Previously entitled beneficiaries, whose entitlement ended due to work, are eligible for EXR if they meet all of the following requirements:

• •

  are “not able” or “becomes unable” to work at the SGA level due to their medical condition,

• •

  are “not able” or “becomes unable” to perform SGA in the month of the EXR request,

• •

  stopped performing SGA within 60 months of their prior termination,

• •

  have a current medical impairment(s) that is the “same as or related” to the original impairment(s), and

• •

  are under a disability based on application of the medical improvement review standard (MIRS).

Claimants are “not able” to perform SGA if, in the month of their EXR request or the following month, they do not work or their work is not SGA.

Claimants “become unable” to perform SGA if, in the month of their EXR request, their work is SGA, but they stop performing SGA by the day they file their request. To meet the requirement of having become unable to perform SGA, they must also not perform SGA in the month following the EXR request.

NOTE: Claimants whose prior entitlement is a closed period of disability are not eligible for EXR.

A beneficiary or recipient reinstated under EXR receives a 24-month initial reinstatement period (IRP). The IRP is completed when the individual has received a total of 24 months payable benefits. After completing the IRP, a Title II beneficiary gets a new trial work period (TWP) and an extended period of eligibility (EPE). If benefits terminate again after completing the EPE, we may reinstate a Title II claimant through a new request for EXR, if the claimant meets the EXR eligibility criteria. After completing the IRP, we can reinstate Title XVI claimants whose benefits stop due to work through a new request for EXR, if the claimant meets EXR eligibility criteria. For more information on the IRP, see DI 13050.066 and DI 13050.067.

Claimants previously entitled to disability insurance benefits (DIB), disabled widow(er) benefits (DWB), or an unmarried childhood disability benefit (CDB) whose monthly benefits terminated due to their own SGA must meet the requirements listed in DI 13050.001B.1 in this section to be eligible for EXR.

NOTE: The EXR provision is applicable to a Medicare Qualified Government Employee (MQGE) beneficiary, which allows reinstatement to Medicare, even though we do not pay monthly benefits.

If we deny a request for EXR for failure to meet the non-medical requirements for EXR (not filed within 60 months, etc.), we may apply the principles of res judicata to a subsequent request. Res judicata does not apply if any aspect of the case has changed, including laws or regulations. For situations in which res judicata is applicable, see GN 03101.160B.

If a claimant requesting EXR is currently entitled to another disability benefit, do not apply collateral estoppel procedures to approve the EXR request. The Disability Determination Services (DDS) must make the medical determination that the impairment is the same as or related to the impairment that was the basis for the previous entitlement, and then make a determination that the claimant is disabled based on the MIRS.

If the claimant became entitled to reduced RIB simultaneously with or after the EXR month of entitlement (MOE), see RS 00615.110B.2. If the claimant became entitled to reduced RIB before the EXR MOE, see RS 00615.110B.3.

NOTE: For retirement benefit computation purposes, consider the period of disability and the EXR period to be one period of DIB.

When we approve a number holder’s request for EXR, an auxiliary on the original record can file for reinstatement on the record. The auxiliary must file a new application for benefits and must continue to meet initial entitlement requirements, per DI 13050.060A.2.

A previously entitled recipient whose monthly benefits terminated due to excess earned income (or a combination of earned and unearned income) must meet the requirements listed under DI 13050.001B.1 in this section and meet all non-medical Title XVI requirements to be eligible for EXR.

If we deny a request for EXR for failure to meet the non-medical requirements for EXR (not filed within 60 months, etc.), we may apply the principles of res judicata to a subsequent request. Res judicata does not apply if any aspect of the case has changed, including laws or regulations. For situations in which res judicata is applicable, see GN 03101.160B.

An eligible spouse can also request reinstatement and may be eligible for up to 6 months of provisional benefits and Medicaid coverage during the provisional benefit period.

A claimant must complete the 24-month IRP to qualify for a subsequent period of EXR entitlement. If a claimant has not completed the IRP, they do not qualify for a subsequent period of EXR.

EXAMPLE: We reinstated Smith’s Title XVI benefits through EXR as of 3/18. Smith returns to work as of 6/19 and has earnings over the threshold amount, making them ineligible for cash benefits. Smith continues to work, and their Title XVI benefits terminate as of 6/20 after 12 months of payment ineligibility. Smith contacts SSA in 7/21 to state that they are no longer able to perform SGA and wants to apply for EXR. Since Smith only completed 15 months of their IRP (3/18 through 5/19), they are not eligible for reinstatement under EXR.

Evaluate a blind claimant's work activity under standards applicable to beneficiaries with statutory blindness in Title II (blind SGA standards) and Title XVI (blind work expenses) see DI 10515.000 and SI 00820.535.

To qualify for EXR, the statutorily blind claimant must undergo the same medical review process as a non-blind disabled claimant. The claimant must undergo the “same as or related” determination, and a MIRS review. The DDS will make an EXR decision and then a comparability decision, if necessary, for a claimant over age 55. If approved, the FO will process the award in the same manner as other EXR cases. Do not use the DIB attainment process normally used to re-entitle a claimant to cash benefits in Title II EXR processing. For more information on DIB attainment, see DI 13010.135 and DI 41005.010.

EXR is applicable for blind claimants only if they completed the TWP and their benefits terminated based on SGA. If the claimant is currently in suspense status, they do not meet the requirements for EXR, see DI 10515.015B.

The FO is responsible for taking the following actions:

• •

  Discuss the criteria for reinstatement with the claimant and provide a comparison of the possible effects of requesting EXR versus filing a new initial claim. For complete instructions on EXR versus a new claim, see DI 13050.020. For complete EXR interview instructions, see DI 13050.045 and DI 13050.050.

• •

  Assist the claimant with the request for reinstatement and determine whether the claimant meets the applicable non-medical criteria.

• •

  Obtain the necessary forms as instructed in DI 13050.045 and DI 13050.050.

• •

  Obtain the prior medical folder if the prior decision was not electronic.

• •

  Initiate provisional benefits via the Post Entitlement Online System (POS) (if applicable) for Title II, or by establishing a start-date record for Title XVI. For complete provisional benefit instructions, see DI 13050.025 and DI 13050.030.

