Identification Number:
DI 42010 TN 10
Intended Audience:See Transmittal Sheet
Originating Office:ORDP ODP
Title:Effectuating ALJ, AC, and Court Decisions (Single Appellant, Single Issue) Sections
Type:POMS Transmittals
Program:All Programs
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM
Part DI – Disability Insurance
Chapter 420 – Processing Appeals Reopenings and Material Received After a Determination
Subchapter 10 – Effectuating ALJ, AC, and Court Decisions (Single Appellant, Single Issue) Sections
Transmittal No. 10, 10/16/2020

Audience

PSC: BA, CA, CS, DE, DEC, DTE, ICDS, IES, ISRA, PETE, RECONR, SCPS, TSA, TST;
OCO-OEIO: BET, BIES, CR, ERE, FDE, PETL, RECONE, RECONR, RECOVR;
OCO-ODO: BET, BTE, CCE, CR, CTE, CTE TE, DE, DEC, DES, DS, PAS, PETL, RECONE;

Originating Component

ODP

Effective Date

Upon Receipt

Background

We reviewed and updated instructions regarding termination of interim benefits (IB). Because of the OIG Audit A-02-18-50543, we clarify the exact date of interim benefit termination.

Summary of Changes

DI 42010.205 Interim Benefits in Cases of Delayed Final Decisions — Title II

Subsection C we updated instructions and added an example of when a disability decision becomes final.

Subsection D we updated instructions to explain what to do when a claimant does not meet insured status and IB apply.

Subsection E we updated instructions to explain retroactivity of IB.

Subsection F we updated instructions to explain suspension and reduction events involving IB.

Subsection G we updated instructions overpayment situations involving IB.

 

DI 42010.215 Processing Interim Benefits in Cases of Delayed Final Decisions

Subsection B we formatted this subsection with a bulleted list to help explain claim specialist responsibilities.

Subsection C we updated instructions and added an example of when a disability decision becomes final.

 

DI 42010.230 Effectuating Final Decision in ODIO/PSC—Interim Benefits Being Paid

Subsection B we updated instructions and added an example explaining when a disability decision becomes final.

DI 42010.205 Interim Benefits in Cases of Delayed Final Decisions — Title II

CITATIONS:

Social Security Act, Section 223(h)
20 CFR § 404.969(d)

A. Payment of disability interim benefits (IB)

If the Appeals Council (AC) initiates review of an administrative law judge’s (ALJ) favorable disability decision and the agency does not issue a final decision within 110 days from the ALJ’s decision, we will pay the claimant interim benefits.

NOTE: To process interim benefit payments for Title XVI Supplemental Security Income (SSI) cases, see SI 02007.000.

B. Who is entitled to Title II disability IB

We pay IB to disabled wage earners, disabled widow(ers), and childhood disability beneficiaries.

IB are payable only to the claimant filing for disability benefits. Defer payment of auxiliary benefits until receipt of a final decision.

C. When IB begin and end

1. When IB begin

We pay interim benefits under Title II beginning the month before the month in which the 110th day falls.

EXAMPLE: If the 110th day after the ALJ’s favorable disability decision is October 5, 2015, IB begin September 2015. Begin processing IB once the start order is received from the Office of Appellate Operations (OAO).

2. When IB end

We pay IB under Title II through the month before the month in which the Commissioner issues a final decision. For guidance on when a decision becomes final, refer to GN 03101.060. Do not consider IB as an overpayment even if SSA stopped IB late, unless fraud is involved. For more information see DI 42010.205G.

EXAMPLE: The Commissioner issues a final decision on December 15, 2015 after AC's own motion review. IB would terminate November 2015.

REMINDER: The date on the ALJ decision becomes the final decision date if the claimant does not appeal or the AC does not initiates its own motion review. The Office of Appellate Operations (OAO) sends a stop order once the decision becomes final.

D. Claimant does not meet Title II insured status requirement

IB are payable even if the claimant does not meet Title II insured status requirements. Compute the monthly IB amount using the onset date established in the ALJ decision for the disabled individual based on the earnings record for the social security number on which the ALJ's favorable decision was issued. If the informational/certified earnings records system (ICERS) is unable to determine the primary insurance amount, use the interactive computation facility program (ICF). ICF will calculate the beneficiary’s PIA, ignoring the insured status requirement. See ICFT2 001.001 for more information on ICF.

