Identification Number:
DI 13005 TN 13
Intended Audience:See Transmittal Sheet
Originating Office:ORDP ODP
Title:Medical Issues
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 130 – Continuing Disability
Subchapter 05 – Medical Issues
Transmittal No. 13, 09/24/2019

Audience

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

Originating Component

ODP

Effective Date

11/04/2019

Background

This transmittal updates Program Operations Manual System (POMS) sections, which includes revisions to the titles, cross-references and content.

 

Summary of Changes

DI 13005.025 Initiating the CDR

This section includes cross-references to instructions. We revised the title of this section to reflect the content in the section.

 

DI 13005.030 FO Personal Contacts

We revised the section title to reflect the content and included cross-referenced information from DI 13005.035.

 

DI 13005.035 Exceptions to the Personal Contact

We archived this section and relocated the information in DI 13005.030.

DI 13005.025 Field Office (FO) Actions to Initiate a Continuing Disability Review (CDR)

To initiate a medical CDR, the FO must follow the instructions in this section.

A. Initial request to initiate a CDR

The FO must send an initial notice for the CDR and request the completion of the required forms for each case, see DI 13005.040C. Use the Workload Action Center (WAC) program to send a notice with the appropriate CDR Type Notice language (for example, face-to-face, by mail).

The initial CDR notice gives the individual or representative payee 30 calendar days to respond to the request (either by mail with completed paperwork or to come-in or call-in to the local office). For example, if the initial CDR notice date is 4/15/2019, the individual or representative payee must comply by 5/15/2019.

The individual must provide the information and evidence needed to determine if his or her disability continues. If the individual or representative payee does not respond within 15 days after the date on the initial notice, review the case to determine if any special handling considerations apply.

B. Special handling considerations

The FO must provide additional assistance when the FO identifies that the individual has one of the special handling considerations as listed in this chart.

Special Handling Considerations

Reference

Appointed Representative

  • GN 03910.040 Appointment and Revocation of Appointment of Representative

  • GN 03910.050 Contacting a Represented Claimant

Representative Payee

Title XVI Disabled Child (DC)

Age-18 Redeterminations and Individuals aged out of Foster Care in the last 2 years.

  • DI 11070.030 Disability Redeterminations – Age-18 Cases

Homeless

Mental Impairment

  • GN 00301.180 Identifying Claimants Who May Need Assistance

Limited English Proficiency (LEP) or Hearing-Impaired

  • GN 00203.011 Special Interviewing Situations: Limited English Proficiency (LEP) or Language Assistance Required

  • GN 00203.012 Special Interviewing Situations for Deaf or Hard-of-Hearing Customers

  • GN 00301.180 Identifying Claimants Who May Need Assistance

C. Follow-up to the initial request

If there is no response within 15 days of the date on the initial notice and there are no special handling considerations, use the chart below to complete the following actions:

CDR Follow-up Process - No Special Handling Considerations

Step 1

15 calendar days after the date on the initial notice:

Attempt contact by telephone.

If the telephone contact is successful – Remind the individual or representative payee to return the requested documentation or forms for the CDR. Document the outcome of the telephone contact in the disability control file (DCF). Proceed to Step 2 and there is no need to complete Step 3.

If the telephone contact is not successful – In the DCF document the outcome of the telephone contact. Proceed to Step 2.

Step 2

15 calendar days after the date on the initial notice:

Send a follow-up notice using WAC. Document the DCF with the date that the follow-up notice was sent. If telephone contact was not successful, proceed to Step 3. If telephone contact was successful, proceed to Step 4.

Step 3

Complete any additional development as stated in DI 13005.025C.1, then 35 days after the date on the initial notice; proceed to Step 4.

Step 4

35 days after the date on the initial notice:

If the FO does NOT receive the completed CDR forms – Make a failure to cooperation – insufficient evidence decision (FTC) determination, document the FTC status in the DCF and put the individual in non-payment status.

NOTE: Do not suspend the benefits prior to 35 days from the date of the initial request. For additional information on suspending the individual’s benefits, see DI 13015.001 or DI 13015.011.

NOTE: The follow-up notice gives the individual or representative payee 15 days to comply. The FO cannot proceed with the FTC or whereabouts unknown (WU) procedures until 35 calendar days after the date of the initial notice. For additional information on WU procedures, see DI 13015.011. For example, if the initial CDR notice date is 1/1/2019 and the follow-up notice is 1/16/2019, the FO cannot suspend the monthly benefits until 2/4/2019.

