Identification Number:
DI 40525 TN 3
Intended Audience:See Transmittal Sheet
Originating Office:ORDP OISP
Title:Other Processing Issues
Type:POMS Transmittals
Program:All Programs
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM
Part DI – Disability Insurance
Chapter 405 – Processing Continuing Disability Review Cases
Subchapter 25 – Other Processing Issues
Transmittal No. 3, 09/14/2020

Audience

OQR: DE, PA, PE, TL;
PSC: BA, CA, CS, DE, DEC, DPS, DTE, ICDS, IES, ISRA, PETE, RECONR, SCPS, TST;
OCO-ODO: BET, BTE, CLT, CR, CST, CT, CTE, CTTA, DE, DEC, DS, LSC, PAS, PCS, PETL, RCOVTA, RECONE, RECONR, RECOVR;
ODD-DDS: ADJ, DHU;
FO/TSC: AWIC, CS, CS TII, CS TXVI, CSR, CTE, DRT, FR, OA, OS, RR, TA, TSC-CSR;
RO: CDP;

Originating Component

ODP

Effective Date

Upon Receipt

Background

The Office of Disability Policy published updated failure to cooperate guidance for the field office (FO) and the disability determination services (DDS), which became effective 01/06/2020. In this transmittal, we are updating the program service center (PSC) guidance to conform to the FO updated guidance.

Summary of Changes

DI 40525.001 Failure to Cooperate- Insufficient Evidence Decision (FTC) and Whereabouts Unknown (WU) During a Continuing Disability Review (CDR) -Program Service Center (PSC)

We updated the term failure to cooperate to it's full new name, failure to cooperate- insufficient evidence decisions. Adjudicators may continue to refer to this policy as its acronym, FTC.

We added clarifying language as to the PSC's responsibilities with FTC or WU cases.

We updated references to the FO FTC and WU policy sections.

DI 40525.001 Failure to Cooperate- Insufficient Evidence (FTC) Decision and Whereabouts Unknown (WU) During a Continuing Disability Review (CDR)- Program Service Center (PSC)

A. FTC and WU Policy

When the Social Security Administration (SSA) conducts a CDR, or there is a question about whether an individual continues to be disabled, the individual has a responsibility to provide SSA with medical or other evidence. In claims for title XVI disabled children, this responsibility ultimately rests with the applicant or representative payee (usually the child's parent or other caregiver).

An FTC or WU issue may arise at any time during the CDR when a disabled individual cannot be located, does not furnish medical or other evidence, or fails to attend a scheduled physical or mental consultative examination by a certain date.

An individual's FTC, without good cause, or whereabouts unknown are reasons to suspend or cease benefits only when there is insufficient evidence to justify a continuance.

1. Field office (FO) streamlined FTC CDR process

On January 27, 2007, SSA implemented a streamlined medical CDR FTC process for the FO. If the beneficiary does not comply with the FO's request for information or evidence needed during a medical CDR, the FO suspends benefits. If the FO's suspension input to the Disability Control File (DCF) fails, the PSC must take manual action using MACADE to suspend title II benefits and create the DEV CDR line on the Master Beneficiary Record (MBR) (For information on CDR transaction, see SM 03005.110 ). The FO is responsible for correcting the suspension inputs for title XVI. If the beneficiary does not cooperate during the 12-month suspension period, benefits automatically terminate effective the 13th month. During the suspension period, the CDR remains in the FO. The DDS does not receive the CDR during this period until the beneficiary submits the requested information.

The streamlined process does not apply to claims that have been transferred to the DDS for a determination. For FTC that arises while the CDR is at the DDS, the DDS follows DI 28075.005.

For additional information on FO FTC procedures during a CDR, see DI 13015.001-DI 13015.005.

NOTE: The streamlined FTC process does not apply to Work CDRs or extended Medicare cases. For FTC in initial disability claims, see DI 11018.005.

2. Beneficiary's whereabouts are unknown

WU occurs when there is a question about whether a beneficiary or recipient continues to be disabled and we are unable to find him or her after exhausting all reasonable efforts to locate the beneficiary or recipient as described in Whereabouts Unknown (WU) Determinations and Reinstatement Procedures for Continuing Disability Review (CDR)- Field Office (FO) DI 13015.013. A WU issue may arise at any point during the CDR.