E. Retroactivity of IB

If we did not process the IB payments timely, and the agency ultimately issues an unfavorable final decision, IB are still payable the month before the month in which the 110-day falls, through the month before the month of the unfavorable final decision.

EXAMPLE: In November 2015, SSA receives an IB start order dated March 2015 with a start date of February 2015, after a final decision dated October 2, 2015. A closed period of IB would be payable February 2015 through September 2015.

F. Suspension and reduction events for IB

Prior to initiating IB payments, verify that proof of US citizenship or lawful presence is on record. See RS 00204.010 for lawful presence payment provisions.

Do not pay IB if the claimant is subject to non-payment provisions due to prison conviction and confinement, or if lawful presence is not resolved. See GN 02607.160 and RS 00204.010.

IB payments are subject to reduction due to workers’ compensation (WC), public disability benefit, and windfall elimination provision offset. If you are unable to verify WC data and no payment amount is alleged, use the State’s maximum weekly WC rate based on the year of the date of injury listed in DI 52150.045 to determine offset amount.

Annotate form SSA-5002 (Report of Contact) with any pertinent payment information, e.g., WC offset. For electronic folders, create a barcode coversheet and fax the SSA-5002 into eView. For paper folders, fax the complete form SSA-5002 into the non-disability repository for evidentiary documents system (NDRED).

IB are not payable in cases where we certify payments to the Railroad Retirement Board (RRB). SSA cannot certify payment to the RRB in the absence of a final decision.

G. Overpayment situations involving IB

If the final decision is unfavorable, do not consider IB to be an overpayment, unless fraud is involved. Do not establish an overpayment because SSA stopped IB untimely.

If SSA erroneously processed an ALJ decision that was pulled for AC’s own motion review, see DI 42010.220C.

If we did not apply suspension timely based on any suspension provision, and the claimant was otherwise eligible to receive IB, do not consider any IB paid for those months to be an overpayment. See, DI 42010.205F.

EXAMPLE: SSA begins paying IB August 2015. In December 2015, we find that the IB should have been suspended as of August 2015 due to the prisoner provisions. Because we did not apply the prisoner suspension timely, we cannot consider the IB paid from August 2015 through December 2015 to be an overpayment. Suspend IB beginning January 2016. For more information on prisoner suspension, see GN 02607.160.

DI 42010.215 Processing Interim Benefits in Cases of Delayed Final Decisions

A. Disability interim benefits

Interim benefits (IB) are payable when the Appeals Council (AC) exercises its own motion authority to review an administrative law judge’s (ALJ) favorable disability decision, but a final decision has not been issued within 110 days from the ALJ decision date. The AC may exercise this authority if an SSA office protests the ALJ's decision, or because of quality review sampling.

When the AC decides to review a decision, the claimant receives a notice. The notice informs the claimant that their favorable ALJ decision has been selected for review. The notice also informs the claimant of the delay in payment of benefits while the case is under review and that there is a limit to the delay.

B. Claims Specialist (CS) responsibilities

The CS receives the IB start orders via the Paperless case control system. If no start order is received for IB, see DI 42010.225A.

CS are responsible for contacting the Office of Appellate Operations (OAO) to clarify any inconsistencies in the IB start order.

CS are required to provide the Benefit Authorizer (BA) with the following details:

  • IB start date,

  • if applicable, IB suspension months due to non-payment provisions,

  • primary insurance amount, and

  • monthly benefit amount after any benefit adjustment due workers’ compensation (WC), public disability benefit, and windfall elimination provision offset. If the CS is unable to verify WC data and no payment amount is alleged, use State’s maximum weekly WC rate based on the year of the date of injury listed in DI 52150.045 to determine offset amount.

The CS will instruct the BA if the case is concurrent Title II and Title XVI, and if an appointed representative or representative payee is involved.

NOTE: Defer completion of form SSA-831-UF (Disability Determination and Transmittal) or an A101 and EF101 (Determination of Award) until issuance of a final decision.

