how, and why you are making the referral. Discuss the following:

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    Detail the actions or inaction that raised suspicion about possible appointed representative misconduct;

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    Communications with the appointed representative that occurred in the course of normal case development about the issues that raised suspicions;

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    Whether you referred this matter for possible fraud or similar fault using ARIS and the reason for your decision per DI 23025.000;

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    When applicable, the name and title of DDS management who reviewed and approved the referral for appointed representative misconduct.

F. References

DI 31001 TN 16 - Representation of Claimants - 4/15/2022