Identification Number:
DI 13015 TN 9
Intended Audience:See Transmittal Sheet
Originating Office:ORDP ODP
Title:Special CDR 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 15 – Special CDR Issues
Transmittal No. 9, 09/24/2019

Audience

FO/TSC: AWIC, CS, CS TII, CS TXVI, CSR, CTE, DRT, FR, OA, OS, RR, TA, TSC-CSR, WIL;
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, RECONR, RECOVR;

Originating Component

ODP

Effective Date

11/04/2019

Background

In response to feedback we received from our internal and external stakeholders we are revising the term failure to cooperate (FTC) to failure to cooperate-insufficient evidence decisions. The revised term provides the distinction that when we cannot obtain the claimant's cooperation we will make a determination based on the available evidence unless we do not have sufficient evidence to make the determination. When we do not have sufficient evidence, we will cease benefits based on FTC-Insufficient evidence. Adjudicators may continue to refer to the acronym FTC. We also reorganized the entire DI 13015 chapter for better flow. Specifically, we are separating FTC and whereabouts unknown (WU) into separate sections and adding new sections to improve the layout. Lastly, we moved the development procedures to DI 13005.025-DI 13005.030 as these procedures apply to all medical CDRs (to publish with this transmittal).

Summary of Changes

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

We made the following changes to this section:

  • Revised the title.

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

  • Moved information related to WU policy to a new section, DI 13015.011.

  • Transferred the policy guidance related to general development in subsections C and D to DI 13005.025 Field Office Action to Initiate a Continuing Disability Review and DI 13005.030 Field Office Personal Contacts and Exception because the development steps apply to all medical CDRs.

  • Incorporated FTC policy guidance in DI 13015.010, DI 13015.015, and DI 13015.020 to remove duplication, and placed instructions related to FTC and WU in their own single location.

 

DI 13015.005 Failure to Cooperate -Insufficient Evidence Decision (FTC) Suspension Procedures for Continuing Disability Review (CDR)- Field Office (FO)

We made the following changes to this section:

  • Revised the title.

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

  • Moved references related to WU procedures to a new section, DI 13015.013.

  • Transferred instructions related to general development requirements of a medical CDR from subsection A.2 to DI 13005.025 and DI 13005.030 because these development steps apply to all medical CDRs.

  • Expanded documentation instructions for FTC cases. We added references for the Disability Control File (DCF), and deleted duplication in the instructions. We incorporated FTC procedures in DI 13015.010, and DI 13015.020 to this section to remove duplication and improve flow.

 

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

We created a new section for policy guidance on reinstatement of benefits after a FTC suspension.

 

DI 13015.010 Failure to Cooperate (FTC) Suspension and Cessation/Termination Months and Whereabouts Unknown (WU) Cessation Date Determination

We archived this section and relocated FTC information to sections DI 13015.001 (policy) and DI 13015.005 (procedures) and the WU information to DI 13015.011 (policy) and DI 13015.013 (procedures).

 

DI 13015.011 Whereabouts Unknown (WU) Policy for Continuing Disability Reviews (CDR)- Field Office (FO)

This is a new section focused on WU policy. The new section is to clarify and minimize confusion between WU and FTC policy. We incorporated WU policy from DI 13015.010, DI 13015.015, and DI 13015.020 (to be archived).

 

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

We added this new subsection solely focused on WU determinations and reinstatement procedures to provide distinction between WU and FTC processes.

  • We moved WU procedures from DI 13015.010, DI 13015.015, and DI 13015.020 (to be archived) to remove duplication, and improve flow.

  • We standardized instructions for processing a Title II WU case regardless of folder location.

 

DI 13015.015 Benefit Continuation in FTC/WU Cases

We are archiving this small section because it primarily references other POMS.

 

DI 13015.020 Individual Subsequently Cooperates or Is Located

We are archiving this section and incorporated FTC information in sections DI 13015.001 (policy) and DI 13015.005 (procedures), and the WU information to DI 13015.011 (policy) and DI 13015.013 (procedures).

 

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

We renamed, reorganized and updated cross-references to improve clarify and consistency with DI 13005.045 and DI 13005.110.

 

Conversion Table
Old POMS ReferenceNew POMS Reference
DI 13015.001DI 13015.001
DI 13015.005DI 13015.005
DI 13015.007DI 13015.007
DI 13015.010DI 13015.001, DI 13015.005, DI 13015.011, DI 13015.013
DI 13015.015Obsolete
DI 13015.020DI 13015.001, .005, .011, .013
DI 13015.025DI 13015.025

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

This subchapter provides policy guidance to field offices (FOs) when the beneficiary or recipient does not provide information requested during a CDR.

A. FTC CDR policy

FTC during a CDR occurs when:

  • there is a question about whether a beneficiary or recipient continues to be disabled

  • he or she fails to provide the requested information or evidence within the specified period, and

  • the FO followed the development steps in DI 13005.025 Field Office (FO) Actions to Initiate a Continuing Disability Review (CDR) and DI 13005.030 Field Office (FO) Personal Contacts and Exceptions.