Only when there is insufficient evidence to justify a continuance, we will terminate benefit payments for the first month in which the FO,DDS, or PSC discovers that the beneficiary's whereabouts are unknown, but no earlier than the month in which the continuing disability issue arose.

NOTE: Title II WU is a non-medical cessation of benefits. For title XVI, WU is a technical suspension of benefits. For more information, see DI 13015.011A.2.

3. Medical improvement review standard (MIRS) and exceptions

The DDS evaluates CDRs under the MIRS process. The MIRS states that an individual's period of disability continues unless evidence shows medical improvement (MI) in his or her prior impairment(s) since the last favorable disability determination and the individual can now engage in substantial gainful activity (SGA), where relevant, unless an exception applies.

The law provides for exceptions where disability can be found to have ended without evaluating MI.

Among the exceptions to the MIRS requirement for MI are the following:

  • FTC- Failure to comply with requests to take an action or to provide evidence, without good cause or,

  • WU-We are unable to find the individual to determine if disability continues

For more information on the MIRS exceptions, see

DI 28020.001 General-Groups I and II of Exceptions to Medical Improvement (MI)

DI 28020.900 Group II Exceptions

4. Cessation or suspension month

When there is not enough evidence to justify a continuance in FTC cases (streamlined suspension process described above does not apply) and in WU cases, we will cease benefit payments in the first month in which:

a. FTC

The individual, without good cause, does not provide the requested information or evidence within the specified period and the development steps have been taken in DI 13005.025 and DI 13005.030.

When FTC arises at the DDS, the DDS makes a medical determination based on the available evidence. If there is insufficient evidence, the DDS makes a cessation determination.

b. WU

SSA or DDS learns that the individual's whereabouts are unknown, but no earlier than the month in which the continuing disability issue arose. This is a non-medical title II cessation or technical title XVI suspension of benefits, determined by the FO. If the FO's input to cease title II benefits for WU does not process, the FO contacts the PSC via the modernized development worksheet (MDW) process for assistance. To avoid a beneficiary receiving payments not due to him or her, the PSC must take immediate action to input the cessation determination.

5. Good cause

If, after the FTC or WU cessation, the beneficiary makes contact with SSA, he or she can file an appeal if within the appeal period or file a new claim. For more information, see also DI 40525.001E in this section. If the appeal period expired, determine whether an individual has good cause for not responding to our requests, and consider the individual's limitations, i.e. physical, mental, educational, and verbal (including any lack of facility with the English language). For general guidelines regarding good cause determinations, see GN 03101.020. For special handling considerations, see DI 13005.025B.

Statutory benefit continuation (SBC) does not apply to FTC or WU cessations. If the FO finds good cause in accepting a late appeal request, the appeal is routed to the office of jurisdiction (DDS or OHO).

NOTE: For title XVI WU reinstatements, refer to DI 13015.013B.

B. PSC procedures in a FTC or WU case

1. Development during a CDR

If the FTC or WU issue arises during the course of PSC development, request the FO assistance in locating or obtaining cooperation from the beneficiary via the MDW or paper form SSA-5526-U3.

The FO follows CDR development procedures in DI 13005.025 and DI 13015.005 for FTC and DI 13015.011 for WU.

2. FO FTC suspension input in the DCF

If the FO has taken all necessary actions, including the DCF input to place the beneficiary in suspense (S0 -CDRFTC suspension code), and the DCF input fails, the exception generates a paperless alert to the PSC for action.

If the alert is not resolved by 15 days, the FO sends a follow up request to the PSC via the (MDW). PSC must take manual action to suspend benefits (see SM 03005.110 Continuing Disability Review Transactions). Suspend benefits effective the first month that does not cause an overpayment. Ensure the MBR reflects the following data:

  • LAF S0

  • RFST (Reason for suspension/termination) CDRFTC for a medical CDR failure to cooperate-insufficient evidence decision.

  • DEV CDR line- Suspense Start- MM/YYYY; Suspense Reason-FTC-Medical

Develop Continuing Disability (CDIB) Data for suspension data applicable to other CDR issues, see SM 00883.235.

3. Beneficiary cooperates while in FTC suspension

If the beneficiary submits the requested information while in suspense, the FO will complete the CDR and transfer the CDR to DDS for a medical determination. The FO's transfer input in the DCF triggers an MBR update to resume benefits.