• •

  For Title II, the FO identifies all SGA and non-SGA months in the 12-month period prior to the month of filing or from the benefit termination month (BTM), whichever is later, in item 2C of the Continuing Disability Review/Post Entitlement (CDR/PE) section on the SSA-823 and documents first possible month of entitlement regardless in MM/YY format regardless of SGA.

• •

  If the claimant meets all the non-medical requirements for EXR, the FO transfers the case to the DDS for a medical determination.

• •

  Establish EXR on the Disability Control File (DCF).

• •

  If the claimant does not meet the non-medical requirements for EXR, and the claimant insists on filing for EXR, the FO issues a technical denial. For technical denial instructions, see DI 13050.065.

• •

  If the DDS allows the EXR,

  • –

    For Title II, the FO processes an Electronic Form 101 (EF101) per DI 13050.060B, and forwards it to the program center (PC) for processing, see EXR EF101 Guide.

  • –

    For Title XVI, the FO will terminate the record, stops provisional benefits, and then start-date a new EXR record.

• •

  If DDS denies the EXR, terminate provisional benefits in not currently paid.

  For complete EXR award instructions, see DI 13050.060 and DI 13050.061.

The DDS reviews the medical evidence and determines if the claimant's current impairment is the “same as or related” to the impairment that led to the previous entitlement to benefits, using the comparison point decision (CPD). If a “same as or related impairment” exists, the DDS will determine whether the claimant is disabled based on the MIRS. The DDS determines the EXR month of entitlement in allowance determinations. The DDS prepares an SSA-832 Title XVI Cessation or Continuance of Disability Determination and Transmittal, or SSA-833 Title II Cessation or Continuance of Disability to document the determination. If the DDS allows the EXR, the DDS will return the case to the FO. If the DDS denies the EXR, the DDS will prepare and send the denial notice containing a Personalized Explanation to the claimant, before returning the case to the FO. For complete instructions on DDS EXR claims processing, see DI 28057.000.

NOTE: The determination that an impairment is "the same as or related to" is a medical determination that can be made only by the DDS.

The PCs process all EXR awards for Title II benefits through the District Office Final Authorization (DOFA) procedures. The PC will:

• •

  Terminate provisional benefits, if necessary, and adjust the benefits payable for provisional benefits paid, and

• •

  Adjudicate Medicare entitlement as appropriate, and

• •

  Prepare and send the appropriate award and overpayment notices. For PC EXR procedures, see SM 00856.000 and DI 13050.095.

NOTE: The DCF controls EXR requests from the time of the request through adjudication. It is important to initiate the EXR event on the DCF and show the transfer of the case between the FO, DDS, and PC to control the cases accurately, and to provide accurate management information. Further, controlling the EXR case through the DCF helps ensure the accuracy of future actions during the IRP, TWP, and EPE (if applicable).

Review the DIB line of the MBR for the date of the disability benefit cessation (DBC) field or the TERMINATION field on the most recent occurrence of the BENE ENT line (see SM 00510.190 and SM 00510.200). If the date the EXR request is filed is within the 60-month period beginning with the date of benefit cessation (as shown in the DBC field or the TERMINATION field), consider the request timely filed.

Check the date of the T31 entry in the computation history (CMPH) segment of the appropriate SSID record. If the date the EXR request is filed is within the 60-month period beginning with the date of eligibility termination (the date of the T31 entry), the request is timely filed.

A claimant who meets the non-medical requirements and completes a request for Expedited Reinstatement (EXR) may receive up to 6 months of provisional cash benefits and Medicare while we make a determination on their request. Medicare coverage during the provisional benefit period is the same Medicare coverage the claimant had at the time of their termination.

A claimant is not eligible for provisional benefits when any of the following applies:

• •

  they do not meet one of the eligibility requirements for EXR listed in DI 13050.001B.1;

• •

  an event has occurred that would preclude entitlement (a childhood disability benefits (CDB) recipient has married); or

• •

  the Disability Determination Services (DDS) determines the claimant does not meet the disability requirements for EXR.

A claimant can decline provisional cash benefits, but still elect to receive Medicare coverage during the provisional benefit period.

NOTE: Provisional benefits are not payable to auxiliary claimants, other than a previously entitled disabled widow(er) benefit (DWB) or CDB who is eligible and requests EXR. Provisional benefits are not payable to a claimant requesting EXR of CDB benefits on the record of a living number holder who is not currently entitled.

We do not pay provisional benefits on an EXR request if the claimant previously requested EXR for the same period of eligibility and received provisional benefits based on that request, regardless of how many months they received provisional payments on the previous request. However, we can pay provisional payments on a subsequent EXR request if the claimant:

• •

  was approved for EXR on a previous request;

• •

  completed the initial reinstatement period (IRP);

• •

  completed a trial work period (TWP);

• •

  completed an extended period of eligibility (EPE);

• •

  had their benefits later terminated due to substantial gainful activity (SGA), and

• •

  filed a new request for EXR within 60 months of that termination, or we can find good cause for late filing.

Example 1:

An individual requests EXR on March 4, 2016, and we approve the request on May 4, 2016. They receive 3 months of provisional benefits before they are re-entitled to disability benefits. They complete their IRP, TWP and EPE. After completing the EPE, benefits terminate due to SGA in January 2023. On April 12, 2023, the individual files for EXR again because they are no longer performing SGA. As they completed the IRP, TWP, and EPE on the new entitlement period, had their benefits terminated for SGA, and then filed a new EXR request within 60 months of that termination, they are eligible to request a subsequent EXR and receive provisional benefits.

Example 2:

An individual requests EXR on March 4, 2021, and we medically deny the request on May 4, 2021. They received 3 months of provisional benefits. The individual refiles for EXR on May 2023. Because we paid at least one month of provisional benefits on the prior request, we cannot pay provisional benefits on the subsequent request.

Compute the provisional benefit following these steps:

1. a. 

   Base the provisional benefit payment amount upon the payable benefit amount at the time the previous entitlement terminated, increased by intervening cost of living adjustments (COLA) and re-computations. This is regardless of any other changes (such as overpayments, offsets);

2. b. 

   Base the provisional payment amount upon the prior reduced benefit payable, if the prior payable benefit was reduced due to offset or other reductions;

3. c. 

