Effective Dates: 9/09/2024 - Present

Identification Number:
DI 11018 TN 6
Intended Audience:See Transmittal Sheet
Originating Office:ORDP ODP
Title:Failure to Cooperate and Whereabouts Unknown
Type:POMS Full Transmittals
Program:All Programs
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM

Part DI – Disability Insurance

Chapter 110 – Initial Claims Processing

Subchapter 18 – Failure to Cooperate and Whereabouts Unknown

Transmittal No. 6, 09/09/2024

Audience

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

Originating Component

ODP

Effective Date

Upon Receipt

Background

The Office of Disability Policy updated the field office responsibilities in a failure to cooperate insufficient evidence decision.

 

Summary of Changes

DI 11018.005 Field Office Responsibilities in a Failure to Cooperate-Insufficient Evidence Decision (FTC)

Revised section title.

Subsection A: Minor rephrasing, reformatting, and updated applicable references.

Subsection B: Reformatted and simplified guidance. Moved references from subsection A to subsection B.

Subsection C:

  • •

    Updated reference to specific claims processing systems by name to a broader "SSA claims processing systems".

  • •

    Simplified documentation requirements.

Subsection E:Broadened language referring to claims processing systems.

Subsection F:

  • •

    Removed references at the beginning of the subsection.

  • •

    Revised F.3 to refer to DI 12005.010 for appealing a technical denial.

  • •

    Revised F.4 to clarify and removed unnecessary references.

DI 11018.005 Failure to Cooperate-Insufficient Evidence Determination in an Initial Disability Claim

Citations: 20 CFR §404.1516; §416.916

This section provides field office (FO) instructions when, during the development of an initial disability claim, you have not received a response from the claimant to your requests for evidence or action.

NOTE: When the claimant's whereabouts are unknown or the claimant does not wish to pursue their claim, refer to DI 11010.045 for title II claims and DI 11055.085 for title XVI claims.

A. Field office (FO) responsibilities

During the disability claim interview:

1. Tell the claimant about the evidence we require

Provide the claimant with the following information:

  • •

    Why we require the evidence;

  • •

    Where they can obtain the evidence, if known;

  • •

    When we need to receive the evidence; and

  • •

    What is the outcome of their claim if we do not receive the evidence by the due date.

2. Provide the claimant with a list of required evidence

Include the evidence required on a notice, receipt, or other form of documentation to give or send to the claimant. For example, the attestation cover notice with request for evidence listed.

3. Attempt to obtain from the claimant a primary and an additional third-party contact

Providing a primary and additional third-party contact gives the Disability Determination Services (DDS) another resource should they need assistance obtaining information or action from the claimant.

For more information on obtaining and documenting third-party contacts see DI 11005.022 and DI 11005.023.

IMPORTANT: While we highly encourage claimants provide third-party contacts for their claim, failure to provide a third-party contact is not a reason to develop for FTC. Claimants may have valid reasons not to provide a third-party contact.

B. FTC development

It is the claimant’s responsibility to submit evidence to establish eligibility or entitlement for disability benefits, when requested. When a claimant does not provide the evidence requested within 15 calendar days from the request date, follow the instructions in this subsection.

NOTE: The claimant may not be capable of obtaining the evidence on their own and may need assistance. To determine whether special handling procedures apply and for guidance on providing assistance, refer to the following instructions

  • •

    GN 00301.180 Identifying Claimants Who May Need Assistance

  • •

    SI 00601.100 General Guidance for Information or Evidence

1.  Review the file for required evidence

After the initial request, review the file and if the requested evidence or action remains unresolved, determine whether:

  • •

    The claimant may need additional assistance or time to obtain the required evidence.

  • •

    The third-party contact named during the interview can assist the claimant with submitting the requested evidence.

NOTE: 

Use judgement on whether it is appropriate to wait longer than 15-days. When determining what is a reasonable amount of time for the claimant to provide the requested evidence, consider the types and volume of documents requested, the source of the evidence, and whether the claimant is actively trying to obtain the evidence. For example, it may take a claimant longer to obtain a document from a source in another country or out of state.

2. When to develop for FTC

When it has been 15 days since the initial request, send a follow-up request with the 30-day closeout date explaining that we will deny the claim 30 days from the date of the original request.

Develop for FTC when:

  • •

    The claimant does not respond to your initial request for evidence or action and;

  • •

    The assistance from the third-party contact, appointed representative, or representative payee is unsuccessful and;

  • •

    The follow-up notice to the claimant is unsuccessful.

3. Closeout process

Follow the closeout procedures provided in the sections listed:

C. Document efforts to resolve FTC

Document all efforts to resolve FTC situations as follows:

1. Electronic Disability Collect System (EDCS) case established

a. EDCS case has not been transferred to the DDS

NOTE: 

For a technically denied claim established in EDCS, close the record per Processing Field Office Determinations DI 81010.140.

b. EDCS case transferred to the DDS

  • •

    Document all efforts in EDCS through the Update-After-Transfer (UAT) function.

  • •

    Use the Transfer/Updates feature to document your efforts on the form SSA-5002 and follow DI 81010.095C.

c. EDCS case transferred to the Office of Quality Review (OQR)

While an EDCS case is pending OQR review (if selected for quality assurance), the FO may receive an assistance request to develop substantial gainful activity (SGA).

Use the EDCS Transfer/Updates feature to create the SSA-5002 to document your efforts, and store in the CEF.

