Effective Dates: 8/14/2023 - Present

Identification Number:
DI 28030 TN 43
Intended Audience:See Transmittal Sheet
Originating Office:ORDP ODP
Title:General Development of CDR Cases
Type:POMS Full Transmittals
Program:All Programs
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM

Part DI – Disability Insurance

Chapter 280 – Continuing Disability Review Cases

Subchapter 30 – General Development of CDR Cases

Transmittal No. 43, 08/14/2023

Audience

PSC: CS, DE, DEC, DTE, IES, RECONR, SCPS, TSA, TST;
OCO-OEIO: CR, ERE, FDE, RECONE;
OCO-ODO: BET, CR, CTE, CTE TE, DE, DEC, DS, PETE, PETL, RECONE;
ODD-DDS: ADJ, DHU;

Originating Component

ODP

Effective Date

Upon Receipt

Background

Background of Major Revisions:

1) Provide clarification that an Supplemental Security Income Display (SSID) query should be obtained for all continuing disability review (CDR) cases, including Title II only, Title XVI only, and Title II/Title XVI Concurrent cases (Subsection A)

  • •

    The Disability Determination Services (DDS) must perform a query on all CDR cases prior to medical evaluation, for all beneficiaries and recipients, ensuring a comprehensive and equitable approach to identifying and resolving potential issues early in the CDR evaluation process.

    The revisions clearly state the requirement to obtain a query to review potential discrepancies at the initiation of case development for all initial-level CDR cases. This clarification provides clear instructions on when this requirement applies, and establishes a more consistent, comprehensive, and equitable approach to address any issues that may arise for disability beneficiaries and recipients.

    The purpose of performing a query during a CDR is to identify potential issues early in case development to correct or address them. By addressing issues early in the review process, this action reduces the burden on the beneficiary and recipient, as well as the field office (FO) staff and the DDS staff. Title II, Title XVI or Title II/Title XVI Concurrent beneficiaries or recipients stand to benefit from clearly and plainly stating this requirement to review the query fields discussed in this section, as it leads to improved identification of issues to avoid unnecessary processing, and ensuring appropriate communication is received to the correct address and payee.

  • •

    Perform an SSID query (as opposed to SSID, SSI2, or SSI3)

    The prior version of this Section indicated that the SSID, SSI2, or SSI3 query should be performed for CDR cases. We have revised the instructions to perform the SSID query because it is the most comprehensive version that includes all the indicator sections discussed within this POMS Section.

 

2) Remove the requirement to perform a query upon closure (Subsection A)

  • •

    The requirement for the DDS to obtain a query upon the receipt of the case remains, but we are removing the requirement to obtain an additional query upon closure of the CDR case. This requirement is not necessary, as updates or changes to the case record for the criteria discussed in DI 28030.010 would be sent from the FO to the DDS through an Update After Transfer (UAT). This process is discussed in DI 81010.095. The DDS will then accept any updates and perform any necessary actions.

 

3) Added clarification of query documentation requirements (Subsection E)

  • •

    Instructions have been added to this section to indicate when a copy of the query should be scanned in or uploaded to the electronic folder and documentation requirements. We have added instructions for consistency with existing electronic folder policy in DI 81020.050, and general documentation requirements for disability development in DI 20503.001E.

 

4) Created a table with query fields, the meaning of the fields, and additional references and notes specific to DDS review, interpretation, and action (Subsection C and D)

  • •

    A table was added to this POMS showing the different query fields the DDS must review, which includes specific query field codes and the content meaning for the DDS. This information is specific and provides directions to look for specific discrepancies.

Summary of Changes

DI 28030.010 Understanding and Using Supplemental Security Income Display (SSID, SSI2 or SSI3) Query Replies to Determine Title II Entitlement and Title XVI Eligibility

  • •

    Revised the title from "Understanding and Using Supplemental Security Income Display (SSID, SSI2 or SSI3) Query Replies to Determine Title II Entitlement and Title XVI Eligibility" to "Use of the Supplemental Security Income Display (SSID) Query in Continuing Disability Review (CDR) Cases."