   Apply current tax levies or garnishments to provisional payments in accordance with GN 02410.110 and GN 02410.210;

4. d. 

   Apply any Medicare premium arrearages to provisional benefits;

5. e. 

   If an overpayment exists on the record, do not recover this against provisional benefits without the claimant’s written consent; and

6. f. 

   If we award the EXR request, adjust for offsets, such as Workers Compensation/Public Disability Benefits, Government Pension Offset, Windfall Elimination Provision, overpayments, and other payment issues with the first month of reinstated benefits.

When a claimant requests reinstatement on one record and is currently receiving a Title II benefit on another record, the provisional benefit is payable only if the provisional benefit amount is greater than the current benefit payable on the other record. If the current benefit amount is higher than the provisional benefit amount, no provisional benefits are payable. If a claimant requests EXR for more than one benefit, pay provisional benefits on the record that yields the highest benefit payable amount. If provisional benefits end for a dually entitled beneficiary, payment will resume on the other record as long as they are still eligible for benefits on that record.

NOTE: A claimant must file separate EXR requests for multiple entitlement situations. Evaluate each request against the EXR requirements and process accordingly.

For DWB and CDB claimants, the payment of provisional benefits may cause the total benefits payable on the record to exceed the family maximum (FMAX). In such cases, pay the provisional benefit amount outside the FMAX and do not adjust the benefit amount for any auxiliary already entitled on the same record during the provisional benefit period.

Provisional benefits are payable beginning with the month the claimant submits a signed and completed EXR request per DI 13050.045B.2., assuming benefits have not already been paid for that month. If the claimant performed SGA in the month of filing, provisional benefits are payable in the month after the month of filing. We can only pay provisional benefits during the consecutive 6-month period beginning with the month of the EXR request, or the following month if there is SGA in the month of filing.

NOTE: Do not use the protective filing date for determining when provisional payments begin. Use the protective filing date to determine the retroactive scope of the EXR.

Example 1: A claimant contacts SSA about filing for EXR on April 24, 2023 but does not return the signed request forms until June 03, 2023. They did not perform SGA in June. Provisional benefits will begin June 2023, the month they completed and submitted their EXR request.

Example 2: A claimant completes and returns a signed request for EXR on June 25, 2023. They performed SGA in the month of June, but stopped performing SGA by the date of their request. Provisional benefits will begin July 2023, the month after they stopped engaging in SGA.

Provisional benefits cannot start until the previous benefits terminate and the master beneficiary record (MBR) Ledger Account File (LAF) Code is T6, T8, U or X7. If we made a determination to terminate the previous benefit but the MBR does not reflect it, the field office (FO) will contact the program center (PC) to expedite the termination in order to begin provisional benefits. Use the exclusion case procedures described under DI 13050.025I.3. in this section to expedite the previous benefit termination. We cannot pay provisional benefits for any month in which the claimant has already received the same type of benefit payment on the same entitlement.

Regular payment provisions apply. Consider windfall offset. Title II provisional benefits are income for SSI computation purposes. The claimant must file a separate request for reinstatement under Title XVI.

Provisional benefits terminate when a claimant attains FRA. Provisional benefits do not automatically revert to an retirement benefits at FRA. If the claimant wishes to receive aged benefits, they must file an application, or already be entitled to a benefit that will automatically convert to an aged benefit at full retirement age (regular widow's benefit or retirement).

The appeal of a prior claim denial, or termination, has no effect on the claimant’s eligibility for EXR. The claimant can receive provisional benefits and reinstatement through EXR, if the claimant meets EXR eligibility requirements in the month of the EXR request.

Input the request for provisional benefits on the Provisional Payment (PEPP) screen of the Title II POS. Instructions are in MS 06303.040. Follow these steps to access the PEPP screen:

1. a. 

   Select option “2”, Title II/PE, on the SSA MAIN menu and press “Enter”.

2. b. 

   On the POS Menu (PEMU) screen, select “1” to establish and complete the required fields, then press “Enter”.

3. c. 

   On the Post Entitlement Selection List (PESL) screen select “item 1” (Addr/Dir Dep/Tel) and “item 7” (Provisional Payments) for the appropriate BIC and, press “Enter”.

4. d. 

   On the Post Entitlement Address (PEAD) screen, enter any changes to the claimant’s address, direct deposit, or telephone number propagated to the PEAD screen from the MBR. If no changes are necessary , press “Enter” to advance to the PEPP screen.

5. e. 

   On the PEPP screen, enter the provisional payment start month in MMYY format. Add any necessary remarks, and press “Enter”. The provisional benefit start month is the month we receive the EXR request package. However, if the claimant engaged in SGA in the month of the request, the provisional payment start month is the following month. If the provisional benefit start month is later than the current operating month (COM), hold the POS input after the next COM changes.

NOTE: If the claimant engaged in SGA in both the month of the EXR request and the following month, deny the request for EXR. For denials, see DI 13050.065

Some cases require manual processing in the PC to start provisional benefits. The following situations will generate an exception alert in the PC:

• •

  concurrent Title II/Title XVI cases and a prior month accrual (PMA) check is payable;

• •

  DWB and CDB cases in which there are other entitled auxiliaries on the same record; and

• •

  cases where the individual requesting EXR is already entitled to another Title II benefit.

If the direct input excepts, do not re-input through POS. Check PCACS for an Action Control Record (ACR) with TOELs DIPROV PAYMENT. It may take up to three business days for the ACR to appear in PCACS. If the ACR does not appear in PCACS after three business days, contact the PC of jurisdiction.

If the ACR appears in PCACS, tickle the case for 15 business days to allow for PC processing. If the MBR does not update after 15 business days, contact the PC of jurisdiction and tickle the case for 15 days for follow up.

To contact the PC of jurisdiction:

• •

  Use PCACS to identify which PC/Module has jurisdiction.

• •

  Access the Detailed Office/Organization Resource System (DOORS) using the search SSN function to send an email to the appropriate PC module with the subject line "Provisional Benefit Request." Add a special message to the MBR indicating the date the request was sent.

If the MBR does not update after the second 15-day tickle or if a dire need/adverse public relation situation exists, FOs will use the Manager-to-Manager process to contact the PC per GN 01070.228.