B. FTC- medical CDR

1. Streamlined FTC process- FO

The streamlined FTC process, implemented for medical CDRs on January 27, 2007, enables the FO to suspend Title II and Title XVI benefits when the beneficiary or recipient does not respond to our requests for information or evidence. When the streamlined process applies:

  • The FO suspends benefits or payments, and does not refer the case to the disability determination services (DDS) for a medical determination.

  • If the beneficiary or recipient cooperates and provides the requested information for the CDR within the 12 months, and there are no other outstanding factors to resolve, the FO can reinstate benefits and continue the medical CDR process. The FO then forwards the CDR to the DDS for a medical determination. This does not apply if the record has terminated. For FTC cases that have terminated, obtain an appeal if within the appeal period or obtain a new application.

  • If benefits or payments remain in suspense for 12 months, eligibility terminates effective the 13th month.

Note: Statutory benefit continuation (SBC) does not apply per DI 12027.015 Cases Excluded from Statutory Benefit Continuation (SBC).

2. FTC DDS or Program Service Center (PSC) requests FO assistance

The DDS or PSC may request FO assistance in obtaining the individual's cooperation, or in conducting the medical CDR interview. For more information, see DI 13015.025 Field Office Assistance in a Medical Continuing Disability Review (CDR) and Failure to Cooperate- Insufficient Evidence Decision (FTC) or Whereabouts Unknown (WU) Cases.

3. Exception to streamlined CDR FTC process

The streamlined CDR process does not apply to medical CDRs for extended Medicare cases. For information on extended Medicare entitlement see DI 28055.001B. If the beneficiary does not cooperate with the FO's requests for information or evidence for this type of CDR, refer to DI 13015.005D.

C. Overview of streamlined CDR FTC process

1. Beneficiary or recipient fails to provide requested information to the FO

  • The FO makes a FTC determination and records it on the Disability Control File (DCF) after following the development steps in DI 13005.025 and DI 13005.030.

  • The DCF FTC input places benefits in non-payment status (LAF S0 for Title II/ PS N20 for Title XVI).

  • The suspension notice automatically generates when the transaction is processed.

If the beneficiary subsequently cooperates and provides the requested information during the 12-month suspension period, reinstate benefits for any previous months for which they are otherwise payable if all other factors of entitlement are met. The beneficiary does not file an appeal to have benefits reinstated.

If the beneficiary does not cooperate during the 12-month suspension period, benefits automatically terminate effective the 13th month. No benefit continuation will be offered.

Note: For FO FTC procedures refer to DI 13015.005 Failure to Cooperate-Insufficient Evidence Decision (FTC) Suspension Procedures for Continuing Disability Reviews (CDR)- Field Office (FO).

2. Suspension month

We will suspend benefits effective with the first month that does not cause an overpayment. Note: For Title II claims, we will also suspend benefits to any auxiliaries on the record.

3. Termination month

After 12 months of suspension, we will terminate eligibility effective with the 13th month if the individual did not comply with our request for necessary information or evidence. No DDS medical determination is necessary to terminate benefits.

Example: After all contact attempts have been unsuccessful, the beneficiary does not respond by the final closeout date of 04/25/2018. The FO records the FTC determination on the DCF; benefits are suspended effective 06/2018 (the first month that does not cause an overpayment). If the beneficiary does not cooperate during the period of suspense, benefits terminate effective the 13th month (06/2019).

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

This subchapter provides FO procedures for processing FTC suspension actions when the beneficiary or recipient does not respond to our request for necessary information in a CDR.

A. FO FTC documentation requirements in a CDR, streamlined process applies

Follow DI 13005.025 for FO development requirements when initiating a CDR. Record all development actions on a Report of Contact and save in eView, or for paper folders file the Report of Contact in the folder and fax a copy into the Non Disability Repository (NDRed).

Documentation must include:

  • Date of the initial written request (copies of the request letters must be retained in the folder, if not accessible in ORS);

  • Date the period to comply ended (including extensions);

  • If there are special handling considerations (for example, homeless or mental impairment) see DI 13005.025A for special handling considerations. Document a description of additional development efforts; and

  • Results of follow-up attempts.

B. FO FTC actions to suspend benefits

Once the FO has taken the steps outlined in DI 13005.025, documented development actions, and determined that the streamlined FTC procedures apply as explained in DI 13015.001A, take the following steps to input the FTC suspension. The FTC suspension action cannot be earlier than 35 calendar days (45 days for special handling situations) from the date of the initial CDR notice.

Note: Prior to suspending Title XVI payments ensure appropriate Goldberg/Kelly due process notice has been issued. Obtain office management approval to suspend Title XVI cases (payment status N20) per SI 02301.235J Failure to Provide Information (N20). Follow local office procedures for how to obtain the required management approval.

  1. 1. 