 

Subsection A:

  • •

    Revised the title from "Overview of the SSID" to "When to perform a query for a CDR case." Subsection A provides clear instructions that the DDS should perform a query for all CDR cases and provides related references. The content in Subsection A also reflects the update to the policy that a query only needs to be performed upon DDS receipt of the case, revising the requirement to perform a query upon receipt and prior to closure at the DDS (previously in Subsection B).

  • •

    The content previously in Subsection A that provides information about why a query is performed and the type of information it may produce is in to Subsection B.

 

Subsection B:

  • •

    Revised the title from "DDS use of the query" to "Why queries are performed for CDR cases." The content was previously in Subsection A, and is now in Subsection B.

 

Subsection C:

  • •

    Revised the title from "Understanding the Title XVI supplemental security income (SSI) record using the SSID query system" to "Understanding the SSID query." This content was expanded and put in a table for easy readability. References, notes, and DDS reviewer content was added.

 

Subsection D:

  • •

    Revised the title from "References" to "Instructions to clarify information and when to contact the FO." The reference Subsection is now in F.

  • •

    This Subsection correlates to query fields in Subsection C and provides instructions to resolve information and related references for different scenarios.

 

Subsection E:

  • •

    New Subsection created. This Subsection is titled "Query scanning and documentation requirements." This Subsection explains when a copy of the query should be scanned into the file (and alternatively when it is not necessary to upload a copy of the query in the file). Related references are also included.

 

Subsection F:

  • •

    Subsection F (previously D) contains related references to content in the Section. Updated references.

DI 28030.010 Use of the Supplemental Security Income Display (SSID) Query in Continuing Disability Review (CDR) Cases

A. When to perform a query for a CDR case

The Disability Determination Service (DDS) must make an SSID system query for all initial-level CDR cases (including Title II only beneficiaries, Title XVI only recipients, and Title II/Title XVI concurrent beneficiaries) upon receipt of the CDR case. The DDS must review the query along with the information in the case file to determine whether a CDR should proceed or should stop to address any pertinent development related issues. For documentation requirements, see DI 28030.010E in this section.

The adjudicator is not required to perform an alternate query (such as a Title II Master Beneficiary Records (MBR)) upon receipt of the CDR if the SSID query returns a response of "NO RECORD" or "NIF".

The DDS is not required to make a system query upon receipt of the CDR if the field office (FO) performed a query within 30-days of the DDS adjudicator's receipt of the case and the query is uploaded to the file for review. The DDS may review the results of the query rather than accessing a new query.

 

NOTE: The requirement to perform an SSID query upon case receipt at the DDS does not apply to expedited reinstatements (EXRs). For related policy on EXRs, see DI 28057.000.

References:

B. Why queries are performed for CDR cases

Queries may provide the DDS with critical information early in case development of a CDR that the DDS may otherwise be unaware of. The SSID query should be performed for all CDR cases, regardless of the current case type assigned (e.g., Title II only or Title XVI only). The SSID query includes related fields from the Title II MBR query, such as the Ledger Account File (LAF) code, which provides information about Title II payment status and insight into possible dual entitlement (i.e., concurrent case) issues.

If the individual receives childhood disability benefits (CDB) or disabled widow(er) benefits (DWB), run the query using the individual’s social security number (SSN), not the number holder’s (NH) SSN.

The DDS must obtain the query to:

  • •

    Avoid doing unnecessary CDRs (e.g., case was sent for evaluation to the DDS, but the system indicates the beneficiary or recipient is in terminated or suspended status),

  • •

    Avoid duplicating actions when concurrent issues are not identified in a timely manner (e.g., the query indicates current pay status under another entitlement (e.g., Title II) and a case is receipted for only one entitlement (e.g., Title XVI)),

  • •

    Identify possible scenarios where the beneficiary or recipient may have moved (e.g., a discrepancy exists between system information and information on the SSA-454-BK (Continuing Disability Report) and an attempt to clarify early in CDR development may result in a change of DDS jurisdiction); see DI 28030.010D,

  • •

    Avoid processing a medical CDR that involves a lost folder when the CDR may have been sent prematurely and the diary is not expired, and

  • •

    Identify potential representative payee or appointed representative issues that are critical in case development and correspondence.