Do not make a POS input for exclusion cases as they require manual action by the PC. Some examples of exclusion cases are:

• •

  the provisional benefit is not payable in the first month of the provisional period (payment is suspended) or

• •

  the EXR request date is more than 60 months after the previous termination (good cause found for late filing)

Do not use CPS to start provisional benefits, as any monies withheld from CPS payments for supplemental medical insurance (SMI) premiums are not credited until the provisional benefit action is processed and may result in an incorrect termination of SMI due to non-payment of premiums. Requests for initiation of provisional benefits are high priority actions.

To contact the PC of jurisdiction:

• •

  Use PCACS to identify which PC/Module has jurisdiction.

• •

  Access the Detailed Office/Organization Resource System (DOORS) using the search SSN function to send an email to the appropriate PC module with the subject line "Provisional Benefit Request." Add a special message to the MBR indicating the date the request was sent.

Tickle for 15 days to follow up. If the MBR does not update after the 15-day follow up tickle expires or if a dire need/adverse public relation situation exists, use the Manager-to-Manager process to contact the PCs per GN 01070.228.

The performance of SGA during the provisional benefit period terminates provisional benefits. The FO technician must:

• •

  Develop work activity during the provisional benefit period.

• •

  Document the work on Forms SSA-820-BK (Work Activity Report Self-Employment) or SSA-821-BK (Work Activity Report - Employee) and record the determination on Form SSA-823 (Report of SGA Determination – For SSA Use Only) and store the completed forms in the electronic file in not in EDCS.

• •

  Notify the DDS examiner of the finding by telephone.

• •

  Terminate provisional benefits through POS input, see MS 06303.024. The last month provisional benefits are payable is the first month of SGA. Provisional benefits do not resume after termination due to SGA, even if SGA later ends.

• •

  If applicable, access the Detailed Office/Organization Resource (DOORS) using the search SSN function to send an email to the appropriate PC module with the subject line "EXR Provisional Benefit Termination Request" to request termination of Medicare. Add a special message to the MBR indicating the date the Medicare termination request was sent.

If the claimant performs SGA in the month of the EXR request and the following month, recall the folder from the DDS and process an FO jurisdiction technical denial as outlined in DI 13050.065D. For EXR requests filed prior to April 17, 2017, if the claimant performed SGA in the month of filing, recall the folder and deny the request.

Terminate provisional benefits (if currently being paid) when the DDS makes a medical determination to deny EXR. The last month provisional benefits are payable is the month the FO mails the EXR denial notice. To stop provisional benefits input the medical decision using POS, refer to DI 13050.065B.3. To determine how a medical determination may affect Medicare coverage, see DI 13050.070.

When a claimant reaches FRA during the provisional benefit period, provisional benefits automatically terminate. If the claimant wishes to receive aged benefits, they must file an application, or already be entitled to a benefit that will automatically convert to an aged benefit at full retirement age (regular widow's benefit or retirement).

Provisional benefits and Medicare based solely on the provisional benefit period automatically terminate after six months of payments.

If the claimant dies during a month that comes after the EXR request but before a medical decision by the DDS, stop the provisional benefits. The month before the month of death is the last month that provisional benefits are payable. The DDS should make a medical decision based on the evidence provided. If we approve the EXR request based on the medical evidence, pay any retroactive benefits as an underpayment per GN 02301.030.

Query the MBR to determine if the claimant was previously entitled to a disability benefit under Title II (i.e., disabled number holder, disabled surviving spouse, or disabled child). If entitlement has terminated, determine the reason for termination. A combination of three of the following MBR entries, along with a Ledger Account File (LAF) code of T6, T8, U, or X7, indicates entitlement terminated due to the performance of SGA:

• •

  BENEFIT Line - reason for suspension/termination (RFST) coding of DIBCES.

• •

  DIB Line - Cessation Disability Reason-code of E (CDR-E).

  NOTE: A medical cessation which occurs after an SGA cessation may overlay the CDR-E code with CDR-M coding. CDR-M coding is not conclusive evidence that benefits did not terminate due to SGA. Further, a medical cessation occurring after an SGA cessation does not preclude potential eligibility for EXR.

• •

  DIB Line - A difference between the extended period of eligibility begin date (EBD) and the disability benefit cessation (DBC) dates of three or more years.

• •

  DIB Line - An entry in the extended period of eligibility Medicare begin date (EMD) field that is at least 78 months earlier than the Medicare Part A termination date (or 24 months earlier if the Part A termination date is prior to 10/1/00).

• •

  HI-DIB Line - A Medicare Part A termination date more than 78 months (or 24 months if termination date is prior to 10/1/00) after the applicant's disability cessation date (ADC).

• •

  HISTORY Line - an RFST of EPESGA in the SUSP/TERM field, followed by DIBCES in subsequent lines.

• •

  SP MSG – A special message with information relating to SGA cessation and termination.

Review other sources of information to verify that termination was due to SGA, rather than medical or other reasons:

• •

  Work CDR application – compare the most recent decision with the DIB line and History data on the MBR.

• •

  Disability Control File (DCF) – query the most recent T2 WORK event (#6 on the ECDR screen) to see if the decision was a cessation.

• •

  eView or Evidence Portal (EP) – search eView or EP for a SSA-833.

NOTE: Be alert to situations in which the claimant stopped performing SGA within the extended period of eligibility, and to the possibility of reopening an erroneous decision. If you determine that benefits terminated due to work, review the most recent Work CDR determination. In these cases, do not pursue EXR, but instead pursue reopening of the prior decision to reinstate benefits.

Determine if the EXR request is within 60 months (five years) of the previous benefit termination. Add 59 months to the DBC month reflected on the DIB line to determine the end of the 60-month period. For further information about the EXR request period and consideration of good cause for late filing, refer to DI 13050.010. Also, consider the protective filing guidelines in DI 13050.015.

The FO technicians must screen cases for EXR eligibility per DI 13050.001 and DI 13050.045A, and discuss filing a new claim versus an EXR with the claimant per DI 13050.020.

• •

  If the claimant does not meet the technical requirements for EXR and insists on filing for EXR, the FO must deny the request per procedures in DI 13050.065D.