2. SSA mainframe claims processing systems when there is no Electronic Disability Collect System (EDCS) case established

For EDCS exclusions:

  • •

    Document all FO efforts on the Report of Contact screen within the appropriate SSA claims processing system, including the dates and results of those efforts.

  • •

    Identify the outstanding issue on the development worksheet of the claims processing system along with the initial request and follow-up request dates.

  • •

    If a paper folder exists, annotate the same information on a paper SSA-5002 and include in the paper folder.

D. FTC issue resolved

If the requested information or action is resolved at any point prior to the FO's insufficient evidence denial, forward the claim(s) to the DDS for a medical determination.

E. FTC issue not resolved

When the claimant does not respond to the FO's requests for evidence or action after following the procedures in DI 11018.005B, in this section, document the FO's actions to obtain the requested information from the claimant and the outcome of those actions. Continue to process the claim as follows:

1. Medical evidence of record (MER) or developmental evidence is in the file

Forward the claim to the DDS for a medical determination if the following is in the file:

  • •

    MER as defined in DI 22505.001, or

  • •

    A completed disability report (e.g. SSA-3368 (Disability Report - Adult)) and signed SSA-827 (Authorization to Disclose Information to SSA).

NOTE: 

Developmental evidence is not considered “in file” if the SSA-827 or the appropriate disability report is missing or incomplete.

2.  MER or developmental evidence is not in the file

Deny the claim for insufficient evidence following the steps, in this section, if the claimant:

  • •

    Does not respond or provide the required evidence after our attempts to assist in obtaining the evidence are unsuccessful and after sending the closeout letter,

  • •

    Does not ask for more time to submit the evidence, and

  • •

    Meets the non-medical factors of entitlement.

    NOTE: 

    If the claimant does not meet a non-medical requirement, (e.g. does not meet DIB insured status or excess income for SSI eligibility), deny the claim for that specific reason.

For EDCS cases, process an FO “No Determination” (ND) to close the EDCS case per DI 81010.140.

a. Title II claims

Deny the claim for “Insufficient Evidence Furnished.”

For a complete list of regulation basis codes, see DI 26510.045.

  • •

    Use regulation basis code 0M5.

  • •

    Use regulation basis code 0M6 when the:

    • –

      Date last insured (DLI) is in the past (DIB claims),

    • –

      Prescribed period has ended (DWB claims),

    • –

      Re-entitlement period last met is prior to the date of the current determination (CDB claims).

  • •

    Prepare a manual denial letter via the Document Processing System (DPS) and mail it to the last known address.

b. Title XVI claims

Deny the claim as "N18" failure to cooperate and issue a denial letter to the last known address.

3. FTC issue arises after a favorable medical determination

When an FTC issue occurs after the DDS makes a favorable determination, follow these instructions:

  • •

    Title II claims

    GN 01010.410 Failure to Submit Essential Evidence

  • •

    Title XVI claims

    SI 00601.110 Final Request - Failure to Cooperate (N18) - Initial Claims

F. Claimant submits requested evidence after insufficient evidence denial

1. Evidence submitted within the appeal period

When a claimant submits the requested information within the appeal period, treat the submission as an implied request for reconsideration and follow DI 12005.010.

NOTE: If you reverse the FO FTC denial, resume processing the initial application. Transfer the EDCS case to DDS as an initial claim. See procedures in DI 12005.010F.

2. Evidence submitted after the appeal period

When a claimant submits the requested information after the appeal period, treat the submission as an untimely implied request for reconsideration. We can process an untimely filed request for appeal if the claimant submits a written explanation for the delay and we determine good cause for late filing exists.

a. Good cause determination

Develop and document the file with a good cause determination by following the instructions in GN 03101.020 and DI 12005.015.

b. Good cause established

If you determine the claimant had good cause for the late filing, process the appeal request as though the claimant filed it timely.

c. Good cause not established

If you determine the claimant did not have good cause for the late filing, follow the procedures in DI 12005.015C.

If the claimant wishes to re-file, follow the instructions in DI 12005.015D.

If the claimant does not wish to re-file, see DI 12005.015E.

3. Processing reconsideration requests of FO determinations

For instructions on how to process requests for reconsideration on technically denied claims, see:

  • •

    DI 12005.010 Processing a Reconsideration Request for an Initial Non-Medical or Technical Denial

  • •

    DI 81010.145 Processing Reconsideration Requests of Field Office (FO) Determinations

4. Reopening M5/M6 insufficient evidence or N18 denial

If the claimant provides new and material evidence but is not within the appeal period, consider reopening the claim following the guidelines in GN 04010.030. Generally, we do not reopen or revise a correct determination. If within the reopening time limits, apply reopening procedures only if the FTC denial was incorrect, and:

  • •

    The claimant contacts us after the appeal period ended; or

  • •

    You cannot establish good cause for an untimely filed reconsideration request.

EXAMPLE: A claimant denied by the FO for insufficient evidence recontacts the FO after the appeal period has ended. The FO cannot find good cause for late filing of an appeal. The FO discovers that the FTC denial was incorrect because the requested evidence was submitted timely but was not associated with the claim. The FO can reopen the incorrect FTC denial.

For more information on reopening rules, refer to:

  • •

    GN 04001.070 Do Not Reopen Correct Determinations- Operating Policy

  • •

    SI 04070.010 Title XVI Administrative Finality - Reopening Policies

  • •

    SI 00601.110B.10 Final Request- Failure to Cooperate (N18) Initial Claims

  • •

    DI 27505.001 Conditions for Reopening a Final Determination or Decision


DI 11018 TN 6 - Failure to Cooperate and Whereabouts Unknown - 9/09/2024