C. Understanding the SSID query

The table shows the query reply fields with the meaning for the DDS to review upon receipt of a CDR case.

SSID Query Fields and Meaning

Query Fields

Content for DDS Review

DDS Review

Notes

References

PSY (Displayed on the NAME line)

Payment status, possible concurrent case

TITLE II ONLY CASE: If the DDS receives a Title II only claim and the PSY code starts with a “C”, “E”, or “M”, this indicates a Title XVI entitlement and clarification with the FO is necessary, see DI 28030.010D.6.

TITLE XVI ONLY OR CONCURRENT TITLE II/TITLE XVI CASE: If the PSY entry begins with "T" (associated with terminated status), see DI 28030.010D.3.

If the PSY code entry begins with "H", "N", "P", or "S", the DDS should contact the FO to see if a CDR determination is needed, see DI 28030.010D.4.

The PSY code is associated with current pay status for Title XVI recipients.

A PSY field code of C01, E01, E02, M01, or M02 indicates the Title XVI recipient is eligible for Supplemental Security Income (SSI). Other corresponding PSY codes are "T for terminated status, “H” for hold status, “N” for nonpayment, “P” is for nonpayment but potentially eligible pending SGA involvement, and “S” which is for “suspended” status.

SM 01305.001G SM 10802.130 SM 01601.805

AUTH

Appointed Representative (Attorney or Non-attorney)

If there is a discrepancy with the information displayed in the authorized representative (AUTH) query section (corresponds with appointed representative) for the current case and the information in Disability Case Processing System (DCPS) or other documents such as the SSA-454, see DI 28030.010D.2.

Compare information in this field with additional documentation received in eView, such as information on the SSA-454 and any appointed representative documentation, such as the SSA-1696 and Fee Agreement. Do not contact the FO if the query only identifies an appointed representative on a previous case and not the current case.

SM 01601.490

LAF (Displayed on RCRD segment in query)

Payment status, possible concurrent case

TITLE II ONLY CASE OR CONCURRENT TITLE II/TITLE XVI CASE: If the DDS receives a Title II only case and the LAF code starts with an “A”, “D”, “S”, “T”, or “X”, this indicates a beneficiary that is not currently receiving Title II monthly benefits. The DDS should review the code indicated and determine what the payment status is as additional clarification or action by the FO may be necessary, see DI 28030.010D.3. and DI 28030.010D.4.

TITLE XVI ONLY CASE: If the case is Title XVI only and the LAF code is "C" or "E", this indicates the indicates the individual is receiving Title II benefits and clarification with the FO is needed, see DI 28030.010D.6.

The LAF code corresponds with Title II payment status. 

A LAF code of “C” or “E” indicates a Title II beneficiary in insured current payment status, receiving monthly benefits (i.e. in current pay status).

LAF code “A” corresponds with a withdrawn or adjusted status, “D” for deferred, “S” for suspended, “T” for terminated, or “X” for other (e.g., beneficiary deported, uninsured status).

SM 00550.020 SM 1601.520C.8 SM 10802.120

ADDR, TL, RADR

Address and telephone numbers

Review for information that differs from the information provided on the SSA-454 or in DCPS, see DI 28030.010D.5.

The query may contain an indicator “Current Action Date” or “Address Change Date” (ACD) that provides the last date the address was updated in the query field. If this date is more than 12-months from the date the case is assigned to the adjudicator, default to the information in DCPS. Additional clarification with the FO may be necessary, depending on the evidence.