    Record the FO FTC determination on the Disability Control File (DCF) by selecting #4 on the IFOA screen Failure to Cooperate and the FO of jurisdiction in the "Office Responsible for Next Action" field. Refer to DI 13010.620 CDR FO Input (IFOA) Screen, MSOM CDR 001.001 Disability Control File (DCF) Overview, and MSOM CDR 001.007 CDR FO Input Screen (IFOA) for detailed input procedures.

  2. 2. 

    Enter the remark "MED CDR FTC" in the DCF remarks section, see MSOM CDR 001.009 CDR Remarks Input Screen (IRMK) for more information.

  3. 3. 

    For Title II add a special message to the MBR: "MED CDR FTC LAF S0 suspension on mm/dd/yy"

  4. 4. 

    For Title XVI enter the remark "N20 on mm/dd/yy- MED CDR FTC" by using the SSR Remarks screen (CRMK).

Allow two days for the transaction to process. The DCF FTC input places benefits in non-payment status (LAF S0 for Title II/ PS N20 for Title XVI).

If the FTC suspension processed correctly, the MBR or SSID will show "DEV CDR" and "Suspense Reason=FTC-Medical". With this coding present on the MBR or SSID, the termination should occur automatically in the 13th month. If the suspension action did not process, see instructions by title below.

If the beneficiary or recipient does not cooperate during the 12-month suspension period, disability benefits will terminate effective with the 13th month. The disability determination service (DDS) does not make a medical determination. Statutory benefit continuation does not apply.

Title II

Benefits automatically suspend (LAF S0) when the DCF input processes effective with the first month that does not cause an overpayment. If the DCF input fails to suspend benefits:

  • Do not attempt to re-enter the suspension. The DCF exception generates a Paperless action for the processing service center (PSC) to input a manual MACADE suspension action. Verify the Processing Center Action Control System (PCACS) has a suspension action pending for the PSC.

  • After 15 days, query the record to ensure the PSC's manual action processed and that notice was sent to the beneficiary. This may require a follow-up contact to the PSC via the Modernized Development Worksheet (MDW). Follow GN 01070.440D.2 for follow-up procedures.

Note: In addition to the LAF code of S0, the DEVCDR line with suspension reason FTC-Medical and suspension month start date will appear on the MBR when the FTC suspension input processes. The presence of the DEVCDR line starts the 12-month suspension count and is how the record establishes a termination action on the 13th month.

Title XVI

  • If the DCF transaction did not suspend payments, input an N20 suspension in MSICCS to suspend effective with the first month that does not cause an overpayment. For more information on N20 suspension see SI 02301.235 Failure to Provide Information (N20), and

  • The suspension notice automatically generates to the beneficiary or recipient and Title II auxiliaries when the transaction processes. Always query ORS to verify that the transaction issued a notice. If a notice was not sent, send a manual notice.

C. FTC termination after suspension

If the FTC suspension processed correctly, the record will automatically terminate in the 13th month of suspension. Once the record terminates, close out the FTC CDR issue on DCF by entering 5=SSR/MBR/STOP CDR on the IFOA screen of DCF (for more information on DCF inputs see MS 00501.007 CDR FO Input Screen (IFOA)).

Review the case in the 14th month to confirm termination. If the record did not terminate, enter the termination manually via the SSR for Title XVI and for Title II, send an MDW to the PSC requesting action to terminate the record. See MS 03901.003 MDW Worksheet (MMDW) for instructions on establishing an MDW. Alert the PSC that the FTC termination did not process in the 13th month (MM/YY) and request record be updated to show FTC termination as of MM/YY. Also, request the PSC send a notice of termination to the claimant's last known mailing address.

D. Additional considerations in the FTC suspension process

1. Title II additional considerations in the FTC process

a. Medicare entitlement

When Title II benefits are suspended, the beneficiary's Medicare entitlement continues, but the beneficiary will be billed separately for the monthly Medicare premiums. If the Title II benefits terminate due to FTC, the Medicare entitlement ends. The Medicare termination is effective with the end of the month after the month in which the beneficiary is notified that entitlement to benefits will end. Example: Termination of Title II benefits notice dated 10/18/2018, Medicare terminates 11/30/2018.

b. Auxiliary benefits

When the FO enters the DCF FTC action to suspend the disabled wage earner's benefits, benefits for all entitled beneficiaries on the record will also be suspended. Refer to SM 03020.050B Develop for Continuing Disability (CDIB).

c. Auxiliary benefits: Spouse (B2) or E entitled, last child in care suspended

When the FO enters the DCF FTC action to suspend benefits for a disabled minor child or an adult childhood disability beneficiary (CDB) who is the last child in care for a young spouse (B2) or widow (E), benefits must be manually suspended for the B2 or E; refer to SM 03020.050B.

d. Beneficiary in suspension status due to substantial earnings

If at the point of FTC suspension, the beneficiary is in suspense status LAF S7 due to substantial earnings from a work CDR, the DCF FTC suspension should process to add the Continuing Disability Investigation (DEV CDR) Data Line to the MBR. The presence of the DEV CDR data on the MBR triggers the termination at the 13th month. If the DEVCDR line is not present on the MBR, send a an MDW to the PSC and request the DEV CDR line be added to the MBR along with the Suspense Start- MM/YY and Suspense Reason FTC-Medical.

