Identification Number:
DI 11010 TN 65
Intended Audience:See Transmittal Sheet
Originating Office:ORDP ODP
Title:Initial Disability Claims Processing
Type:POMS Transmittals
Program:
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM
Part DI – Disability Insurance
Chapter 110 – Initial Claims Processing
Subchapter 10 – Initial Disability Claims Processing
Transmittal No. 65, 09/20/2019

Audience

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

Originating Component

ODP

Effective Date

Upon Receipt

Background

This is a Quick Action Transmittal. These revisions do not change or introduce new policy or procedure.

Summary of Changes

DI 11010.115 Non-Medical Completion

Subsection D #4 was updated to reflect the discontinuation of the Appointment Representative Datebase (ARDB) and the creation of the Registration, Appointment and Services for Representative (RASR). Updated language to adhere to plan language guidelines.

DI 11010.115 Non-Medical Completion

A. Policy – Field Office (FO) responsibilities

This policy applies to FO employees who adjudicate Title II and concurrent Title II/XVI cases. Under the Earnings Computation (EC) non-medical completion procedures, most Disability Insurance Benefits (DIB) initial and reconsideration claims are processed to final payment or denial, at the time of the Disability Determination Services (DDS) or Disability Quality Branch (DQB) clearance.

The background and exclusions described in this section apply to the Modernized Claim System (MCS) Earnings Computation (EC) non-medical completion process.

Also see Details in Earnings Computation Screens - Overview MSOM MCSEC 001.001 for many of the exclusions to the EC non-medical completion process.

B. Procedure – non-medical completion

This process is contingent upon the FO completion of non-medical development per Guidelines for Deferral of Non-Medical Development -

DI 11010.025 - DI 11010.075 and signaling the system that the claim is ready for final processing when the DDS/DQB enters the medical decision. This is accomplished by FO completion of the appropriate screens (DECI, MREQ, MCR1, DAPP) in the Modernized Claims Systems (MCS) and EC paths. See Earnings Computation Screens - Overview - MSOM MCSEC 001.001.

C. Other considerations

Consider the instructions contained in Common Partial Adjudication Situations - GN 01010.110GN 01010.120 and FO Action on a Delayed Claim - GN 01010.140 in relation to the non-medical completion procedures. The FO may:

  • input its "final" action as many times as necessary, prior to the DDS trigger.

  • Retrigger the claim if there is any outstanding development necessary after the basic entitlement data for the NH have been resolved. Issues such as lag earnings, proofs, etc., which may require extensive or lengthy development may cause this re-trigger.

  • If the outstanding data is received prior to the DDS trigger, the FO can re-trigger the claim and update the system by entering the new information. If the data is not received by the time the final DDS decision is input, the case is processed based on the information the FO has input, and any additional data would be handled on a post-adjudicative basis.

The FO should also consider deferred development procedures in Guidelines for Deferral of Non-Medical Development - DI 11010.025.

These procedures apply only to DIB initial and reconsideration cases. Certain types of claims (e.g., Disabled Widow(er)s Benefits (DWB), Childhood Disability Benefits (CDB) and Medicare Qualified Government Employee (MQGE)) are excluded from these procedures.

D. Procedure - non-medical completion exclusions

The following situations describe exclusions to the non-medical completion process.

1. Insured status is met within 1 year of Alleged Onset Date (AOD)

Non-medical completion does not apply in non-traumatic onset cases when the claimant does not meet insured status as of the alleged onset date (AOD), but does meet it within 1 year prior to the AOD. Failure to adhere to this instruction may result in an inappropriate code 090 denial being generated. The DDS determination for these cases covers disability for the period within the 1 year before the AOD.

NOTE: These are instances where code 90 is incorrectly derived for an NH insured under the special insured status provisions of the l983 amendments. These are non-medical completion exclusions.

2. Statutory blindness claims

Statutory blind cases are excluded from the non-medical completion process.

3. Foreign claims

Any case containing a foreign address is a non-medical completion exclusion.

4. Representative Fee Claims

Representatives who are eligible for direct payment (i.e., attorneys or non-attorneys ) must register via SSA-1699 as a condition of receiving direct fees from us. Registered representaitives will appear on the Registration, Appointment and Services for Represntatives (RASR) as eligible to recieve direct payment and linked to the particular claimant after completing the direct payment information section of the SSA-1696 (required for each claim). Payments are processed in the Single Payment System (SPS). Instructions about SPS and when to use it can be foundin SM 00834.001. Representative Fee claims are excluded from the non-medical completion process. The coding shown on Check/Notice (NOT2) Screen in the Claims Clearance path of the MCS claim is used to code Authorized Representative fees. The coding in the “last withholding date” (LWD) allows for correct computation of the retroactive benefits. In Title II cases, the LWD is the month before the month of adjudication. The DECI date should be the month after the LWD. Since the month of adjudication is not known until both the DDS and FO have made their respective inputs, this field cannot be accurately coded until the DDS returns the case and the FO completes the MCS EC processing.

5. SSI offset involvement

Cases with SSI offset (Windfall) involvement where there is outstanding development for proof of age; lag earnings and/or WC affecting the PIA, are excluded from the non-medical completion process.

6. Prisoner or fugitive felon (FF) provisions

To assist in the prevention of payments of past due monthly benefits to beneficiaries who may become subject to prisoner or FF suspension provisions, do not use the non-medical completion process. See details in GN 02612.020 No Social Security Benefits for Prisoners (NSSBP) Title II Field Office (FO) Processing.

7. Medicare-Qualified Government Employment (MQGE)

MQGE disability claims are exclusions to the non-medical completion process.

8. Processing Disability Claims with WC/PD

It is recommended that claims with potential WC/PDB offset not be processed using the Non-Medical Completion process.


DI 11010 TN 65 - Initial Disability Claims Processing - 9/20/2019