If the address in DCPS differs from the SSID query but the beneficiary or recipient completed and returned any forms that were mailed to the address in DCPS, there is no need to clarify this information with the FO. This also applies to telephone numbers if the beneficiary or recipient is successfully contacted at the number in DCPS but the SSID query indicates a different number. The DCPS information would be considered the most up to date, unless information during case development suggests otherwise.

The address (ADDR) segment of the SSID query provides mailing address data. If the mailing address differs from the recipient’s residence address (RADR), a different address displays in the RADR portion of the ADDR segment.

The beneficiary or recipient’s telephone number is in the ADDR segment in the telephone (TL) field.

SM 01601.535

REPY, LEGG

Representative Payee (Payee) or Guardian

If this field is not displayed, this means there is not a representative payee or guardian assigned to the case.

If there is a discrepancy with the current information displayed in the query and the information receipted electronically in DCPS or the SSA-454, see DI 28030.010D.1.

Information describing a representative payee, including the telephone number, is in the PAYEE or Representative Payee (REPY) Data segment.

Information describing a legal guardian, including the telephone number, is in the Legal Guardian Data or LEGG segment.

SM 01601.505 SM 01601.565

DIAR

Diary information

The requirement to review this field only applies to lost folder cases.

If the date in the diary (DIAR) field has not matured and will not mature within the next three months (and no other reason is identified for an earlier review), the CDR may have been sent to the DDS for medical review prematurely, see DI 28030.010D.7.

Review the file for accompanying documentation in the claim folder and DCPS to see if additional correspondence was received providing a rationale to review the case earlier (such as earnings record postings or potential fraud or similar fault, see DI 13001.005 and DI 28003.005C).

NOTE: Generally, this information will be in the SSA-831, SSA-832, or SSA-833 in the comparison point decision (CPD) folder and there is no need to review this field in the query. If the case is a lost folder and the prior folder documents are not available, the DDS adjudicator must review this field in the query.

SM 01601.580

UMIH

Possible concurrent case

If the case is Title XVI only and there is an entry of "A" in the in the Type (T) field of the Unearned Income Data (UMIH) segment, this indicates the recipient may also receive Title II benefits. Contact is needed with the FO for clarification to determine if a Title II CDR review is also necessary, see DI 28030.010D.6.

The UMIH segment of the SSID query shows receipt of various types of unearned income, including Title II benefits and the associated claim number. Title II benefits are coded as “A” type unearned income in the Type (T) field.

SM 01601.760

D. Instructions to clarify information and when to contact the FO

The DDS should contact the FO when there is a discrepancy in the case information outlined in the table in DI 28030.010C. The DDS is responsible for attempting to resolve inconsistencies during the case development process, see DI 22501.002D. The DDS does not need to contact the FO if the claim folder or DCPS already contains documentation (usually on an SSA-5002, Report of Contact) or in the Alerts and Messages tab in eView (see DI 81005.040)) indicating the FO is aware of the issue (e.g., payment status or resolving a payee issue) and a CDR determination is required.

The DDS must attempt to confirm information with the individual (i.e., beneficiary or recipient), their payee, guardian, or appointed representative before updating any contact information (e.g., telephone number, address) in DCPS. The DDS must follow instructions for initial contact with the individual in DI 28030.015 and document actions to resolve any discrepancies or inconsistencies. The DDS may update confirmed information as DCPS user profile permissions allow. If the DDS is not able to update the information, contact with the FO may be necessary. The DDS must document all efforts and the outcome of any attempts to clarify information in a document in the case folder. The DDS must include this information for electronic CDR (eCDR) cases in the Disability Determination Explanation (DDE), an SSA-5002, or the case development worksheet.

For Electronic Disability Collect System (EDCS) exclusion cases, the adjudicator must perform an SSID query when the case is assigned and follow documentation guidelines in DI 28030.010E.

For documentation requirements, see DI 20503.001E.

For instructions about DDS contact with the FO and exchange of information, see DI 28030.015B and DI 10005.010.

