Identification Number:
GN 01010 TN 30
Intended Audience:See Transmittal Sheet
Originating Office:ORDP OISP
Title:Adjudicative Policy and Standards
Type:POMS Transmittals
Program:All Programs
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM
Part GN – General
Chapter 010 – Adjudication
Subchapter 10 – Adjudicative Policy and Standards
Transmittal No. 30, 11/13/2020

Audience

PSC: BA, CA, CCRE, CS, DE, DS, ICDS, IES, ISRA, PETE, RECONR, SCPS, TSA, TST;
OCO-OEIO: BET, BTE, CAQCR, CCRE, CR, CTE, ERE, FCR, FDE, FDEC, PETL, RECONE, RECONR, RECOVR;
OCO-ODO: BET, CCE, CR, CST, CTE, CTE TE, DE, DEC, DS, DSE, PAS, PETE, PETL, RCOVTA, RECONE, RECOVR;
FO/TSC: CS, CS TII, CS TXVI, CSR, CTE, DRT, DT, FR, OA, OS, RR, TA, TSC-CSR;

Originating Component

OISP

Effective Date

Upon Receipt

Background

We are updating this section of POMS to elaborate and clarify the responsibilities of a Benefit Authorizer (BA). Additionally, we updated job titles and acronyms throughout. We also removed references to the paper claims transmittal form throughout, as it is no longer in use.

Summary of Changes

GN 01010.285 Processing Center (PC) Screening

Updated the term "Processing Center" to "Program Service Center" throughout the section. Updated headings to "sentence case", where appropriate, per guidelines in Policy Writer's Toolkit.

Subsection A - Updated job titles.

Subsection B.1

  • Added a note for BAs to be mindful of missing or incomplete remarks.

  • Added the BA responsibility of addressing discrepancies between award screens and Master Beneficiary Record (MBR) data points.

  • Clarified that BAs prepare necessary diaries, listings, or notices referred to in the award remarks screen that the Field Office (FO) or Workload Support Unit (WSU) failed to annotate.

  • Updated job titles and removed references to the paper claims transmittal form.

Subsection B.2. - Removed restrictive language pertaining to Lump Sum Death Payment (LSDP) disallowances and made it more general so that it will apply to awards as well.

Subsection C - Updated job titles and removed references to the paper claims transmittal form.

Subsection D

  • Updated job titles and removed references to the paper claims transmittal form.

  • Added a leading paragraph to identify the intended audience for this subsection.

  • Added a reminder about the A101/EF101 feedback form.

GN 01010.285 Program Service Center (PSC) Screening

A. Policy on PSC claim screening

The role of the PSC is generally limited to payment effectuation activities. However, a Benefit Authorizer (BA) performs limited reviews, often in conjunction with technicians and clerks (e.g., Claims Specialist (CS), Technicial Expert (TE), Claims Clerk Examiner (CCE), etc.). Therefore, any reference to BAs in this section includes these delegated personnel.

B. BA responsibility

1. Limited review

  • Examine the claims transmittal screen for any special instructions or remarks. An example of a special remark is a reference to a Report of Contact (RPOC), Benefit Continuity Remarks/Notice (BCRN) screen, or paper forms SSA-795, SSA-5002, etc. in file for actions such as adding a special paragraph to the award notice. NOTE: Be mindful of missing or incomplete remarks and refer back to the Modernized Claims System (MCS) RPOC(s) or documentation in the MCS path, Electronic Viewer (eView), or Claims File User Interface (CFUI), when necessary;

  • Address discrepancies, including conflicting information between award screens and Master Beneficiary Record (MBR) fields;

  • Prepare any necessary diaries, listings, or notices not established or annotated on the award remarks screen by the Field Office (FO) or Workload Support Unit (WSU). You will sometimes discover the necessity for such actions when handling other alerts and exceptions; and

  • Perform other special post-adjudicative actions (e.g., claims folder cross-reference) as indicated by the FO on the screen. For the Office of Disability Operations' (ODO) responsibilities in reviewing Non-District Office Final Authorization (Non-DOFA) End-Stage Renal Disease (ESRD) Medicare claims, see DI 45001.005C.

2. Lump-Sum Death Payment (LSDP) claims

  • Process or coordinate any adjustments for outstanding checks or underpayments;

  • Input coding and prepare notices (indicated by the FO), as necessary; and

  • Resolve any outstanding alerts or exceptions.

C. CS responsibility

Follow the instructions below when performing a limited or full CS adjudicative review in the PSC.

1. Limited review

Focus on resolving the problem(s) identified in the screening process. Review the claim’s material related to the problem identified.

Ordinarily, the CS review is limited to:

  • Applicable queries (e.g., MBR, Payment History Update System (PHUS), etc.);

  • The latest RPOC in file;

  • The transmittal screen; and

  • The current claims determination action.

NOTE: Review of the Decision Input (DECI) screen, Interface (INTE) screen, Check/Notice 2 (NOT2) screen, and Notice 3 (NOT3) screen is discretionary.

Indicate that you performed a limited review on a District Office Final Authorization (DOFA) claim. Annotate the claims file electronically with the remark “CS/LR”, the CS's initials, and the date you completed the review.

2. Full adjudicative review

a. Criteria for conducting a full adjudicative review

  • An Automated 101 (A101) or Electronic Form 101 (EF101) is transferred to the PSC but is not adjudicated;

  • The A101 or EF101 routing screen does not show whether it is DOFA; or

  • An alert or exception condition needs to be resolved.

NOTE: A full adjudicative review is not required merely because of referral from the screening operation. Do not do an unnecessary review.

b. Full adjudicative review due to an alert or exceptions

If you determine a full adjudicative review is necessary, obtain the approval of the Assistant Module Manager (AMM) or other designated personnel, and provide suitable documentation. For instance, if you identify a problem that affects a basic entitlement factor (e.g., proof of age), a full adjudicative review may be deemed necessary.

D. Screening manual claims

The screening manual claims instructions below apply to BAs, CSs, Post-Entitlement Technical Experts (PETEs), and Claims Technical Examiners (CTEs).

1. General review

When reviewing manually processed awards:

  • Note any remarks made by the FO on the routing screen (e.g., references to RPOC, A101, etc.) for special actions such as adding a dictated paragraph to the award notice; and

  • Prepare any necessary diaries, listings, or notices not indicated by the FO.

REMINDER: The A101/EF101 feedback form located here allows PSC technicians an opportunity to provide feedback to the FO on incorrectly coded A101s and EF101s sent to the PSC by the FO.

2. EF101 review

Review EF101 entries. Correct or complete incorrect, incomplete, or omitted entries when possible, see GN 01010.220. In questionable situations (i.e., entitlement concerns or errors other than consistency errors), refer to a CS or other appropriate technician for review of the erroneous situation.

3. Subsequent claims

Compare the prior file or MBR with the current claim. For example, check for the payment status of the number holder (NH) in the case of a subsequent auxiliary claim or for the presence of an outstanding overpayment. You could reveal situations where corrective action is required.

Check for intervening actions (e.g., Automatic Earnings Reappraisal Operations (AERO)) that occurred between FO adjudication and PSC screening that might affect the accuracy of the claims determination input. Review a current MBR to determine if intervening actions have occurred.

4. Routing the claims

Route manually processed claims appropriately, depending on what you find when screening the claim. You may have to route a few of these claims to a CS to resolve a particular problem.


GN 01010 TN 30 - Adjudicative Policy and Standards - 11/13/2020