2. Title XVI additional considerations in the FTC process

The DCF input automatically updates the SSR with the FTC payment status (N20-Title XVI- failure to provide necessary information), refer to SM 01305.001 Payment Status Code for more information. There could be a delay of several days for this automatic update to the SSR to occur. The Medical Issue (MG) field in the Disability Data segment (DISB) of the SSR will also update with a code of "F" to show FTC status. The combination of payment status N20 with the MG code of F identifies the case as FTC. If the SSI record does not update to N20, follow manual input procedures in SI 02301.235 Failure to Provide Information (N20).

E. FTC- extended Medicare cases, streamlined process does not apply

The streamlined CDR process does not apply to extended Medicare cases where the beneficiary terminates due to work. These beneficiaries are eligible for the work incentive that extends his or her Medicare entitlement. The DDS must make a medical CDR determination to decide if entitlement to Medicare should continue.

The FO will:

  • Initiate the CDR per DI 13005.025 through DI 13005.030 and DI 81010.230 (select "paper" and do not select "key" to avoid edits at transfer);

  • Document efforts to contact the claimant per DI 13015.005A;

  • Input the transfer from the FO to the DDS in the DCF. Do not input FTC on the DCF. For information on the DCF CDR screens see, DI 13010.610 The Disability Review Establishment (DRES) Screen, DI 13010.620 The CDR FO Input (IFOA) Screen, MSOM CDR 001.016 Disability Review Establishment Screen, MSOM CDR 001.007 CDR FO Input Screen (IFOA));

  • Enter a remark on the DCF CDR Remarks Input Screen (IRMK) (MSOM CDR 001.009) such as "Medical CDR Determination needed by DDS for extended Medicare. Streamlined FTC process does not apply";

  • For electronic CDRs, include the following statement in EDCS Messages/Alerts, "Extended Medicare FTC Case- Need DDS Medical Determination. DO NOT RETURN TO FO, streamlined FTC process does not apply." For paper folder CDRs, annotate the same statement on the route slip attached to the front of the paper folder;

  • Transfer the eCDR or paper modular disability folder (MDF) to the DDS.

Note: If the beneficiary is in FTC suspension when the FO completes a work CDR resulting in termination, follow the steps above and request DDS make a continuing disability determination. Document the previous attempts to contact the claimant that led to the FTC suspension as well as any contact attempts made during the Work CDR.

F. FTC- work issue only, streamlined process does not apply

1. Title II case

When work is the sole issue, make a substantial gainful activity (SGA) determination whenever possible using any available evidence of earnings. Use all methods and sources of wage verification outlined in DI 10505.005C Determining and Verifying Gross Earnings from Employment. Refer to DI 13010.185 Due Process in Work Issue Cases, DI 13010.170 Completing the SSA-833 (Cessation or Continuance of Disability or Blindness Determination and Transmittal-Title II) for processing instructions.

If the earnings evidence is insufficient to determine that the beneficiary is engaging in SGA, proceed with the FTC cessation:

  • Provide due process per DI 13010.185 Due Process in Work Issue Cases.

  • After following the steps in DI 13010.185 for due process and the beneficiary has not submitted the requested information, cease benefits in the first month that all attempts to have the beneficiary respond have been unsuccessful.

  • Input the cessation via the Post-entitlement Online System (POS), see MSOM T2PE 003.024. Once the input processes, the MBR will display LAF T9.

2. Title XVI case

Follow procedures in SI 02302.030 Section 1619 Process and Procedures. See also DI 13005.016 CDR for Title XVI Section 1619 Recipients and DI 13005.018 Field Office Actions for Section 1619 Cases.

G. FTC- medical and work issues combined

When both work and medical issues are involved, prepare a work issue determination whenever possible based on available evidence. If the work issue determination does not result in a termination of benefits, proceed with the medical CDR. If the beneficiary does not cooperate with the FO's request for information, take the necessary steps to place the beneficiary in suspense following the procedures in DI 13015.005B.

H. Beneficiary or recipient moves to another FO jurisdiction while benefits are suspended

If the beneficiary or recipient moves to another FO jurisdiction while in suspense (and continues to not respond to the FO's request), transfer the case on the DCF to the new FO. This transfer will not reinstate benefits.

