Identification Number:
EM-19001 REV
Intended Audience:All RCs/ARCs/ADs/FOs/TSCs/PSCs/OCO/OCO
Originating Office:DCO OPSOS
Title:System Enhancements for Medical Continuing Disability Review (CDR) Appeal Process
Type:EM - Emergency Messages
Program:Title II (RSI); Title XVI (SSI); Disability
Link To Reference:See References at the end of this AM.
 
Retention Date: December 28, 2019

REVISION: We recently updated the EM to further explain the automated enhancements that are designed to improve the medical CDR appeal tracking and controlling process.

A. Purpose

This emergency message (EM) provides an explanation of changes to case processing of appeals for medical continuing disability reviews (CDRs), including an explanation of the automated enhancements designed to improve case monitoring and tracking.

B. Background

Unprocessed Medical Cessation (UMC) cases occur when the agency fails to terminate payments timely after a medical cessation determination. UMC cases remain in pay status for an extended period and adversely affect the agency’s trust fund.

Beginning January 26, 2019, system enhancements added functionality to prevent unprocessed medical cessations. These enhancements include changes to the Disability Control File (DCF) screens, the Electronic Disability Collect System (EDCS), the Title II Redesign System (T2R), Terminations, Attainments, Transfers and Terminations (TATTER) and Management Information (MI) Central functionality for improved case monitoring for CDR appeals. These new processes reduce the need for manual action and further automate the medical CDR appeal process.

C. Field Office (FO) Procedure

Before inputting a cessation appeal into EDCS, FO technicians should verify the presence of an initial medical or reconsideration medical determination in the DCF, review the Master Beneficiary Record (MBR) and Supplemental Security Income Display (SSID) to ensure the most recent medical determination data is posted, and, if an appeal is filed, obtain the necessary medical cessation appeal forms. FO technicians will use the collected information to update our systems using the newly outlined process explained in the chart below:


      1. Title II
      Title II: Process Before 1/26/2019
      Title II: Process After 1/26/2019
      1. Complete Post Entitlement Online System (POS) inputs to record the cessation appeal and Statutory Benefit Continuation (SBC) election.

      2. In EDCS, complete and transfer medical cessation appeals to Disability Determination Service (DDS) or Office of Hearing Operations (OHO).

      3. Upon receipt of the medical cessation determination, proceed with POS inputs to update the affirmations or reversals that do not automate.

      4. Review MBR to ensure the medical cessation appeal determination is reflected properly and SBC benefits are terminated.

      5. If the appeal determination did not process via the (TATTER) program, the PSC technician must process the input via MACADE.

      1. Document the CDR information, including SBC election, in EDCS.
          NOTE: A POS input is no longer necessary because the information in EDCS automatically updates the DCF, which in turn updates the MBR, via T2R, with the appeal level and the appropriate pay status. For this reason, if a beneficiary is late requesting SBC and we do not find good cause, we will select “no” in EDCS for the SBC election to prevent improper payments.

      2. In EDCS, complete and transfer the medical cessation appeal to DDS or OHO depending on the appeal level. The EDCS transfer will update the DCF and MBR with the applicable appeals type and SBC election.

      3. Upon receipt of the medical cessation determination, review the MBR to ensure the applicable information received from EDCS and the DCF updated automatically. No POS action is required. Verify the PRY code and the termination of SBC. The MBR should update within 5 days.

      4. If the MBR does not update within 5 days, technicians should verify that the DIBCESS issue is pending on PCACS and follow-up as necessary.


      2. Title XVI
      Title XVI: Process Before 1/26/2019
      Title XVI: Process After 1/26/2019
      1. Update SSID via Modernized Supplemental Security Income Claims Systems (MSSICS) or Direct Supplemental Security Record (SSR) Update to document medical cessation appeal filing as well SBC election.

      2. In EDCS, complete and transfer the medical cessation appeal to DDS or OHO.

      3. Upon receipt of the medical cessation appeal determination, verify SSID. Screen for pertinent fields (e.g. PSY, MG and DIA) that build the correct payment status.

