Identification Number:
DI 11018 TN 3
Intended Audience:See Transmittal Sheet
Originating Office:ORDP ODP
Title:Failure to Cooperate and Whereabouts Unknown
Type:POMS Transmittals
Program:All Programs
Link To Reference:
 
DELAYED IMPLEMENTATION TRANSMITTAL (DIT)
DIT's ARE FOR FUTURE IMPLEMENTATION AND DISPLAYED
FOR INFORMATIONAL AND TRAINING PURPOSES ONLY

PROGRAM OPERATIONS MANUAL SYSTEM
Part DI – Disability Insurance
Chapter 110 – Initial Claims Processing
Subchapter 18 – Failure to Cooperate and Whereabouts Unknown
Transmittal No. 3, 09/24/2019

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

11/04/2019

Background

We are updating this section to introduce the revised term from "failure to cooperate" to "failure to cooperate-insufficient evidence decision". Adjudicators may continue to use the acronym FTC to refer to this policy. We also added the requirement to obtain two third-party contacts at the time of the application, updated cross-references, and made minor updates to comply with plain language guidelines.

 

Summary of Changes

DI 11018.005 Field Office Responsibilities When a Claimant Fails to Cooperate (FTC)

In this section, we:

  • Revised the title of this section.

  • Rewrote this section to improve clarity, delete duplication and comply with plain language guidelines.

  • Updated the term failure to cooperate- insufficient evidence decision (FTC).

  • Added the requirement to obtain two third-party contacts at the time of filing.

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

20 CFR 404.1516; 416.916

This section explains the actions you must take when developing an initial disability claim and you require additional evidence from the claimant. Refer to DI 11010.045 Claimant Cannot Be Contacted or Whereabouts Unknown or Claimant Does Not Wish to Pursue Title II Claim when you are unable to locate claimant or claimant does not wish to pursue his or her Title II claim. For Title XVI, refer to DI 11055.085 Claimant Does Not Wish to Pursue Claim or Whereabouts Unknown for Title XVI claims.

A. FO responsibilities

In all disability claims, you must:

  • Inform the claimant of what evidence we require, why we require it, and if known, where he or she can obtain it.

  • Obtain two third party contacts from the claimant. Having two third party contacts gives the DDS additional sources should they need assistance obtaining information from the claimant.

  • Provide the claimant with a list of required evidence (e.g., attestation cover notice with proof request).

NOTE: 

The claimant may not be capable of obtaining the evidence on their own and may need assistance. Determine if special handling procedures apply, refer to the special handling charts in DI 13005.025 Field Office Actions to Initiate a Continuing Disability Review (CDR) for special handling consideration. Refer to GN 00301.180 Identifying Claimants Who May Need Assistance and GN 00301.185 Helping Claimants Obtain Evidence for guidance on the providing assistance.

B. FTC development

1. When to develop for FTC

Develop for FTC when:

  • the claimant does not respond to your initial request for evidence;

  • efforts to obtain evidence from the claimant are unproductive; or

  • the disability determination service (DDS) requests FO assistance in contacting the claimant.

It is the claimant’s responsibility to submit evidence to establish eligibility or entitlement for disability benefits. If the claimant does not provide the evidence within 20 calendar days (15 days plus 5 additional for mailing) follow instructions in this subsection.

NOTE: 

: When determining what is a reasonable amount of time for the claimant to provide the requested evidence, take into consideration the types of documents requested, from where they are requested, and if the claimant is actively trying to obtain the obtain the evidence. For example, a document from a source in another country or in another state from where the claimant resides may take longer to obtain or from an agency that from your prior experience requesting information from this office, you know takes several weeks to respond.

2. Review file for required evidence

Review the disability folder to determine whether:

  • Medical evidence of record (MER) as defined in DI 22505.001 is in the file.

  • Developmental evidence, i.e. completed disability report and completed SSA-827 (Authorization to Disclose Information to the Social Security Administration (SSA) are in the file. See DI 11018.005D.1 (in this section) for additional information.

  • Due to the nature or severity of the claimant's impairment or condition, he or she needs assistance obtaining the evidence. For details about how to identify claimants who need assistance and how to provide assistance, see GN 00301.180.

  • A relative, friend, third party, or medical source named during the interview can provide assistance by either contacting the claimant or obtaining the required evidence.

If the above does not apply (there is no MER in the file, the disability report and SSA-827 is not in the file, assistance from us to obtain the evidence based on the claimant's alleged impairment is not needed, and a third-party cannot assist with obtaining the evidence) send a follow-up request to the claimants mailing address with the 30-day closeout date explaining that we will deny the claim 30 days from the date of the original request.

3. Closeout process

Follow the closeout procedures referenced below:

Title II

Title XVI

C. Document efforts to resolve FTC

Document all efforts made to resolve FTC situations in:

1. SSA mainframe systems Modernized Claims System (MCS) or Modernized Supplemental Security Income Claims System (MSSICS)

Document all efforts on the Report of Contact (RPOC) screen in MCS or the Report of Contact (DROC) screen in MSSICS including the dates and results of those efforts. Identify the outstanding issue on the DW01 screens of MCS and MSSICS along with request and follow-up dates.