 

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

A. Reinstatement of benefits, beneficiary or recipient cooperates after FTC suspension

If the beneficiary or recipient cooperates with our request for necessary information within the 12-month suspension period and is otherwise eligible, reinstate benefits or payments by selecting "2" Transfer Case on the CDR FO Input (IFOA) screen of the Disability Control File (DCF) and:

  • For medical CDRs, follow normal CDR processing instructions per DI 13005.025 Field Office (FO) Actions to Initiate a Continuing Disability Review (CDR) and DI 13005.030 Field Office (FO) Personal Contact and Exceptions. Complete a transfer action in the DCF to update the record and on the same day transfer the eCDR in the Electronic Disability Collect System (EDCS) or paper folder to the Disability Determination Services (DDS) for processing. The DCF transfer will reinstate benefits. Query the record to ensure benefits resume. For information on DCF inputs see MSOM CDR 001.007.

  • If work activity is the sole issue, follow procedures in DI 13010.210 Extended Period of Eligibility (EPE) - Overview, to determine if benefit reinstatement is appropriate.

Note: The beneficiary or recipient does not file an appeal to have benefits reinstated.

1. Title II reinstatement of disability benefits

a. Beneficiary cooperates- medical CDR

The DCF transfer triggers a Master Beneficiary Record (MBR) update to reinstate benefits and pay retroactive benefits due to the beneficiary and auxiliaries from the first month of suspension. Allow two days for this action to process. If the DCF input to reinstate benefits fails, the system generates an alert to the Program Service Center (PSC) for their action. Do not attempt multiple inputs in the DCF.

Note: When the PSC must take a manual action to reinstate benefits because the DCF input did not process successfully, the (FO) must monitor and follow-up with the PSC until the PSC completes their action to update the record. If after 20 days from the attempted input the PSC action remains pending, send a high priority follow-up via the Modernized Development Worksheet (MDW). For follow-up guidelines, follow GN 01070.440D.2.

b. Beneficiary cooperates- work activity involved

If work activity is involved, follow DI 13010.210 Extended Period of Eligibility (EPE)- Overview to determine whether benefits are payable before reinstating.

c. Reinstating Title II benefits if case cannot be transferred to the DDS

If the otherwise eligible beneficiary responds to our request for necessary information, but the case cannot be transferred to the DDS (e.g., there is an administrative delay on forwarding CDRs to the DDS), benefits must be reinstated manually. Contact the PSC to reinstate benefits through a high priority MDW. See GN 01070.440D.2 for PSC follow-up time frames.

d. Benefits terminated for reason other than FTC

If Title II benefits terminate for a reason unrelated to FTC during the 12-month period of FTC suspension, and the beneficiary subsequently cooperates with the medical CDR by providing the requested information, benefits that were withheld due to FTC and prior to termination may be released to the beneficiary and auxiliaries. Because the benefits terminated, the FO must determine the payable months and work with the PSC to release payment.

Example: The FO places a childhood disability beneficiary (CDB) in suspense for FTC effective 03/2018 (projected termination month is 03/2019). The CDB marries and disability benefits are terminated 09/2018. In 02/2019, the CDB contacts the FO and provides all the information requested for the medical CDR. The FO releases benefits from 03/2018 through 08/2018 since the CDB cooperated prior to the end of the 12-month suspension.

2. Title XVI reinstatement of disability benefits

a. Recipient cooperates

Reinstate benefits per SI 02301.210 Reinstatement, and follow normal CDR processing instructions for completing the medical CDR.

b. Supplemental Security Record (SSR) coding necessary for reinstating benefits

If the payment status code is N20 and the recipient cooperates, remove the N20 payment status. This will update the Medical Issue (MG) field in the Disability Information (DISB) line of the SSR with a code of "P" showing that FTC status has been removed. Also, remove any SSR remarks that refer to FTC. Input a CDR transfer in DCF and transfer the eCDR or paper CDR folder to the DDS of jurisdiction.

c. Reinstating Title XVI benefits if case cannot be transferred to the DDS

If the otherwise eligible recipient responds to our request for necessary information, but now the case cannot be transferred to the DDS (e.g., there is an administrative delay on forwarding CDRs to the DDS), use the Modernized Supplemental Security Income Claims System (MSSICS) to reinstate benefits. Add a remark on the SSID with the reinstatement date and reason for not transferring the medical CDR.

B. Beneficiary or recipient cooperates, benefits terminated after 12 months of suspension

If the beneficiary or recipient does not cooperate to provide the requested information or evidence, and benefits are in suspense for 12 months, eligibility terminates in the 13th month and no medical determination is necessary. If the beneficiary or recipient contacts the FO after the termination, he or she may file an appeal if within their appeal period or file a new application. This includes Child Disabled Benefits (CDB) and Disabled Widows Benefits. For information on CDB and DWB re-entitlement, refer to DI 10115.001 Requirements for Entitlement to Childhood Disability Benefits (CDB) and DI 10110.001 Requirements for Disabled Widow(er)'s Benefits (DWB).

For subsequent applications, DDS may be able to establish onset in certain CDB re-entitlement situations, see DI 25501.330A.7 Establishing an Established Onset Date (EOD) for Childhood Disability Benefits (CDB) Claims. For DWB re-entitlement, the DDS may be able to establish onset if the prescribed period has not ended.