      4. Review SSID to ensure SBC benefits have ended.

      1. Update the SSID via MSSICS to document medical cessation appeal filing as well as the SBC election. NOTE: If Direct SSR update is required, an EDCS Exclusion results. See EDCS Exclusion section below

      2. Access EDCS to ensure appeal and SBC election data propagated successfully from MSSICS. EDCS appeal data should mirror the appeal entered in MSSICS.

      3. Complete and transfer medical cessation appeal to DDS or OHO in EDCS.

      4. Upon receipt of medical cessation determination review the SSID. Screen for pertinent fields (e.g. PSY, MG, and DIA) that build the correct payment status.

      5. Review SSID to ensure SBC benefits have ended.

      6. If the SSID does not update, technicians should proceed with manual actions to update the SSID.

      3. Concurrent
      Concurrent: Process Before 1/26/2019
      Concurrent: Process After 1/26/2019
      1. Perform POS and MSSICS actions to document medical cessation appeal filing, including SBC election.

      2. Complete and transfer medical cessation appeal to DDS or OHO in EDCS.

      3. Upon receipt of the medical cessation appeal determination, proceed with POS inputs to update the MBR. Verify the SSID to screen for pertinent fields that build the correct payment status.

      4. Review both the MBR and SSID to ensure the medical cessation appeal determination is properly reflected and SBC benefits have ended for BOTH titled programs.

      1. First, prior to entering EDCS, update the SSID via MSSICS to document the medical cessation appeal filing as well as SBC election.

          NOTE: If case is concurrent appeal, you MUST first complete MSSICS before opening EDCS.

      2. Access EDCS to verify the concurrent appeal segments and ensure appeal and SBC election data propagated successfully from MSSICS. Enter additional Title II appeal data.

      3. In EDCS, complete and transfer the medical cessation appeal to the DDS or OHO. Ensure both the Title II and Title XVI segments are included in case transfer.

      4. Upon receipt of the medical determination, review both the SSID and MBR to ensure the medical cessation appeal determination automatically posted; and that SBC benefits have ended for BOTH titled programs. No POS action is generally required for the Title II claim. The MBR and SSID should both update within 5 days.

      5. If the MBR and SSID do not update within 5 days, for Title II, technicians should verify that the DIBCESS issue is pending on PCACS and follow-up as necessary. For Title XVI, manual actions to update SSID should be pursued.

      4. T2 Medical Cessation
      Upon receipt of the medical cessation request or determination on TII, review the MBR to ensure the applicable information received from EDCS and the DCF updated automatically. No POS action is required.
        · Medical cessation appeal request: Verify the PRY code and ensure SBC benefits begin as appropriate.
        · Medical cessation determination: Verify the PRY code and the termination of SBC benefits.
        · For both medical cessation appeal requests and determinations, the MBR should update within 5 days. If the MBR does not update within 5 days, technicians should verify that the DIBCESS issue is pending on PCACS and follow-up with the PSC as necessary.
        · If there is no DIBCESS issue on PCACS, or no exception on the THIS query, the FO should contact their Regional Office (RO) Coordinator for assistance. RO coordinators should report these problems on the SharePoint site via the DCF Problem Report.

D. Additional Implementation Changes

      1. EDCS


      EDCS serves as the communication hub for cessation appeal information creating consistent data that allows for automation and comprehensive tracking and monitoring of pending cases.

          a. For Title II cases, enter appeals directly into EDCS. EDCS will pass the information downstream, allowing it to post automatically to the MBR. EDCS collects appeal and statutory benefit continuation (SBC) data for Title II cases; and sends all pertinent appeal data to the Disability Control File (DCF)

          b. For Title XVI cases, continue to access MSSICS to load appeals and send the appeal and SBC data to the SSID. EDCS receives appeal data from MSSICS and sends all pertinent appeal data to the DCF.

          c. For concurrent cases, follow the sequence of steps outlined above. Begin with the Title XVI MSSICS process then enter Title II appeals into EDCS. This sequence initiates simultaneous automation: creates concurrent appeals segments in EDCS, sends pertinent appeals data to the DCF and updates the SSID/MBR as appropriate.

          d. For non-EDCS cessation appeals, see #6 below.