 

1. Query raises a payee or guardian issue

The DDS must send an assistance request (AR) to the FO for clarification if there is a discrepancy regarding the current payee or guardian information between the query and other electronic information received, such as the information in DCPS, the claim folder, the SSA-454, or the SSA-3881. Follow the instructions for submitting an AR to the FO in DI 81020.100.

NOTE: The DDS must perform normal case development that does not involve the questioned payee or guardian, such as development of medical evidence. The DDS must not contact the payee or guardian until the FO resolves the discrepancy. This does not apply to an individual(s) in question if they are identified as a current third party contact that may assist with claim. The DDS may contact the individual for the usual purposes of third party contacts.

For development guidelines for FTC or WU, see instructions:

2. Query raises an appointed representative issue

If the query indicates an appointed representative is currently designated to the case (not if the query provides representative information for a prior claim only) but there is not a current SSA-1696 (Appointment of Representative) or Fee Agreement in the file, the DDS must attempt to clarify this information by submitting an AR to the FO following the guidelines in DI 31001.001B.2. The DDS does not need to clarify appointed representative information if the query indicates that the representative is not current and is from a prior claim only.

The DDS will continue development of the CDR case while clarification is pending. Do not discuss any aspect of the claim or assume the undesignated representative is the appointed representative until the FO resolves the discrepancy and clarifies a current recognized appointed representative.

See DDS procedures for addressing potential appointed representative issues in DI 31001.001B and DI 31001.010.

3. Individual is in terminated payment status, but the CDR case was sent to the DDS

The DDS will prepare and image an SSA-5002 to the claim folder or provide an explanation on the case development worksheet explaining the reason(s) for stopping the CDR, see DI 28030.001E. The DDS should indicate the type of query performed, cite the termination status code, and explain that a CDR is not needed because the beneficiary or recipient is in terminated payment status. The DDS will process a no determination (ND) transaction, following instructions in DI 81020.127.

NOTE: There are situations when the Title II individual is in terminated status due to work and does not cooperate with the FO during the CDR, however, the FO sends the case to the DDS because a medical CDR determination is required to determine if entitlement or eligibility to extended Medicare Benefits should continue, see DI 28055.001B and DI 28075.005D.1. If the FO documents a medical CDR determination is necessary, the DDS must process the case.

4. Suspended, Hold, or other “Nonpay” payment status

A suspended, held, or other nonpayment status may indicate that the CDR is not necessary. A suspended payment status may also mean the DDS retains jurisdiction for development and evaluation while the FO is working on clarifying an issue. These scenarios correspond with a Title II LAF entry starting with “A”, “D”, “S”, or “X”, or a Title XVI PSY entry of “H”, “N”, “P”, or “S.”

If the FO sends a case to the DDS without a statement acknowledging the suspended, held, or nonpayment status code and indicates a medical CDR determination is still needed, the DDS must contact the FO to clarify if the medical CDR should proceed.

For example, LAF code “S6” indicates suspension pending development for a better (correct) address, while “S8” indicates representative payee development is underway and benefit payments have been suspended pending the outcome of that development. In those scenarios, the DDS may retain jurisdiction while the FO works on related clarification and development of the issue. If the FO has sent the case to the DDS and has documented the need for a medical decision regardless of suspended or other non-pay status, the DDS should process a medical determination for the CDR. It is not necessary to contact the FO in this scenario.

The FO must clarify these issues to determine if the CDR should proceed or if the FO sent the CDR case to the DDS in error. If the FO has not provided an additional explanation regarding the suspension (usually in an SSA-5002), the DDS must initiate contact with the FO to determine if the CDR development should proceed and follow the instructions in DI 81020.100C. If the FO does not provide clarification and confirm a medical CDR is necessary, the DDS should follow up as instructed in DI 22505.020D. If the FO fails to provide clarification after the first follow-up and subsequent follow-up attempts outlined in DI 22505.020, the DDS should provide an explanation and return the case to the FO as an ND.