If work activity is involved, follow DI 13010.210 Extended Period of Eligibility (EPE)-Overview to determine if benefits are payable before reinstating.

C. Beneficiary or recipient cooperates after medical cessation- streamlined process does not apply

If the DDS processes a medical cessation due to FTC and the beneficiary or recipient cooperates after the cessation determination, obtain the appropriate appeal forms and route to the DDS (or the Office of Hearing Operations (OHO) for hearing requests). If the appeal period has passed and there is no good cause for late filing, the claimant may file a new application.

D. Beneficiary cooperates after Title II work cessation by the FO

1. Work issue cases

Refer to DI 13010.145 Reconsideration or Reopening of Continuing Disability Work Issue Cases- Title II.

2. Work and medical issue

If benefits ceased for FTC in a work CDR and the beneficiary cooperates after the work cessation, obtain an appeal if within the appeal period along with the medical CDR forms. If the appeal determination reverses the cessation determination and entitlement based on earnings can continue, transfer the medical CDR to the DDS.

3. Manually close the CDR in DCF for Title II FTC termination cases

If the Title II FTC termination posts to the MBR, the input sends a transaction to DCF during the DCF batch run. This transaction will usually close the CDR event in DCF. FOs should identify these cases in the Workload Action Center (WAC) and ensure the CDR event closes in DCF. If the CDR event is not closed, manually close the Title II FTC CDR issue on DCF by annotating STOP CDR (see DI 13010.620 and MSOM CDR 001.007).

DI 13015.011 Whereabouts Unknown (WU) Policy for a Continuing Disability Review (CDR) – Field Office (FO)

CITATIONS:

20 CFR sections 404.1579(e)(3); 404.1579(g)(6); 404.1586(e)(3),404.1587; 404.1594(e)(3); 404.1594(g)(7); 404.1596(b)(2)(ii); 416.994(b)(4)(iii); 416.994a(f)(3)

This subchapter provides policy guidance when the FO is unable to locate the beneficiary or recipient during the CDR process and determines that WU applies. The FO, Disability Determination Services (DDS), or Program Service Center (PSC) may identify the WU issue at any point during development. The FO is responsible for developing and processing WU issues.

A. WU CDR policy

1. Overview of WU

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

2. WU cessation (Title II) or suspension (Title XVI) month

When there is not enough evidence to justify a continuance, we will stop benefit payments for the first month in which the FO, DDS, or PSC discovers that the beneficiary or recipient's whereabouts are unknown, but no earlier than the month in which the continuing disability issue arose.

  • Title II WU is a non-medical cessation of benefits. Our regulations specifically require benefits to be terminated for Title II WU cases, see 20 CFR 404.1579(e)(3), 404.1586(e)(3), and 404.1594(e)(3). Note: Statutory benefit continuation (SBC) does not apply to Title II WU cases per DI 12027.015 Cases Excluded from Statutory Benefit Continuation (SBC).

  • Title XVI WU is a technical suspension of benefits (pay status S06). Our regulations specifically require Supplemental Security Income (SSI) benefits to be suspended in Title XVI WU cases, see 20 CFR section 416.994(D)(4)(iii) and 416.994(a)(f)(3). Note: Goldberg-Kelly (GK) procedures do not apply, S06 suspensions are an exception to the GK due process procedures. See SI 02301.240 Whereabouts Unknown (S06).

Reminder: The FO must follow the steps in DI 13015.013 Whereabouts Unknown (WU) Determinations and Reinstatement Procedures for a Continuing Disability Review (CDR)- Field Office(FO) before ceasing or suspending payments due to WU.

Example: On 1/27/2018, the FO sends a letter requesting that the Title II beneficiary call by 2/11/2018. The Post Office returns the letter on 2/10/2018 indicating that the addressee is unknown at that address. After following all development steps in DI 13015.013, the FO cannot locate the beneficiary. The FO determines that disability ceased in 2/2018.

3. Title II work issue only

If there is enough information or evidence to make a determination due to work, adjudicate the work determination and annotate the Master Beneficiary Record (MBR) with a special message that WU existed at the time of the work determination.

  • If the determination is a cessation or termination due to work, refer to DI 13010.170 Completing the SSA-833 (Cessation of Continuing Disability or Blindness Determination and Transmittal-Title II) for instructions on preparation of the substantial gainful activity (SGA) determination.

  • If the determination is a continuance, complete the determination and terminate Title II benefits based on WU.

  • If there is not enough evidence to make a cessation determination, proceed with the WU determination.

B. Jurisdiction of medical CDR

1. CDR is pending at the FO

The FO is responsible for initiating the CDR and securing the requested medical information per DI 13005.025 Field Office (FO) Actions to Initiate a Continuing Disability Review (CDR) and DI 13005.030 Field Office (FO) Personal Contact and Exceptions. If, after following the steps in DI 13015.013 Whereabouts Unknown (WU) Determination and Reinstatement Procedures for a Continuing Disability Review (CDR)-Field Office (FO), the FO is unable to locate the beneficiary or recipient, the FO will make a WU determination.