In foreign cases, the FO does not make personal contact by telephone. The Office of Earnings and International Operations (OEIO) will send a notice to the individual or representative payee and request completion of Form SSA-454-BK Continuing Disability Review Report as follows:

Reason for the CDR

Title

Notice

Medical Improvement Expected (MIE) diary

Title II Only

SSA-L1190-U2

Medical Improvement Possible (MIP) diary

Title II Only

SSA-L1219-U2

NONDIARIED review

Title II Only

SSA-L293-U2

D. Individual fails to respond to the follow-up notice

The FO must make every effort to contact the individual or representative payee to follow-up on all requests.

NOTE: If the case meets the special handling considerations listed in DI 13005.025A in this section, follow the procedures in DI 13005.025C2 in this section.

1. Efforts to locate and contact the individual

The FO must contact any party that may have contact with the individual who could provide information such as:

  • a third-party contact,

  • a financial institution (FI),

  • a post office (PO), or

  • an employer(s).

If the individual or representative payee does not respond within 15 days of the follow-up notice, develop and consider:

  • capability, if it appears the individual may not be capable according to GN 00502.020; or

  • the possibility of a new representative payee when the representative payee no longer wishes to serve or is uncooperative according to GN 00504.100.

Follow the FTC or WU procedures in DI 13015.001 or DI 13015.011.

2. When the individual fails to cooperate or cannot be located, and meets the special handling considerations

If there is no response within 15 days of the date on the initial notice, and there are special handling considerations as described in DI 13005.025A, complete the following steps:

CDR Follow-up Process - Special Handling Considerations

Step 1

15 calendar days after the date on the initial notice - Attempt to contact the individual or representative payee by telephone. Make two attempts by telephone on different days and different times.

NOTE: A busy signal does not constitute as a successful attempt.

If the telephone contact is successful - Remind the individual or the representative payee to return the requested documentation or CDR forms. In the DCF, document the outcome of the telephone contact. Proceed to Step 3.

NOTE: There is no need to complete Step 2.

If the telephone contact is not successful - Proceed to Step 2.

Step 2

Query the Supplemental Security Record (SSR), Master Beneficiary Record (MBR) and the Modernized Development Worksheet (MDW) for a current address or telephone number. If a newer address or telephone number is not available, document the DCF. In the DCF, document any forms of development completed for each case. After completing the development, proceed to Step 3.

Step 3

15 calendar days after the date on the initial notice - Send a follow-up notice using WAC to request compliance within 15 calendar days. If the telephone contact was successful, proceed to Step 5.

Step 4 If there is still no response, 15 calendar days after the date on the follow-up notice - The FO must complete the procedures found in DI 13005.025C.1. In the DCF, document any forms of development completed for each case. After completing the development, proceed to Step 5.

Step 5

30 calendar days after the date on the initial notice - Send a come-in or call-in notice using WAC to request compliance within 15 calendar days. Proceed to Step 6.

Step 6

45 days after the date on the initial notice:

If the FO does NOT receive the completed CDR forms– In the DCF, document the FTC or WU status and put the individual in non-payment status.

NOTE: Do not suspend the benefits prior to 45 days from the date of the initial notice. For additional guidance on suspending the individual’s benefits, see DI 13015.001 or DI 13015.011.

Do not consider FTC or WU procedures when the individual:

  • is incapable, unless the representative payee is the legal guardian;

  • requires a representative payee change; or

  • the third party (such as a neighbor, household family member or financial institution) fails to comply and is acting on his or her behalf. For additional information on direct payment to incapable beneficiaries, see GN 00504.105.

E. Exceptions to initiating a medical CDR

Do not conduct a medical CDR in the following situations:

  • For a Title XVI recipient who is ineligible for Section 1611 or Section 1619 benefits; or

  • A Title XVI or concurrent (Title II and Title XVI) individual who is in current suspense or non-pay status (unless the DDS field on the SSR reflects an initial denial); the individual is entitled to Title XVI due process.

For additional information on the conditions to screen out a medical CDR, see DI 13005.020D.

NOTE: For medical CDR processing instructions for beneficiaries whose ticket to work status is “Assigned” or “In Use SVR”, see DI 55025.001 and DI 55025.010.

If the payment status (PSY) field reflects the codes “N07,” “N08,” “N30”-“N54,” “T31,” or “T51,” the individual is not eligible for payment under Title XVI. Consider the case a Title II case only. With the establishment of the Section 1619 provisions, certain suspense and termination codes took on a revised meaning, see SI 02302.030.