          For additional background pertaining to the new EDCS enhancement features, see MSS19-009 EDCS.

      2. Changes to Post Entitlement Online System (POS)

          Most Title II cessation actions are now automated making manual system updates using POS unnecessary. New alerts will be generated when attempts are made to manually enter a POS input that has been automated. The POS program will generate the following alerts when attempting to perform a manual POS input for an action automated by DCF and Title II Redesign (T2R)
                  · This Action May Have Automated; Verify a POS Input is Needed

                  · This Action Should Not Require a POS Input; Verify.

          Technicians should take great care not to proceed with a manual POS entry when alerted, as doing so may alter the automation process and compromise the ability for continued case tracking and monitoring.
      Claimant Request for Cessation Appeal
          After a technician inputs cessation information using EDCS, or DCF, the DCF passes data for the appeal request and SBC elections to Title II Redesign (T2R), which automatically updates the MBR. The DCF receives data from EDCS once the CDR is transferred to a component within the appeal’s jurisdiction.
      Posting Claimant’s Appeal Determination or Decision
          Manual actions to enter medical cessation reconsideration determinations into POS are no longer necessary. POS inputs will only be required to post Administrative Law Judge (ALJ) appeal reversals to the MBR for EDCS Exclusion cases; see #6 below.

          NOTE: A POS input is no longer necessary because information in EDCS automatically updates DCF, which in turn updates the MBR, via T2R, with the appeal level and the pay status. For this reason, if a beneficiary is late requesting SBC and we do not find good cause, we will select “no” in EDCS for the SBC election.

          For additional background pertaining to the new POS enhancement features, see MSS19-008 OTH.

      3. Changes to DCF
          The recent update expanded the DCF to house medical CDR appeal data. The DCF captures case data beyond the initial medical CDR level. Medical cessation appeal case movement and determination data (continuance/cessation) will automatically export from EDCS to the DCF. Limitations to this functionality exist for cessation appeals for EDCS exclusions.

          A new input screen, EDCS Exclusion Appeal Information (EEAI) screen will capture medical cessation appeal data for Title II EDCS exclusion cases. Section #6 below contains additional information regarding the EEAI screen’s role in EDCS exclusion cases.

          The APPE screen will display the appeals events associated with all of the appeals stored on the DCF database.

      4. New DCF Issues and Tickles
          New automated issues and tickles in the DCF alert technicians when additional action may be required for medical cessation cases.

          New issues and tickles include:

                · ALJT2EX: This tickle is generated when the EEAI screen is used to document and monitor the filing of an ALJ HEARING for TII EDCS exclusion cases

                · ADDLDEV: This tickle is generated when the DDS returns a Medical CDR folder/claim to the FO for additional action on a case with a pending reconsideration of a medical cessation. The ADDLDEV tickles will include a location code on the DCF development worksheet and will be visible to technicians in WAC effective with the September 2019 DCF release.

                · AUTOEFF: This tickle is generated for DCF records that fail to update in the nightly batch process. Effective with the September 2019 DCF release, the AUTOEFF tickles will no longer be created in the DCF. Additionally, all previously created AUTOEFF tickles will be removed from the DCF. Please disregard any AUTOEFF tickles that you may encounter.

          DCF tickles requiring action will appear on the FO technicians WMI listings following normal case processing instructions.
For additional background pertaining to the new DCF tickle enhancements, see MSS19-010 DCF.
      5. Changes to Management Information (MI) Central

          Enhancements to MI Central improve case monitoring and tracking efforts. MI Central functionality now tracks medical CDR appeals the same way it tracks initial medical CDRs. Cases available in DCF are now traceable in MI Central.

          NOTE: MI Central will not capture Title II hearings that are not in EDCS as that information isn’t available in DCF and cannot be exported into MI Central. It will not capture location of Title II reconsideration cases entered through the EEAI screen. MI Central will not capture any information for Title XVI cessation appeals not in EDCS.

