Identification Number:
DI 11005 TN 51
Intended Audience:See Transmittal Sheet
Originating Office:ORDP ODP
Title:Disability Interviews
Type:POMS Transmittals
Program:Disability
Link To Reference:
 
PROGRAM OPERATIONS MANUAL SYSTEM
Part 04 - Disability Insurance
Chapter 110 - Initial Claims Processing
Subchapter 05 - Disability Interviews
Transmittal No. 51, 12/2017


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

Originating Component

ODP

Effective Date

Upon Receipt

Background


This transmittal updates field office instructions for completing the form SSA-3367, Disability Report – Field Office, or EDCS 3367 Disability Report.

Summary of Changes

DI 11005.045 Completing the SSA-3367 (Disability Report – Field Office)

We renamed and renumbered sections for consistency with the SSA-3367. We reworded, rearranged, and added bullets for readability and concision. We made changes to the following:

Subsection A. Completing the SSA-3367

Changed the title to FO completes the SSA-3367


    Items 1-5

      · clarified we require a potential onset date (POD) for each Title II claim before you transfer a claim to disability determination services (DDS)

      · clarified the FO must consider the POD separately for each claim type when there are concurrent claims or multiple Title II claims

      · added instructions regarding the POD at the Appeals Council and Federal Court levels

      · added more explicit instructions to the note about periods of disability decided by an ALJ

      · reworded the instructions to explain the reason for POD

      · removed the last bulleted item regarding blindness and visual impairment claims

      · added a note to remind the FO to enter a statement providing the blind date first insured


    Item 6: Provided detailed instructions for blind benefits and DWB claims.

    Item 7


      · moved the IMPORTANT statement up under the subtitle to be more visible

      · changed the wording from last decision to prior decision and added the “s” to make it plural


    Item 9

      · reworded the first sentence regarding FO observations of claimants

      · added a bulleted statement regarding communication in another language

      · reworded the third bulleted statement and put it last on the list


    Item 12

      · reworded the first paragraph

      · added a reference

      · revised the guidance on when to use the remarks section as follows:


        a. Medicare for Qualified Government Employment (MQGE) claims

          · removed the third bulleted statement since it was similar to the fourth bulleted statement

          · added a reference and bulleted the references


        b. Consultative examination (CE) appointment

          · reworded the instruction

          · separated out the examples


        c. Prisoner claims

          · added a reference

        d. Recontacting the claimant

          · reworded the instruction

          · separated out the examples


        e. Curtailing completion of Form SSA-3368-BK (Disability Report – Adult) or SSA-3820-BK (Disability Report – Child)

          · reworded the instruction

        f. Blindness claims

          · removed the section titled “Earnings that are clearly not SGA”

          · removed the parenthetical phrase “EDCS 3367 only” in the heading since this instruction applies to both the SSA-3367 and EDCS 3367

          · in the first sentence, removed the instruction to enter the blind DLI

          · added a statement instructing the FO that they may need to provide 2 DFIs and 2 DLIs if the claimant alleges both a physical impairment and blindness/visual impairment

    Added subsections:

      · h. Fraud or similar fault cases,

      · i. Medicare waiting period cases

      · j. COBRA cases

Subsection B. Supplemental instructions for Form SSA-3367 for specific claim types Reworded and bulleted the paragraph

Subsection B.1. DIB and Freeze cases with a non-blind DLI prior to the filing date and an allegation of blindness, vision problems, or low vision

Changed the title to DIB and freeze claims with a non-blind DLI and an allegation of blindness, vision problems, or low vision

      · reworded and bulleted the first sentence

      · added a reference to the second sentence

      · deleted bullet b

      · combined bullets c and d, which becomes bullet b. “In item 6, Miscellaneous Information”

      · added new bullet c instructing to enter the blind DFI in the Remarks section if the claimant is found statutorily blind

      · removed the note

Subsection B.2. MQGE claims
      · changed bullet b to provide a more explicit instruction

      · added two more instructions under bullets d and e

Subsection B.3. DWB claims reworded the instructions for clarity

Subsection C. removed the reference AM-14047 REV




DI 11005.045 Completing the SSA-3367 (Disability Report – Field Office)

The field office (FO) completes Form SSA-3367 or the Electronic Disability Collect System (EDCS) 3367 Disability Report for initial claims, reconsiderations of initial claim, escalated claims, and continuing disability reviews (CDRs). Complete the SSA-3367 or EDCS 3367 before transferring jurisdiction of a claim to the disability determination services (DDS).