2. CDR is pending at the DDS

If the DDS is unable to locate the beneficiary, the DDS documents their attempt to locate the beneficiary on an SSA-5002 and returns the case to the FO as a "no determination" case. If the FO is unsuccessful in locating the beneficiary or recipient, the FO will prepare a WU determination per DI 13015.013 Whereabouts Unknown (WU) Determination and Reinstatement Procedures for a Continuing Disability Review (CDR)- Field Office (FO).

3. CDR is pending at the PSC

If the PSC cannot complete the CDR because they are unable to locate the beneficiary, the PSC will send the folder to the FO via form SSA-5526-U3 Request for Assistance-Disability or request FO assistance in locating the beneficiary or recipient.

DI 13015.013 Whereabouts Unknown (WU) Determinations and Reinstatement Procedures for a Continuing Disability Review (CDR) – Field Office (FO)

A. WU procedures

1. FO development

Follow the procedures in DI 13005.025 Field Office (FO) Actions to Initiate a Continuing Disability Review (CDR), for contacting the beneficiary or recipient and:

a. Check the Master Beneficiary Record (MBR), Supplemental Security Record (SSR), and other FO records for address and telephone information.

b. Attempt phone contact with the beneficiary or recipient, any authorized person on the record, and auxiliaries (Title II only) who are receiving benefits. Leave a message if unable to speak with the beneficiary, recipient, or other contact.

c. Send an SSA-L2001, Address Information Request to the United States Postal Service (USPS) servicing the mailing address of record unless USPS has returned mail as "undeliverable" or "moved/left no forwarding address" and, at the same time,

d. Send a letter to the financial institution on record to request a current address when direct deposit is involved.

e. Attempt to contact any interested party that may have contact with the beneficiary or recipient based on leads in the folder, such as the payee (if one has been designated), relatives, friends, landlord, employers, shelters for the homeless, city and state welfare agencies, and any medical sources and institutions to which the beneficiary or recipient was previously admitted to. Pursue any available leads.

f. Document all efforts to locate the beneficiary or recipient. Record all efforts to locate the beneficiary or recipient on a SSA-5002 Report of Contact and save in eView for electronic cases, or scanned into NDRed for non-electronic claims and filed in the modular disability folder.

g. For special handling situations, follow the contact procedures in DI 13005.025C.2.

Documentation must include:

  • The event that initiated the CDR;

  • All efforts made to contact the beneficiary or recipient, including the dates and results. For example, document contacts with the USPS, financial institutions, relatives, employers, etc. (retain copies of the requested letters in the folder); and

  • Justification for the determination and cessation month (Title II) or suspension (Title XVI).

Refer to GN 02605.055 Title II Undeliverable Mail-Change of Address for undeliverable correspondence and SI 02301.240 Whereabouts Unknown (S06) for more information.

2. All efforts to locate beneficiary or recipient exhausted

a. Title II medical issue

After the FO has made all efforts listed above in DI 13015.013A.1 and the beneficiary or recipient's whereabouts continue to be unknown, the FO will:

  • Send a due process notice to the last known address. (see DI 13015.095 Exhibit--CDR Due Process Letter for a sample notice).

  • If after 15 days from the date of the notice the beneficiary or recipient does not contact the FO, prepare form SSA-833 (Cessation or Continuance of Disability or Blindness Determination and Transmittal- Title II) cessation determination.

    • Enter a "W" in Item 11 of the SSA-833 immediately following "Reason for Cessation" and

    • Enter paragraph T23 in Item 29 of the SSA-833. See NL 00720.355 Terminations for paragraph language.

  • Annotate the IFOA screen in the DCF indicating WU, see MSOM CDR 001.007 CDR FO Input Screen (IFOA).

  • Input the cessation via the Post-Entitlement System (POS). See MSOM T2PE 003.024 Disability Cessation (PEC1).

  • Enter the remark "MED CDR WU" in the DCF remarks. See MSOM CDR 001.009 MSOM CDR Remarks Input Screen (IMRK).

  • Close out any WU pending tickle on the DCF.

Exception: Paper modular disability folders- If the paper file is not in the FO's possession, do not prepare the SSA-833. Send the due process notice and suspend benefits via POS. Forward the materials to the Program Service Center (PSC) with an SSA-882 and the remark "Whereabouts Unknown".

b. Title II work issue

Whenever possible, prepare a work issue determination based on available evidence as outlined in DI 13015.005E.1. If the work determination does not result in a termination, proceed with the WU cessation.

c. Title XVI medical issue

For WU in a Title XVI case, the FO will:

  • Suspend payment by placing the case in pay status S06. The system automatically generates the Notice of Planned Action (SSA-L8155) to the recipient's mailing address on the SSR.

  • If the recipient's whereabouts remain unknown after 12 months of suspension, eligibility terminates. Ensure the SSR indicates terminated status and update the DCF by annotating a STOP CDR. Enter a remark on the CDR Remarks Input Screen in the DCF such as "T16 Whereabouts Unknown case. Unable to locate the beneficiary after 12 months of suspension."