• •

  If the claimant chooses to file a new initial claim for disability benefits, you may use the request for reinstatement as a protective filing. Close out the protective writing per DI 13050.015E and GN 00204.012. Document the reason the claimant chose to file a new claim instead of an EXR in the remarks section of the new initial application.

• •

  If the claimant is eligible for EXR and decides to file an EXR request, follow the instructions below to complete the EXR request.

Establish an EXR event on the DCF following these steps:

• •

  On the MCDR screen, select 8=Establish Disability Review.

• •

  On the ECDR screen, select 2=EXR.

• •

  Complete the DRES screen to establish the EXR event.

Establish the case in the Electronic Disability Collect System (EDCS) and;

• •

  Enter the date of the Comparison Point Decision (CPD), using the most recent favorable medical decision date;

• •

  Enter the month benefits terminated due to work, see DI 13050.045A and DI 13050.050A.1;

• •

  Enter the established onset date from the previous entitlement;

• •

  Enter EXR filing date; and

• •

  Link the EXR with the prior CPD folder, per DI 81010.235.

NOTE: For any EDCS exclusions, follow paper folder procedures per DI 70005.001 and DI 70005.005.

Explain that the claimant must complete the forms before we can pay provisional benefits and reinstate Medicare. Use initial claims attestation scripts prior to and after filing out forms with the beneficiary per GN 00201.015F. Store the forms in eView or Evidence Portal (EP). The EXR request includes:

• •

  SSA-371 - Request for Reinstatement - Title II. To attest, access the form in Uniforms (if available), and in the “Witness Address” field, type in “ATTESTED” and list your name, your office code, and the date (e.g., Attested by John Doe DO123, 3/31/2020”) and save to the electronic folder. Note: The SSA-371 now includes the Medicare acknowledgement statement.

• •

  Complete the SSA-454-BK - Continuing Disability Review Report,SSA-3367- Disability Report-Field Office, and SSA-827 - Authorization to Disclose Information to the Social Security Administration in EDCS. You may attest the SSA-827 per DI 11005.056D.2.

• •

  SSA-820-BK or SSA-821-BK - Work Activity Report (Self-Employment) or Work Activity Report (Employee) and in the “Witness Address” field, type in “ATTESTED” and list your name, your office code, and the date (e.g., Attested by John Doe DO123, 3/31/2020”) and save to the electronic folder.

  • –

    Use these forms to develop and document all work activity in the 12-month retroactive period, or from the Benefit Termination Month (BTM), whichever is later. Use the initial claim policy rules to evaluate earned wages per DI 10505.005D in EDCS.

• •

  SSA-823- Report of SGA Determination. You may use the click and sign feature in Uniforms to complete form SSA-823. In Item 2C of the Continuing Disability Review/Post-Entitlement (CDR/PE) section, document the following:

  • –

    The month of EXR filing (and protective filing date if applicable), prior termination month, and the SGA determination for each month in the retroactive period. If possible retro-activity prior to the month of filing exists, indicate in the remarks, "possible retro-activity exists prior to the month of filing".

  • –

    If there is SGA in all months of the 12-month retroactive period and in the month of filing, the first possible MOE is the month following the month of filing. In this situation, annotate the remarks of the SSA-823 with “SGA in the month of filing, First possible MOE is MM/YY”. Note: Document first possible month of entitlement regardless in MM/YY format regardless of SGA.

    NOTE: The retroactive period does not include months prior to the BTM. Therefore, if the BTM is fewer than 12 months before the request for EXR, do not provide SGA and non-SGA determinations for months prior to the BTM. If SGA work stopped prior to the BTM, review the prior termination decision and determine if reopening is appropriate.

    Example: EXR filing date is 09/2022. Benefits previously terminated in 01/2022. The retroactive period is 01/2022-08/2022. The claimant engaged in SGA in 01/2022 through 03/2022. The claimant did not engage in SGA 04/2022 through 09/2022. The earliest MOE the DDS could establish is 04/2022, the first non-SGA month in the retroactive period.

• •

  SSA-16-BK-Application for Disability Insurance Benefits, SSA-10-BK Application for Widow(er)’s Insurance Benefits, or SSA-4-BK. A signature is not required as it serves as a supplement to the EXR request.

• •

  SSA-8240-Request wage and employment information authorization and record it in the Wage and Employment Information Authorization (WEIA) application per, GN 00204.150C.

Start provisional benefits, if eligible. Do not use the Critical Payment System (CPS) to initiate provisional payments. For more information about provisional benefits, see DI 13050.025A.

If the CPD is electronic, the FO may transfer the EXR request to the servicing DDS. If the CPD folder is paper, the FO must wait for the receipt of the paper CPD folder before transferring the EXR request to the servicing DDS. DDS will need the comparison point decision (CPD) folder to make the EXR medical determination. If the CPD folder is paper, follow folder retrieval instructions in DI 13015.030 through DI 13015.250, and DI 40525.020 through DI 40525.150. If you are unable to locate the CPD folder, follow instructions in DI 13015.080 and DI 13015.090. If the CPD folder was processed in EDCS, you will be able to "link" it to the EXR case when you create it in EDCS. NOTE: Completing the "REQUEST FOLDER (Y): " field on the DRES screen will not result in the prior file being sent to you. You will need to request any prior paper folder through PCACS, following normal procedures.

• •

  Select the transfer option within EDCS and transfer to the servicing DDS.

• •

  Update the DCF taking the following steps:

• •

  Transfer the event to the servicing DDS per DI 13010.620;

• •

  Establish an issue (for example, EXRDDS) on the DCF development worksheet (CDRW) to control for the DDS decision. For more information about the CDRW, see DI 13010.605.

  If the EXR request is an EDCS exclusion, pair the completed EXR packet with the prior decision folder. If the prior decision was an electronic file, see DI 81010.030E . Attach the "EXR Case Flag View" in PDF to the paper medical folder, and mail the paper folder to the appropriate DDS.

If during the interview you determine that the claimant is incapable of managing their own provisional benefits, develop for a representative payee. If the claimant had a representative payee in the previous entitlement period, determine if the claimant still needs a representative payee. For more instructions about payee development, refer to DI 13050.075 .