This information alerts the DDS to factors that could affect entitlement and guides case development. The entries provide the DDS with information about:

  • current filing including the potential onset date (POD);

  • work before or after the alleged onset date (AOD);

  • non-blind and blind date last insured (DLI), if applicable;

  • prior filings;

  • presumptive disability and presumptive blindness (Title XVI only); and

  • interviewer observations.

EXCEPTIONS: Although EDCS supports electronic CDR processing, complete the paper SSA-3367 for EDCS exclusions i.e., expedited reinstatements (EXRs). For additional EDCS exclusions, complete the paper SSA-3367 as detailed in DI 81010.030.

A. FO completes the SSA-3367

  • Complete one entire paper form for multiple or concurrent EDCS exclusion claims.

  • Complete page 1, items 1 through 6 for each additional claim.

  • Complete form EDCS 3367 as detailed in DI 81010.025.

1. IDENTIFYING INFORMATION (items 1-5)

For data propagation into EDCS, see DI 81010.035. Complete the following information on the SSA-3367.

a. Item 1: Name, Social Security number, gender, date of birth

  • Enter the number holder’s (NH) full name and social security number (SSN).

  • Enter the claimant’s full name, gender, date of birth, and SSN, if different from the NH.

  • Enter the claimant’s name and SSN for auxiliary or survivor claims (e.g., a disabled widow(er) beneficiary (DWB) filing on the deceased spouse’s record, or a disabled minor child (DMC) filing on a parent’s record).

b. Item 2: Claimant’s Alleged Onset Date (AOD)

Enter the AOD.

The AOD is the date the claimant alleges he or she became unable to work because of his or her medical condition, see DI 25501.210.

If the claimant never worked, enter as the AOD, the date he or she believes the condition(s) became severe enough to keep him or her from working.

If the AOD conflicts anywhere in the file (e.g., the AOD is different on the application from the date on the SSA-3368-BK (Disability Report - Adult)):

  • resolve the conflict with the claimant,

  • enter the date selected by the claimant, and

  • explain why the AOD conflicts in the Remarks section on the SSA-3367.

Make all AOD changes in the Modernized Claims System (MCS) and in the Modernized Supplemental Security Income Claims System (MSSICS).

c. Item 3: Potential Onset Date (see DI 25501.220 Potential Onset Date (POD))(check type of claim(s) and enter potential onset date)

The POD alerts the DDS examiner of work issues, insured status, and other non-medical factors that may affect the established onset date (EOD). The POD is claim specific.

  • Before transferring jurisdiction of a claim to the DDS, the FO must enter the POD for each Title II disability claim at the initial and reconsideration levels, including escalated claims, and continuing disability review claims (CDRs). The POD must be after the claimant meets all non-medical requirements.

  • The FO does not have the capability to enter the POD on the 3367 in EDCS at the Appeals Council or Federal Court levels.

  • For Title II disability insurance benefit (DIB) claims, the POD is the earliest possible date that the DDS can establish onset based on non-medical factors. The POD may be the same as, earlier, or later than the AOD. For guidance on how to consider the POD in Title II claims, see the chart in DI 25501.220C.1.b.

  • Enter the POD for Title XVI supplemental security income (SSI) claims only if the POD is different from the protective filing date or the filing date;

  • Consider the POD separately for each disability claim type in concurrent or multiple Title II claims.

To complete items 3 through 6, follow detailed instructions in subsection B. Supplemental instructions for Form SSA-3367 for specific claim types:

  • DIB and freeze claims with a non-blind DLI prior to filing date and an allegation of blindness, vision problems or low vision;

  • MQGE claims; and

  • DWB claims.

NOTE: Be aware that the POD may be in a previously adjudicated period; including a period decided by an administrative law judge (ALJ).

If the FO sets a POD in a previously adjudicated period decided by an ALJ, the DDS does not have the authority to reopen the case but must consider whether reopening and revising a prior determination or decision is appropriate.

The DDS only has authority to reopen if the prior determination is below the ALJ hearing level, see DI 27510.005C.1.

  • If the DDS believes reopening is appropriate, the DDS completes action on the subsequent claim and refers the prior and subsequent claims to the State or Federal Disability Hearing Unit (DHU) or the Office of Disability Operations (ODO) to consider reopening. See DI 27510.005C.2.

  • In some situations, the DDS can establish onset within the prior period without reopening. See DI 27510.005D and DI 27510.005E.

d. Item 4: Reason for Potential Onset Date

Check the appropriate block for the reason for the POD.