Further development is necessary to determine if a case has become Title II only. Document on an SSA-5002 (Report of Contact) the determination, including the rationale. For example, a case that has the following status:

  • “T5” or “T3” for 12 months,

  • “N04” due to an initial excess resources denial, or

  • “M01” but we will not reestablish the record. Attach all documentation to the completed SSA-5002 (Report of Contact).

NOTE: The FO will include an SSA-5002 (Report of Contact) in every folder transmitted to any component including the DDS, which explicitly states whatever disability entitlement exists (for example, Title II only, Supplemental Security Income (SSI) disabled child (DC), etc.).

F. References

  • DI 13015.001 Failure to Cooperate- Insufficient Evidence Decision (FTC) Policy for Continuing Disability Reviews (CDRs) – Field Office (FO)

  • DI 13015.005 Failure to Cooperate- Insufficient Evidence Decision (FTC) Suspension Procedures for Continuing Disability Reviews (CDRs) – Field Office (FO)

  • DI 13015.007 Failure to Cooperate- Insufficient Evidence Decision (FTC) Reinstatement Procedures for Continuing Disability Reviews (CDRs) - Field Office

  • DI 13015.011 Whereabouts Unknown (WU) Policy for Continuing Disability Reviews (CDRs) – Field Office (FO)

  • DI 13015.013 Whereabouts Unknown (WU) Determinations and Reinstatement Procedures for Continuing Disability Reviews (CDR) – Field Office

  • DI 13015.025 Field Office (FO) Assistance in Medical Continuing Disability Reviews (CDRs) and Failure to Cooperate- Insufficient Evidence Decision (FTC) or Whereabouts Unknown (WU) Cases

  • DI 25205.020 Failure Issues

 

DI 13005.030 Field Office (FO) Personal Contact and Exceptions

A. Introduction to personal contact

SSA recommends, but does not require personal contact in each CDR case. Providing personal contact helps to ensure that individual have a full opportunity to present their case. The FO should make personal contact with:

  • the individual; if there is no mental impairment;

  • the individual only or both the individual and the representative payee, if there is one, when the individual has a physical impairment only; or

  • the representative payee only if there is one, when the individual has a mental impairment that is legally incompetent.

One of the purposes of the personal contact is to alleviate the individual or representative payee’s apprehension about the CDR by providing a thorough explanation of the CDR process, including the individual’s role in the process.

B. Policy on personal contact

Personal contact includes an overview of the CDR process, an explanation of the individual’s rights and responsibilities, and an explanation of the disability hearing process to which he or she is entitled at the reconsideration level. The disability hearing is a result of the implementation of Section 4 and Section 5 of P.L. 97-455.

Section 4 and Section 5 of P.L. 97-455 provide for an evidentiary disability hearing (known as a disability hearing) at the reconsideration level for Title II medical cessation cases. The regulations implementing this statute extend the disability hearing process to comparable Title XVI and concurrent (Title II and XVI) cases.

Inform the individual that, if he or she is dissatisfied with the outcome of the CDR, he or she has the right to request a reconsideration of the determination. The disability determination services (DDS) will perform a folder review and develop the reconsideration as it has in the past. However, due to P.L. 97-455, if the DDS cannot make a fully favorable determination after its review, the individual will be entitled to a disability hearing at the DDS before issuing an unfavorable determination. The explanation of the disability hearing should include a brief overview of the items covered in DI 12026.001 through DI 12026.020.

C. Procedures during personal contact

1. The personal contact interview

During the personal contact interview with the individual or representative payee:

  • Complete a form SSA-454-BK (Continuing Disability Review Report) and SSA-827 (Authorization to Release Medical Information to the Social Security Administration) or a local authorization form. Complete the form SSA-827 according to DI 11005.055 through DI 11005.057. For FO electronic case procedures, see DI 81010.000. The DDS will initiate the medical development. NOTE: If the individual meets the requirements for special handling as mentioned in DI 13005.025A, the FO must attempt to obtain two 3rd party contacts and document the information on the form SSA-454-BK in the Remarks.

  • Explain that he or she is responsible for submitting evidence to determine continuing disability. We will assist in obtaining this information but the individual must submit the names and addresses of treating sources and give permission for the Social Security Administration (SSA) to obtain the evidence.