Review the following elements of the SSR to determine if disability ended due to work:

• •

  CMPH segment - the last entry in the Payment Status (PS) field is T31;

• •

  CMPH segment - there is an entry of N01 in the PS field in the month before the T31 month; and

• •

  ENIH segment - there is earned income in the month before the T31 month.

Review the following additional sources of information to verify that termination was due to work:

• •

  Notice - the claimant may have a notice stored in the online notice retrieval system (ORS) that explains the basis for termination; and

• •

  Other records such as a Modernized Development Worksheet (MDW).

Determine if the EXR request is within 60 months of the previous termination (T31) month. Add 59 months to the T31 month reflected on the SSR to determine the end of the 60-month period. For further information about the EXR request period and consideration of good cause for late filing, refer to DI 13050.010. Also, consider the protective filing guidelines in DI 13050.015.

The FO technicians must screen cases for EXR eligibility per DI 13050.001A, DI 13050.050A and discuss filing a new claim versus an EXR with the claimant per DI 13050.020.

• •

  If the claimant is not eligible for EXR due to not meeting the technical requirements for EXR and insists on filing for EXR, the FO must deny the request per procedures in DI 13050.065D.

• •

  If the claimant chooses to file a new initial claim for disability benefits, you may use the request for reinstatement as a protective filing. Close out the protective writing per DI 13050.015E and GN 00204.012. Document the reason the claimant chose to file a new claim instead of an EXR in the remarks section of the new initial application.

• •

  If the claimant is eligible for EXR and decides to file an EXR request, follow the instructions below to complete the EXR package and process the request.

Establish an EXR event on the DCF following these steps:

• •

  On the MCDR screen, select 8=Establish Disability Review.

• •

  On the ECDR screen, select 2=EXR.

• •

  Complete the DRES screen to establish the EXR event.

Establish the case in the Electronic Disability Collect System (EDCS) and:

• •

  Enter the date of the Comparison Point Decision (CPD), using the most recent favorable medical decision date;

• •

  Enter the month benefits terminated due to work, see DI 13050.045A and DI 13050.050A.1;

• •

  Enter the established onset date from the previous entitlement;

• •

  Enter the EXR filing date; and

• •

  Link the EXR with the prior CPD folder per, DI 81010.235.

  NOTE: For any EDCS exclusions, follow paper folder procedures per DI 70005.001 and DI 70005.005.

Explain that the claimant must complete the forms before we can pay provisional benefits. Use initial claims attestation scripts prior and after filling out the forms with the beneficiary per GN 00201.015F. Store the forms in eView or Evidence Portal (EP). The EXR request includes:

• •

  SSA-372 - Request for Reinstatement - Title XVI. To attest, access the form in Uniforms (if available), use the attestation script in GN 00201.015F, and in the “Witness Address” field, type in “Attested” and list your name, your office code, and the date (e.g., Attested by John Doe DO123, 3/31/2020”) and save to the electronic folder.

• •

  Complete the SSA-454-BK - Continuing Disability Review Report, SSA-3367- Disability Report-Field Office, and SSA-827 - Authorization to Disclose Information to the Social Security Administration in EDCS. You may attest the SSA-827 per DI 11005.056D.2.

• •

  SSA-820-BK or SSA-821-BK - Work Activity Report (Self-Employment) or Work Activity Report (Employee) and in the “Witness Address” field, type in “ATTESTED” and list your name, your office code, and the date (e.g., Attested by John Doe DO123, 3/31/2020”) and save to the electronic folder. Use these forms to develop and document all work activity beginning with the month of filing.

• •

  SSA-823 - Report of SGA Determination. You may use the click and sign feature in Uniforms to complete form SSA-823. In Item 2C under Continuing Disability Review/Post-Entitlement (CDR/PE), document the following:

  • –

    the month of filing, and

  • –

    the SGA determination for the month of the EXR filing to present. If there is SGA in the month of filing, add the remark "SGA in the month of filing, First possible MOE IS MM/YY". Note: Document first possible month of entitlement in MM/YY format regardless of SGA.

• •

  SSA-8000-BK-Application for Supplemental Security Income. Complete the SSA-8000-BK in the same manner as for a pre-effectuation review contact (PERC). Develop all factors of eligibility immediately. A signature is not required as it serves as a supplement to the EXR request.

• •

  SSA-8240-Request wage and employment information authorization and record it in the Wage and Employment Information Authorization (WEIA) application per, GN 00204.150C.

If there is an aged spouse, obtain an initial application for SSI Aged and establish entitlement using normal requirements for entitlement. If there is a previously eligible spouse, you may also reinstate the spouse if they request reinstatement and meets the EXR requirements.

• •

  If the spouse is blind or disabled, worked, and meets EXR screening requirements in DI 13050.050A in this section and complete an SSA-372 for the spouse; and

• •

  Complete an SSA-454-BK and SSA-827.

Start provisional benefits if eligible. For more information about provisional benefits, see DI 13050.030.

If the CPD is electronic, the FO may transfer the EXR request to the servicing DDS. If the CPD folder is paper, the FO must wait for the receipt of the paper CPD folder before transferring the EXR request to the servicing DDS. DDS will need the comparison point decision (CPD) folder to make the EXR medical determination. If the CPD folder is paper, follow folder retrieval instructions in DI 13015.030 through DI 13015.250, and DI 40525.020 through DI 40525.150. If you are unable to locate the CPD folder, follow instructions in DI 13015.080 and DI 13015.090. If the CPD folder was processed in EDCS, you will be able to "link" it to the EXR case when you create it in EDCS. Note: Completing the "REQUEST FOLDER (Y): " field on the DRES screen will not result in the prior file being sent to you. You will need to request any prior paper folder through PCACS, following normal procedures.

• •

  Select the transfer option within EDCS and transfer to servicing DDS;

• •

  Update the DCF taking the following steps:

• •

  Transfer the event to the servicing DDS per DI 13010.620 ;

• •

  Establish an issue (for example, EXRDDS) on the DCF development worksheet (CDRW) to control for the DDS decision. For more information about the CDRW, see DI 13010.605 .

If the EXR request is an EDCS exclusion, pair the completed EXR packet with the prior decision folder. If the prior decision was an electronic file, see DI 81010.030E. Attach the "EXR Case Flag" view In PDF to the paper medical folder, and mail the paper folder to the appropriate DDS.