          For additional background pertaining to the new MI Central enhancement features, see MSS19-008 OTH.

      6. EDCS Exclusion Cases
          When technicians are unable to load appeals to MSSICS or EDCS, appeal information does not automatically pass to the DCF. Appeals not in the DCF will not be available or tracked in MI Central. EDCS exclusions are not automatically captured in DCF nor tracked in MI Central.

          For Title II only EDCS exclusion, use the new DCF EEAI screen to record the appeal request. Once entered into the DCF, the information will pass to the Title II Redesign (T2R) system and update the MBR without need for a POS input.

          Reconsiderations: When appeal information is loaded to the DCF, the case will be appear in MI Central. However, EDCS will not be able to update the location. When a decision is received, DCF will automatically update the MBR. No POS input needed.

          Hearings: When an appeal request is entered on the EEAI screen, an ALJT2EX issue/tickle is automatically generated to monitor the case. These cases will not appear in the DCF pending file or in MI Central. When the decision is received, the technician will receipt the issue/tickle. Hearing affirmations, abandonments, dismissals, and withdrawals will continue to automatically post to the MBR using existing processes. However, hearing reversals will require a POS input to update the MBR. The tickle can be receipted once the MBR has updated correctly.

          For additional background pertaining to the new EDCS Exclusion enhancements, see MSS19-008 OTH.

      7. Program Service Center (PC) Updates
          Beginning January 26, 2019, T2R will process most medical cessation decisions and appeal requests previously sent into TATTER for processing. TATTER will continue to process initial medical cessation decisions and affirmation decisions at the OHO level based on an appeal. TATTER has one new exception for this release that will generate when a medical exception is received and there is a work CDR involved. T2R is a more modern system compared to the existing Terminations, Attainments, Transfers and Terminations (TATTER) program that processes various disability cessation transactions. T2R has implemented new exceptions and processing limitations for this release, however, most will never generate in production. Since T2R is receiving a batch file from the DCF, it must include various data edit exceptions to prevent the DCF from generating invalid data that could update to the MBR. For example, if the DCF sent a transaction to T2R, but the Date of Disability Onset (DDO) does not match a DDO in DIB data for that Beneficiary Identification Code (BIC), then T2R will generate B5MC26 to PCACS. However, that should never occur in production because the DCF has access to the MBR.

          Detailed code and remark information for the twelve new exceptions can be found in MSS19-008 OTH.

      8. Notices
          Manual Adjustment Credit and Award Processes (MADCAP), Universal Text Identifiers (UTIs) HIB170 and HIB170 will have an expanded use to include any termination of benefits with Medicare continuation not only for ESRD cases.

          HI170 and HIB17 will also now be available through T2R.
      9. Other
          To reduce improper payments, the known Title XVI problem with building the N07/N08 when a prior medical cessation appeal was present on the SSID was resolved in August 2018. For more information, see Modernized Supplemental Security Income Claims System (MSSICS) – 08/11/18 Maintenance Release - Problem and Resolution MSS18-077 MSI REV.
Direct all program-related and technical questions to your Regional Office (RO) support staff or Processing Center (PC) Operations Analysis (OA) staff. RO support staff or PC OA staff may refer questions or problems to their Central Office contacts.

References

DI 12026.025 Field Office (FO) Processing of the Request for Reconsideration of a Medical Continuing Disability Review (CDR) Determination
DI 12027.010 Processing Statutory Benefit Continuation (SBC)
DI 81010.255 Electronic Continuing Disability Review (eCDR) Cessation Reconsiderations
DI 81010.257 Electronic Continuing Disability Review (eCDR) Cessation Appeals-ALJ Hearing
DI 81010.000 FO Procedures - Electronic Process
Desk Guide New Desk Guide for the Medical Continuing Disability Review (CDR) Appeal Process


EM-19001 REV - System Enhancements for Medical Continuing Disability Review (CDR) Appeal Process - 06/28/2019