If the DCF resumption action fails, the exception alert will generate to the PSC of jurisdiction. The PSC must initiate manual reinstatement to resume benefits. For information on systems inputs see Continuing Disability Review Transactions SM 03005.110 .

If all factors of entitlement are met, retroactive benefits are paid to the beneficiary and auxiliaries starting with the first month of suspension.

If the beneficiary provides the requested CDR information but the FO cannot send the case to the DDS (e.g. there is an administrative delay on forwarding CDRs to the DDS) benefits need to be reinstated if the beneficiary is otherwise eligible for title II benefits. The FO will contact the PSC through established office procedures. The PSC should initiate manual reinstatement, see SM 03005.110.

4.  FO locates beneficiary

Upon the FO's receipt of the PSC's request for assistance in a possible WU CDR, the FO will follow development procedures in DI 13015.013. If the individual is located and the FO obtains the necessary information, the FO transfers the medical CDR to the DDS for a determination.

5. Individual's whereabouts are still unknown

If the FO's attempts to locate the beneficiary are unsuccessful, the FO accepts jurisdiction and prepares the title II cessation determination, see DI 13015.013.

6. Folder or material received in the PSC

If the PSC receives material from another FO, forward the folder to the servicing FO for their action.

C.  Title II benefits terminated due to FTC, family maximum payable

NOTE: Do not take this action while in FTC suspension, take this action only after the beneficiary's FTC termination processes and the appeal period expires.

If title II benefits terminate due to the disabled auxiliary's (BIC= C or W) failure to submit the requested information and other auxiliaries are entitled on the record, redistribute the disabled auxiliary's benefits to the other auxiliaries based on the family maximum provisions. The redistribution of the terminated disabled auxiliary's benefits will be from the suspense start date to the time of termination. The PSC is also responsible for releasing the appropriate notices.

D.  WU cessation determinations

When all attempts to contact the claimant are exhausted as outlined in DI 13015.013 Whereabouts Unknown (WU) Determinations and Reinstatement Procedures for a Continuing Disability Review (CDR)- Field Office (FO), follow these procedures to process a WU cessation determination.

1. Work issue

If the work issue is in the PSC's jurisdiction, the PSC makes a work issue determination whenever possible using any available evidence of earnings. Use all methods and sources of wage verification outlined in DI 10505.005C through DI 10505.005F.

If there is sufficient evidence in file prior to identification of the WU issue to cease benefits, prepare a SSA-833-U3 determination with the month of cessation as indicated by the work activity. NOTE: Prior to preparing the cessation determination, send a due process notice to the last known address.

If the information is inconclusive, document that the evidence is insufficient to make a SGA determination; send due process to the last known address, see Exhibit 1 DI 40525.095; and prepare a SSA-833-U3 cessation based on WU.

2. Medical issue

Release a due process notice if the FO did not send to address on record. For the sample due process notice, see Exhibit 1DI 40525.095.

3. Work and medical issue

If the FO has not taken all the necessary action, see D1 and 2 in this section.

E.  Appeal of a streamlined FTC or WU CDR termination

1. Streamlined FTC FO termination

When the FO applies the streamlined CDR FTC process, the case is placed in suspension for up to 12 months at which point the record terminates in the 13th month. Although it may not occur often, the beneficiary may make contact within the appeal period of the termination. If this occurs, the beneficiary may request an appeal of the terminating action. If the FO obtains a request for reconsideration of a title II streamlined FTC termination, the PSC or the Office of Disability Operations (ODO) obtains jurisdiction of the reconsideration following GN 03102.175.

The appeal request is for the issue that caused the cessation (in this case, the benefits are terminated due to FTC). Determine if the appropriate steps were taken that led to the FTC termination or if the determination was incorrect. Send appropriate notice to the beneficiary informing him or her of receipt of the appeal and send another notice when the determination is made. Ensure all notices are electronically stored for viewing via the Online Retrieval System (ORS).

NOTE: This only applies to FO non-medical issue CDR FTC terminations and does not apply to reconsideration requests for cessation determinations made by the DDS.

2. WU cessation

For reconsideration requests of a title II WU CDR FO cessation, determine if the appropriate steps were taken that led to the WU cessation. For WU development requirements refer to DI 13005.025 and DI 13015.013. The appeal request is for the WU issue. Send appropriate notice to the beneficiary of the appeal determination. Ensure all notices are electronically stored for viewing via ONRS.


DI 40525 TN 3 - Other Processing Issues - 9/14/2020