If, during the interview you determine that the claimant is incapable of managing their own provisional benefits, develop for a representative payee. If the claimant had a representative payee in the previous entitlement period, determine if the claimant still needs a representative payee. For more instructions about payee development, refer to DI 13050.075.

If the claimant is disabled and entitled to EXR, we may reinstate benefits retroactively for up to 12 months before the EXR request date provided the claimant meets all factors of entitlement. The MOE is the earliest month that the claimant did not perform SGA and met all of the EXR eligibility requirements. If there is SGA in all months of the retroactive period and in the month of filing, the first possible MOE is the month following the month of filing. The month of entitlement cannot be before the benefit termination month (BTM) of the previous entitlement. The MOE must be a non-SGA month. If the claimant performed SGA in the month of filing and the following month, the FO must issue a technical denial. Normal suspension and terminating events apply to all reinstated benefits.

Example: A claimant was previously entitled to Social Security disability insurance (SSDI) for back problems and their entitlement terminated due to work in January 2021. In June 2023, they re-injure their back and they are unable to work. In September 2023, they request EXR. The FO develops the case and sends it to the DDS, they document the request date of September 2023 and note the following SGA and non-SGA months in the 12-month retroactive period as follows:

SGA Months: September 2022, October 2022, November 2022, December 2022, January 2023, February 2023, March 2023, and May 2023

Non-SGA Months: April 2023, June 2023, July 2023, August 2023, and September 2023

The DDS decides that the claimant meets the medical requirements of EXR in the month of filing (September 2023). They then look at the first non-SGA month in the retroactive period, which is April 2023. They determine that although they did not perform SGA, they did not meet the Medical Improvement Review Standard (MIRS) criteria in April 2023. They then look at the next non-SGA month (June 2023) and determine that the claimant did meet the MIRS criteria in that month. Therefore, the MOE for EXR is June 2023, which is the first month of the initial reinstatement period (IRP).

Reinstate benefits to auxiliaries previously entitled on the number holder's record, who continue to meet the initial entitlement requirements with the first month of reinstatement for the disabled number holder. Obtain a Form SSA-4 -BK (Application for Child’s Insurance Benefits) for both previously entitled and new auxiliaries and store it in eView or the Evidence Portal (EP). The SSA-4 is a supplement to the EXR, and it not require a signature. Process the claim following EF-101 procedures. If an auxiliary received a benefit based on the auxiliary’s disability, the auxiliary must meet the initial entitlement requirements and continue to meet the disability requirements before reinstatement. You must send the case to the DDS for a continuing disability review (CDR) to confirm they meet disability requirements before reinstating them. For more information on the technical requirements for childhood disability benefits (CDB), see DI 11020.015.

NOTE: While we are required to develop auxiliary applications, do not delay processing fo the number holder's award while pursing.

When the DDS makes an unfavorable medical determination on an EXR request, the determination will appear on the Electronic Disability Collect System (EDCS) Action Items list. The electronic folder will contain a denial notice with a Personalized Decision Notice, and an SSA-832 Title XVI Cessation or Continuance of Disability Determination and Transmittal, or SSA-833 Title II Cessation or Continuance of Disability Determination and Transmittal. If the EXR is an EDCS exclusion, the DDS will send the paper folder to the FO. The determination will not appear on the EDCS Action Items List. Determine the basis for the medical determination by reviewing the following items on SSA-832 or SSA-833:

• •

  Item 10 will have block D indicated, which shows “other”.

• •

  Item 11 will show code 28 for Title II not same as or related denial, 61 for Title XVI not same as or related denial, or normal CDR codes for MIRS denials-see DI 28084.015.

The DDS prepares and sends a denial notice with a Personalized Explanation to the claimant and any appropriate third party. The notice informs the claimant that they may file a new application for disability benefits, request a reconsideration of the EXR decision, or file a new EXR application. For information about appropriate Medicare language in denial notices, see DI 13050.070.

NOTE: The request for reinstatement can be used as protective filing for a new application if the claimant chooses to file a new application.

Terminate provisional benefits (if currently being paid). The last month provisional benefits are payable is the month the DDS mails the EXR denial notice, provided the benefit is not subject to earlier termination for another reason. For termination reasons, see DI 13050.025A.2 and DI 13050.030A.2.

Refer to HI 00801.165C and DI 13050.070 for the effect an unfavorable medical decision has on Medicare entitlement and SI 01730.010 for the effect on Medicaid.

NOTE: If the DDS medically denies an EXR request on a concurrent claimant under the MIRS, initiate a medical CDR for the other title, per DI 13001.005A.8

Document the reason the claimant decided to file a new initial claim instead of an EXR request on the Report of Contact (RPOC) screen in MCS. Close out the existing EXR protective writing by including a closeout statement in the remarks on the initial claim application.

If the claimant is not eligible, but chooses to file for EXR, take the following steps:

• •

  Obtain a form SSA-371- Request for Reinstatement for Title II;

• •

  Establish the EXR event in the DCF, per DI 13010.610;

• •

  Establish the EXR case in EDCS;

  • –

    Select “Claims Action” on the EDCS tool bar at the top of the screen and then select “Add FO Determination”;

  • –

    Select “No Determination” and reason "Misc Clearance";

  • –

    Add the reason for denial in remarks. Example: EXR Tech Denial-SGA; and

  • –

    Select “OK” at the bottom of the screen;

• •

  Document the reason the claimant is ineligible for EXR on an SSA-553-Special Determination, or an SSA-5002 - Report of Contact and store in eView along with any supporting documentation;

• •

  Terminate provisional benefits, if started. For termination instructions see, DI 13050.025;

• •

  If there is Medicare entitlement, refer to DI 13050.070;

• •

  Close the EXR event on the DCF. On the IFOA screen, select 5=SSR/MBR/STOP CDR for the clearance reason.

• •

  Send an EXR denial notice to the claimant and any appropriate third party and store a copy in ORS. Title II EXR denial notices are available in DPS. Include Medicare information as appropriate.

Document the reason the claimant decided to file a new initial claim instead of an EXR request on the Report of Contact page. Close out the existing EXR protective writing by including a closeout statement in the remarks on the initial claim application.