5. Mailing address, residence address, or telephone number discrepancy

The DDS must attempt to clarify the address or telephone number discrepancy by contacting the beneficiary, recipient or designated representative payee, appointed representative, or the designated third-party contact, and document this information in DCPS case notes, the DDE, or the case development worksheet. If the CDR case is an EDCS exclusion, the DDS must document this information in an SSA-5002 or the case development worksheet.

  • •

    If the beneficiary or recipient does not have a payee or appointed representative, the DDS may contact them directly to clarify this information. If the beneficiary or recipient does not comply with the request, continue development, and follow the instructions in DI 22505.014.

  • •

    If the beneficiary or recipient has a payee (e.g., a representative payee or legal guardian) or appointed representative, attempt to clarify this information with the payee or appointed representative and continue case development, see DI 22501.002B.

If contact is unsuccessful, submit an AR to the FO requesting assistance while continuing medical development of the CDR case. If additional information requires an update to the address and the individual has moved, update the file and follow the guidance in DI 20101.015, DI 20101.035, and DI 81020.245.

If the FO does not respond to the AR or the FO is unable to resolve the discrepancy, but the DDS can make a medical determination without cooperation from the beneficiary, recipient, payee, or appointed representative, the DDS should make a medical determination on the CDR case.

If the DDS cannot reach the individual, the FO has not responded to the AR to clarify the requested information, there is not sufficient evidence to make a medical determination without the individual’s cooperation, the adjudicator should follow-up with the FO, see DI 22505.020D. If lack of this information results in a FTC or WU determination, follow guidance in DI 28075.005.

For development guidelines for FTC or WU see instructions:

6. Possible concurrent case issues

If one of the query fields shown in the table in DI 28030.010C (such as the PSY or LAF code, or UMIH) identifies a possible concurrent case issue, explain the potential entitlement issue in the AR to the FO. Follow the instructions for submitting an AR to the FO in DI 81020.100.

7. Other issues

Whenever information received in connection with the CDR raises doubt about how the DDS should proceed and the DDS cannot resolve the issue, contact the FO to attempt to clarify information or to determine how the DDS should proceed with the CDR. The DDS must follow related procedures, such as contact requirements if the beneficiary or recipient’s whereabouts are unknown and cannot be resolved after reviewing the query information or attempting contact with the beneficiary or recipient, or for other scenarios such as those listed in the next section.

E. Query scanning and documentation requirements

1. Query contains information of adjudicative significance

The DDS must include a copy of the query in the certified electronic folder (CEF) if the query included information that led to additional action(s) by the DDS or was of adjudicative significance, see DI 81020.050.

Some examples of information that may be of adjudicative significance include discovering a potential payee issue or a possible concurrent case issue that requires action by the FO. For EDCS exclusion cases, a copy of the query should be placed in the Paper Modular Disability Folder (MDF).

2. Query does not contain information of adjudicative significance

If the query did not lead to additional action by the DDS or was not of adjudicative significance, it is not necessary to scan the query into the CEF. In this scenario, the DDS should document that the query was obtained and reviewed and did not include information of adjudicative significance, consistent with the requirements for documenting disability development, see DI 20503.001E and DI 81020.065A. The DDS may include this information in the DDE, the case development worksheet, an SSA-5002, or the case development worksheet.

For EDCS exclusion cases, the DDS must document the query was obtained and did not include information of adjudicative significance in an SSA-5002 or the case development worksheet and ensure these documents are placed in the MDF in the case development worksheet or an SSA-5002.

F. References

DI 13005.045 Field Office (FO) Actions When the Disability Determination Services (DDS) Refers a Case to the FO

DI 28030.001 Initial Receipt of the Case by the Disability Determination Services (DDS)

DI 28030.015 Contact with the Individual

DI 81020.050 Onsite Scanning Procedures

DI 81020.100 Electronic Assistance Requests (AR)

DI 81020.127 Processing “No Determination” (ND) Claims

SM 01601.595 Disability Data - DISB

DI 28030 TN 43 - General Development of CDR Cases - 8/14/2023