  • Explain that a prompt response is required to any subsequent DDS contact or request, including a request to appear for a consultative examination (CE). Give careful attention to the possibility that the nature of the individual’s impairment(s) (for example, mental impairment) may hinder cooperation. Annotate the claim folder(s) to alert the DDS of possible difficulties. If the individual fails to cooperate and provide sufficient evidence or the individual’s whereabouts are unknown, refer to DI 13015.005 and DI 13015.013. Document the case folder(s) with all efforts made to obtain the individual’s cooperation.

  • Inform the individual that the CDR can be a lengthy process and medical sources do not always respond promptly. The DDS will need time to evaluate the evidence and if the claim folder(s) do not contain sufficient evidence for a determination, a CE would be required.

For FO instructions to create an electronic CDR (eCDR) in the Electronic Disability Collect System (EDCS), see DI 81010.230. After completing the personal interview in paper cases:

  • Add the form SSA-454-BK (Continuing Disability Review Report) and the form SSA-827 to the folder,

  • Prepare appropriate folder movement forms (for example, SSA-408 (Route Slip) or SSA-8028 (Supplemental Security Income Claims Control), and

  • Route the folder to the DDS using a SSA-408 (Route Slip) unless there is a deferral of the CDR and the folder returned to Office of Disability Operations (ODO)/Payment Service Center (PSC)-Disability Processing Branch (DPB).

2. Personal contact for Title XVI childhood disability cases

In addition to the form SSA-454-BK, also complete:

  1. a. 

    Form SSA-3881-BK (Questionnaire for Children Claiming SSI Benefits). To obtain the name of someone else who could help SSA obtain evidence about the child, see DI 11005.030B.2.

NOTE: It is extremely important that the FO make every effort to obtain the name of an “other responsible adult” when completing the form SSA-3881-BK, or to document the file when no third party is available.

b. The appropriate function report for the child (Function Report—Child Birth to 1st Birthday SSA-3375-BK, Function Report—Child Age 1 to 3rd Birthday SSA-3376-BK, Function Report--Child Age 3 to 6th Birthday SSA-3377-BK, Function Report – Child Age 6 to 12th Birthday SSA-3378-BK, or Function Report—Child Age 12 to 18th Birthday, SSA-3379-BK).

NOTE: For FO electronic case procedures, see DI 81010.000.

Advise the payee that he or she may be asked to provide evidence to show that the child is and has been receiving treatment, to the extent considered medically necessary and available, for the condition(s) that was the basis for providing benefits. Advise the payee that, if he or she refuses to comply with this requirement without good cause, we will decide if benefits should go to another payee, at which time the child’s record may be placed in administrative suspense until another payee can be found, or if the child should receive his or her own benefits directly.

D. Exceptions to personal contact

The FO may waive personal contact if:

  • The relationship between the representative payee and the individual is a professional one (for example, an institution, government agency);

  • The individual or representative payee agrees or requests that the CDR occurs by mail;

  • The individual resides in a foreign country, unless the individual is in a United States FO;

  • We receive a notice of work activity in a Title II medical improvement possible (MIP) or medical improvement not expected (MINE) diary case. We will not conduct a CDR immediately, unless we receive allegation of medical improvement. We will establish a trial work period (TWP) diary and send a notice informing the individual that we will contact him or her at the expiration of the TWP. For additional information on the TWP, see DI 13010.035; or

  • The ODO identifies the case as a Section 1619 CDR, see DI 13005.016.

DI 13005.035 Exceptions to the Personal Contact

A. Introduction

A personal contact is recommended, but not required, in each CDR case to help ensure that beneficiaries have a full opportunity to present their cases. The contact should be made with:

  • the beneficiary; if there is no mental impairment; or either

  • the beneficiary only or both the beneficiary and the payee, if there is one, when the beneficiary has a physical impairment only; or

  • the payee only, if there is one, when the beneficiary has a mental impairment.

B. Policy for waiving the personal contact

In the following situations, a personal contact may always be waived:

  • If the relationship between the representative payee and the individual is an official one (e.g., an institution, government agency);

  • If the individual or representative payee agrees or requests that the CDR be conduced by mail;

  • If the beneficiary resides in a foreign country, unless the individual is in a U.S. field office;

  • If a notice of work activity is received in a title II MIP or MINE diaried case. A CDR will not be conducted immediately (unless medical improvement is alleged). A trial work diary will be established and a notice will be sent informing the beneficiary that he or she will be contacted at the expiration of the TWP.

  • If a 1619 CDR has been initiated from ODO, see DI 13005.016.



DI 13005 TN 13 - Medical Issues - 11/04/2019