If the claimant is not eligible for, but chooses to file for EXR, take the following steps:

• •

  Obtain a form SSA-372, Request for Reinstatement for Title XVI;

• •

  Establish the EXR event in the DCF, per DI 13010.610;

• •

  Establish the EXR case in EDCS;

  • –

    Select “Claims Action” on the EDCS tool bar at the top of the screen and then select “Add FO determination and”;

  • –

    Select “ No Determination” and the reason "Misc Clearance";

  • –

    Add the reason for denial in remarks. Example: EXR Tech Denial-SGA; and

  • –

    Select “OK” at the bottom of the screen;

• •

  Document the reason the claimant is ineligible for EXR on an SSA-553-Special Determination, or an SSA-5002 - Report of Contact and store in eView along with any supporting documentation;

• •

  Process the denial. Post payment status code N07 to the SSR, per SM 01701.080 and SM 01305.001O.6;

• •

  Terminate provisional benefits, if started. For termination instructions, see SM 01701.080;

• •

  Close the EXR event on the DCF. On the IFOA screen, select 5=SSR/MBR/STOP CDR for the clearance reason; and

• •

  Send a manual EXR denial notice to the claimant and any appropriate third party. Retain a copy of the notice in the file and fax into eView or Evidence Portal(EP).

If the individual wishes to appeal a non-medical issue, such as a substantial gainful activity (SGA) denial, a denial based on excess resources, or a denial because the prior claim was not terminated due to SGA, complete a Request for Reconsideration, SSA-561-U2. Follow established SSA jurisdiction procedures outlined in DI 12005.010.

If the individual wishes to appeal an unfavorable medical determination, take the following actions;

• •

  Make the necessary systems inputs per DI 13050.085E;

• •

  Establish the EXR reconsideration request in EDCS;

• •

  Complete forms SSA-561, SSA-3441, and SSA-827. Store any non-electronic forms in eView;

• •

  Transfer the EDCS case to DDS and;

• •

  Create an EXRRECON 90-day tickle on the Disability Control File (DCF) development worksheet (CDRW).

When DDS makes a determination, process reversals per, DI 13050.060 and DI 13050.061 and; process affirmations per DI 13050.065.

If the individual disagrees with the reconsideration determination, the individual can request a hearing with an administrative law judge (ALJ). Take the following actions:

• •

  Make the necessary systems inputs per DI 13050.085E;

• •

  Establish the EXR hearing request in EDCS;

• •

  Complete forms HA-501-U5, SSA-3441 and SSA-827. Store any non-electronic documents in eView;

• •

  Transfer the EDCS case to the Office Of Hearing Operations (OHO) and;

• •

  Create and EXRHRN 90-day tickle on the DCF development worksheet (CDRW) for control.

If the individual disagrees with the ALJ's decision, the individual can request an Appeals Council (AC) review of the hearing decision. Take the following actions:

• •

  Make the necessary systems inputs per DI 13050.085E;

• •

  Establish the EXR request for AC review in EDCS;

• •

  Complete form HA-520-U5 (if applicable). Store any non-electronic forms in eView;

• •

  Transfer the EDCS case to the AC, and;

• •

  Create an EXR-AC 90-day tickle on the DCF development worksheet (CDRW) for control.

  The AC will notify the individual of the final action and provide an explanation of any appeal rights.

Use the Post-Entitlement Online System (POS) to record an appeal of an EXR medical denial. Refer to MS 06303.024 through MS 06303.026 for detailed input instructions. Take the following actions:

• •

  From the POS main menu select 6, disability cessation;

• •

  On the PEC1 screen, select 1 for medical cessation;

• •

  On the PEC2 screen, input the date of the appeal request and select 3 for reconsideration request without payment continuation; and

• •

  On the PECN screen, select 1, Decision Notice Released-Additional Systems Notices Possible.

  Add a special message to the MBR to indicate the status of an appeal of a non-medical issue in an EXR case. Indicate the appeal level, date the appeal was filed, SSA employee identifier (such as unit code or last name) and field office code. Indicate in subsequent special messages the outcome of the appeal and any further appeals activity. Also document the reconsideration determination on the IRMK screen of the DCF.

  NOTE: If the case is an EDCS exclusion, select Y to record folder movement and indicate destination of folder on the next screen.

Use the Direct SSR update to record an appeal of an EXR medical denial. Refer to MS 04420.002 through MS 04420.026 for detailed input instructions.

An individual can appeal request the denied EXR request and also file anew initial claim at the same time. For special considerations in processing joint EXR and initial claim actions, refer to DI 13050.090. When an EXR appeal request and simultaneous initial claim both require medical decisions, escalate the initial claim to the reconsideration level, see DI 12045.030 and DI 28057.025. The original EXR request serves as a protective writing for the new initial claim.

An individual can appeal the initial claim denial under current reconsideration procedures while also filing an EXR request, including the start of provisional benefits and Medicare. Escalate the EXR request to the reconsideration level, see DI 12045.030 and DI 28057.025. The denied initial claim does not serve as a protective writing for EXR. See DI 13050.090 for processing instructions and special consideration in processing joint EXR and initial claim actions.

An individual may inquire about EXR while a hearing request is pending at the ALJ- level on a prior termination decision or an initial claim denial. If the requirements for EXR are met, per DI 13050.001B, do not escalate the initial EXR request to the hearing level. Instead, forward the EXR request to DDS for a medical decision. If DDS denies the EXR request and the beneficiary appeals the decision:

• •

  Determine if both cases are “common issue” cases, see DI 12045.010; if yes,

• •

  Escalate the EXR appeal to the hearing and coordinate both cases with the appropriate hearing officer per DI 12045.015.

An individual may inquire about EXR while a request for review (RR) of an ALJ decision is pending with the Appeals Council. If the requirements outlined in DI 13050.001B for EXR are met, follow the instructions in DI 12045.027 to process the EXR request. Send the EXR request to DDS to for normal processing and an initial determination independently of the case at the AC level regardless of the title(s) or common issue, see DI 12045.021. If the claimant opts to file a new claim instead of an EXR request, Social Security Ruling 11-1p may apply if the new claim is under the same title of the Social Security Act and for the same benefit type. Follow the appropriate instructions in DI 51501.001 or DI 12045.027 to process the subsequent claim.