2. Electronic Disability Collect System (EDCS)

a. Claim not transferred to the DDS

Document all efforts on the form SSA-5002 (Report of Contact) in EDCS and send it to the Certified Electronic Folder (CEF). If the claim is an EDCS exclusion, see DI 81010.030 Certified Electronic Folder (CEF) Exclusions and Limitations.

NOTE: 

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

b. Claim transferred to the DDS

Document all efforts on the form SSA-5002 (Report of Contact) in EDCS. Use the EDCS Transfer/Updates feature to create the form per DI 81010.095 Using the Update-After-Transfer (UAT) Utility and send form to the CEF.

c. Claim transferred to the Office of Quality Review (OQR) for review

While a claim is pending OQR review (if selected for quality assurance), the FO may receive an assistance request (AR) to develop substantial gainful activity (SGA). Use the EDCS Transfer/Updates feature to create the SSA-5002, document your efforts, and send the form to the CEF.

3. Paper folder (EDCS exclusion)

Document your efforts on the form SSA-5002 and place it in the blue section of the paper modular disability folder (MDF).

D. FTC issues resolved

If the FTC issue is resolved at any point prior to a denial, forward the claim to the DDS for a medical determination.

E. FTC issues not resolved

If the claimant does not respond after the FO has followed the procedures in GN 01010.410C Failure to Submit Essential Evidence for Title II claims and SI 00601.100 Information/Evidence-- General for Title XVI claims, continue to process the claim following the instructions below. Document actions taken to obtain requested information from the claimant and results in MCS and MSICCS RPOC screens and on an SSA-5002 filed in the CEF paper file.

1. MER or developmental evidence in file

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

NOTE: 

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

2. No MER or developmental evidence in file

Deny the claim following the steps in 2a and 2b below 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, and

  • 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 factor entitlement, disallow the claim for that specific reason (e.g. does not meet DIB insured status or excess income for SSI eligibility).

Close the EDCS record, if applicable. Process an FO “No Determination” (ND) per DI 81010.140 Processing FO Determinations.

a. Title II claims

Deny the claim for “Insufficient evidence furnished.”

  • Use code 0M5 if the claimant does not respond or submit the required evidence within the closeout period or does not ask for more time to submit the evidence.

  • If the date last insured (DLI) is in the past, use code 0M6.

  • Enter the 0M5 or 0M6 disallowance code on the BECF screen in MCS. For information on the BECF screen, see MS 03509.003.

  • Prepare a manual denial letter via the Document Processing System (DPS) and mail it to the last known address (for detailed instructions, see NL 00601.020E.2).

b. Title XVI claims

Follow instructions in SI 00601.110 Closeout Failure to Cooperate (N18) Initial Claims.

3. FTC issue arises after a favorable medical determination

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

  • Title II claims
    GN 01010.410, Failure to Submit Essential Evidence

  • Title XVI claims
    SI 00601.110, Closeout Failure to Cooperate (N18) Initial Claims

F. Claimant submits requested evidence after FTC denial

Follow the instructions in this subsection for:

1. Evidence submitted within the appeal period

If a claimant submits the requested information within the appeal period, treat the submission as an implied request for reconsideration.

2. Evidence submitted after the appeal period

If a claimant submits the requested information after the appeal period, treat the submission as an untimely filed implied request for reconsideration. We can extend the period for requesting a reconsideration if the claimant submits a written request for an extension and if the claimant can show good cause for failing to submit the request for reconsideration timely.

a. Good cause determination

Develop and document the folder with a “good cause” determination by following instructions in GN 03101.020 Good Cause for Extending the Time Limit to File an Appeal.

See Also:

b. Good cause established

Process the request for reconsideration as though the claimant filed it timely.

See Also:

  • DI 12005.015 Late Filing of a Request for Reconsideration

  • DI 81010.145 Processing Reconsideration Requests of Field Office Determinations

c. Good cause not established

If you determine the claimant did not have “good cause” for 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 details in:

  • 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 FTC denial

Generally, you cannot reopen or revise a correct determination. Use reopening procedures only if the FTC denial was incorrectly processed, 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 for FTC recontacts the FO after the appeal period has ended. The FO cannot find good cause for late filing of an appeal. However, the FO discovers that the FTC denial was incorrect because the requested evidence was submitted timely. The FO can reopen the incorrect FTC denial in this scenario.

Follow instructions:

  • Title II claims

    GN 04001.070 Do Not Reopen Correct Determinations- Operating Policy

  • Title XVI claims
    SI 04070.010 Title XVI Administrative Finality- General Reopening Policies

  • See exceptions to the general reopening procedures:

DI 27505.001A Rules for Reopening

SI 04070.010C Policy – Only Incorrect Determinations Can Be Reopened and Revised

G. References



DI 11018 TN 3 - Failure to Cooperate and Whereabouts Unknown - 11/04/2019