B. Title XVI WU reinstatement- recipient is located after WU suspension

If the Title XVI recipient is located and is otherwise eligible, the FO will:

  • Reinstate benefits per SI 02301.210 Reinstatement and update the SSR with the recipient's address, telephone number, and direct deposit information, if applicable.

  • Reinstatement is effective the first month that there is a correct address (and living arrangement for Title XVI).

  • Follow normal CDR processing instructions for completing the medical CDR per DI 13005.025 Field Office (FO) Actions to Initiate a Continuing Disability Review (CDR) and DI 13005.030 Field Office (FO) Personal Contact and Exceptions.

  • Update the DCF with the current CDR status and transfer the case to the DDS.

  • Remove any SSR remarks that may refer to the case as being WU.

Note: The Title XVI recipient does not file an appeal to have benefits reinstated.

C. Title XVI recipient is located, benefits terminated after 12 months of suspension

If the recipient cannot be located and benefits are in suspense for 12 months, eligibility will terminate in the 13th month and no medical determination is necessary. If the determination to terminate benefits is correct because the recipient's whereabouts were unknown for 12 consecutive months, the case cannot be reopened under the rules of administrative finality. See GN 04001.070 Do Not Reopen Correct Determinations- Operating Policy.

The recipient can file a new application for disability. Process the new application following initial disability claims procedures.

If the termination is not correct because the recipient did contact the Social Security Administration (SSA) within the 12-month suspension period, reopen the case to determine if benefits can be reinstated and resume the medical CDR.

D. Title II beneficiary is located after cessation

If the beneficiary is located after we have ceased benefits, the beneficiary may file an appeal (if within the appeal period) or file a new application. Note: the appeal request is for the issue that caused the cessation (in this case for whereabouts unknown). Determine if the appropriate steps were taken that led to the WU cessation. If the WU cessation was an incorrect determination, decide if the determination can be reversed or, if outside of the appeal period, reopened under the rules of administrative finality. For more information on reopening a final determination or decision see DI 27505.001 Conditions for Reopening a Final Determination or Decision and GN 04001.001 Reopenings- General Statement.

If the determination can be revised:

  • Secure or update an SSA-454 Continuing Disability Review Report and obtain new medical release forms (SSA-827) if needed.

  • Conduct the CDR interview in the usual manner.

  • Forward the folder to the DDS for a medical CDR determination.

E. Title II beneficiary is located, work issue

Refer to DI 13010.145 Reconsideration or Reopening of Continuing Disability Work Issue Cases- Title II.

 

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

The disability determination services (DDS) or the program service center (PSC) may request FO assistance in obtaining the individual's cooperation, locating the individual, or in conducting the medical CDR interview.

A. Beneficiary or recipient does not cooperate

1. DDS requests

If the beneficiary or recipient does not cooperate with the DDS, the DDS may send an assistance request (AR) to the FO. If the beneficiary or recipient provides the requested information to the FO, return the AR with the requested information to the DDS for completion of the CDR.

If the beneficiary or recipient fails to cooperate with the FO and does not provide the requested information, document the attempts to obtain the information and return the AR to the DDS. The DDS will make a determination based on the evidence in the folder.

2. PSC requests

If the beneficiary does not cooperate with the PSC, the PSC forwards the folder to the FO. If the beneficiary does not cooperate with the FO, follow the FTC streamlined procedures in DI 13015.005 Failure to Cooperate-Insufficient Evidence Decision (FTC) Suspension Procedures for Continuing Disability Reviews (CDR)-Field Office (FO). Do not send the CDR to the DDS for a medical determination. If the beneficiary cooperates and provides the requested information, return the case to the PSC for completion of the CDR.

B. Beneficiary or recipient cannot be located

1. DDS requests

If the DDS cannot locate the beneficiary or recipient when developing the CDR, the DDS will send the file to the FO for assistance in locating the individual. If the FO cannot locate the beneficiary or recipient, and the DDS indicated that there is insufficient medical evidence to make a determination, the FO will prepare the WU determination. If the DDS indicated that the folder contains sufficient medical evidence, the FO will send the folder back to the DDS for a determination.

2. PSC requests

If the PSC cannot locate the beneficiary, the PSC forwards the folder to the FO. If the FO cannot locate the beneficiary and his or her whereabouts are still unknown, the FO accepts jurisdiction and prepares the WU determination.

C. References

DI 13005.045 Field Office (FO) Actions When the Disability Determination Services (DDS) Refers a Case to the FO

DI 28075.005 Failure to Cooperate (FTC) and Whereabouts Unknown (WU) During a Medical Continuing Disability Review (CDR)

DI 40525.001 Failure to Cooperate (FTC) and Whereabouts Unknown (WU) Cases

 



DI 13015 TN 9 - Special CDR Issues - 11/04/2019