C. Benefit Authorizer (BA) responsibilities

1. Initiating CPS payment

BAs are responsible for determining any retroactive benefit amount. In concurrent Title II/XVI, coordinate with the field office (FO) to avoid creating a Title XVI windfall. Contact the servicing FO to provide the Title II IB amount and to ensure the FO defers Title XVI IB until processing of Title II IB. See SI 02007.001.

The BA initiates IB payments using the Critical Payment System (CPS) and sends the notice titled “Notice of Interim Benefits for Administrative Law Judge Cases – Section 8001, P.L. 100-647 – Exhibit” to the claimant and, if applicable, the claimant’s appointed representative. See NL 00703.580. Suppress the regular CPS notice. Receipt of IB is an initial determination. Include due process language in your notice of IB.

2. Terminating CPS payments after an unfavorable decision

OAO issues a stop order when the decision is final. For Title II decisions, OAO sends the stop order to the appropriate Program Service Center (PSC). Process the stop order upon receipt. Do not consider IB paid as an overpayment, unless fraud is involved. Terminate IB effective the month before the month of the final decision. Do not establish an overpayment due to untimely termination of IB.

Manually archive CPS data on the master beneficiary record. See MSOM INTRANETCPS 001.001.

EXAMPLE: An ALJ issues a final decision on December 15, 2015 after AC's own motion review. IB would terminate November 2015.

NOTE: The ALJ decision date becomes the final decision date if the claimant does not appeal or the AC does not initiate its own motion review. The OAO will send a stop order when the 60-day appeal period ends (without an appeal), or action is taken on an appeal of the unfavorable decision.

D. References

NL 00703.580 Notice of Interim Disability Benefits for ALJ Cases.

DI 42010.230 Effectuating Final Decision in the Program Service Center—Interim Benefits Being Paid

A. Favorable decision

Process any favorable or partially favorable final decision manually using an EF101. The benefit authorizer should adjust for payments previously released against payments currently due. See DI 42010.000 for instructions on processing administrative law judge (ALJ) and Appeals Council (AC) decisions. Develop any outstanding issues, e.g., workers' compensation, following instructions in DI 52150.001 - DI 52150.090. Handle any overpayment in accordance with GN 02201.000.

B. Unfavorable decision

Interim benefits (IB) are payable up to the month before the month in which the Commissioner issues a final disability decision. Because a decision is not final if the claimant appeals the decision, the Office of Appellate Operations (OAO) does not issue the stop order until the appeal period ends. For this reason, consider the appeal period months IB payments and do not create an overpayment, unless fraud is involved.

Code the MADCAP action to ignore the erroneous payments. See SM 00865.045. Manually archive CPS data on the master beneficiary record. See MSOM INTRANETCPS 001.001.

NOTE: The ALJ decision date becomes the final decision date if the claimant does not appeal or the AC does not initiates its own motion review. The OAO will send a stop order when the 60-day appeal period ends (without an appeal), or action is taken on an appeal of the unfavorable decision.

C. Partially favorable decision

When an ALJ changes his or her decision from fully favorable to partially favorable after AC own motion review, SSA will not consider any IB paid during an unfavorable period as an overpayment, unless the IB were fraudulently obtained. SSA will adjust for payments previously released against payments currently due, only for entitlement concurrent with payments due during the IB period.

Example: A fully favorable decision grants a claimant entitlement beginning October 2011. SSA began paying IB August 2015. After the AC’s own motion review, the ALJ issues a partially favorable decision. The claimant is granted a closed period of disability beginning October 2011 and ending January 2013. Because SSA paid IB beginning August 2015 outside of the new favorable period, SSA will not create an overpayment for any IB unless the IB were fraudulently obtained. SSA will release any underpayment due during the favorable closed period, since no payments due were payable during entitlement to IB.

D. Applicability of attorney fees

SSA does not consider IB in the past-due benefits calculation to determine applicable attorney or representative fees. When calculating past due benefits for purpose of determining applicable attorney fees, exclude any IB payments from the past due benefit calculation.


DI 42010 TN 10 - Effectuating ALJ, AC, and Court Decisions (Single Appellant, Single Issue) Sections - 10/16/2020