  • SSI application date

  • Date last insured

  • Date first insured

  • Controlling date

  • Other (explain in item 5)

  • Work before or after the AOD (check all that apply):

    • UWA;

    • SGA;

    • Not SGA;

    • SSA-823 in file

IMPORTANT: You must complete Form SSA-823 (Report of SGA Determination - For SSA Use Only) in all initial claims that require an SSA-820-BK (Work Activity Report - Self-Employment) or an SSA-821-BK (Work Activity Report - Employee).

Do not complete an SSA-821-BK or SSA-823 if the work is clearly not SGA per DI 10505.003.

For detailed information on work activity reports, see:

  • DI 10510.025 Documenting Self-Employment Cases Using the SSA-820-BK (Work Activity Report-Self-Employment) and the SSA-823 (Report of SGA Determination- For SSA Use Only)

  • DI 10505.035 Documenting Employment Cases Using Forms SSA-821-BK (Work Activity Report-Employee) and SSA-823 (Report of SGA Determination-For SSA Use Only)

e. Item 5: Explanation for Potential Onset Date, when applicable

If you check “Other” in Item 4, explain the reason for the POD, for example:

  • The POD and the AOD are inconsistent. (You must resolve and explain any inconsistencies in work activity or other non-medical factors that may affect the onset date.)

  • The claimant’s work is clearly not SGA per DI 10505.003.

  • The date first insured (DFI) is the reason for the POD. Enter the DFI.

2. Item 6: MISCELLANEOUS INFORMATION

Provide the following information:

  • Enter the protective filing date. Find the protective filing date in the electronic folder under the case data tab in eView.

  • Enter the non-blind DLI for DIB and Freeze claims.

  • Enter the blind DLI if the claimant is insured for blind benefits, and alleges blindness, a visual impairment, or low vision. For claims involving potential blindness, see Remarks Section, 9.f.

    NOTE: It is possible that a claimant will be insured for blindness only and therefore, not be insured for non-blind benefits.

  • Enter the prescribed period and controlling date for DWB claims, see subsection B.3. For EDCS cases, verify that the propagated prescribed period and controlling date are correct. For detailed guidance, see DI 11005.050.

  • Check “yes” or “no” for a closed period of disability case.

See also:

DI 25510.001 Closed Period of Disability

DI 25510.010 Establishing a Closed Period of Disability and Protecting a Closed Period Freeze Under Title II

DI 25510.015 Closed Period of Disability Under Title XVI

3. Item 7: PRIOR FILING INFORMATION – Use Remarks, if additional space is needed

List ALL prior filings with a medical determination or decision and SGA denials on the SSA-3367 (or the EDCS 3367). Use the Remarks section, if you need additional space. The DDS does not need filing information for technical denials (e.g., N13, N04, N18, 090).

Indicate whether the claimant has a prior filing(s).

If yes, and you are not sending the prior folder(s) to the DDS, provide the following information:

  • Type of prior claim(s);

  • SSN(s) of prior claim(s);

  • Date of prior decision(s) (MM/DD/YYYY);

  • Level of prior decision(s) (initial, reconsideration, etc.);

  • Outcome of prior decision(s) (allowance or denial);

  • Location of prior folder; and

  • Prior folder requested; if “yes” include the date requested or “no.”

For instructions on prior filings, see Prior Claims Activity in DI 11005.085.

4. Item 8: PRESUMPTIVE

Check the block(s) for any presumptive disability (PD) or presumptive blindness (PB) criteria that apply in SSI (Title XVI) claims.

Refer to detailed FO procedures on processing PD and PB claims in DI 11055.240.

5. Item 9: OBSERVATIONS/PERCEPTIONS

How was the interview conducted?

Observations are very valuable to DDS examiners for both face-to face and telephone interviews. Record the following information:

  • type of interview

    • teleclaim with claimant,

    • face-to-face with claimant, or

    • no contact with claimant;

  • if claimant communicated in a language other than English, record that language;

  • difficulties with any of the activities listed (check “yes,” “no,” or “not observed/perceived”);

  • description of the claimant’s behavior, appearance, grooming, or degree of limitations; and

  • any additional comments about your observations.

6. Item 10: FO DEVELOPMENT

Document any development initiated by the FO.

For information about FO development, see

  • DI 11010.485 through DI 11010.495 for medical evidence

  • DI 22501.002B. for non-medical evidence.

CAPABILITY/REMARKS

7. Item 11: If medical evidence was brought in to the FO by the claimant, check here

Indicate whether the claimant submitted medical evidence of record (MER) to the FO.

8. Item 12: Is DDS capability development needed?

If capability is questionable and you cannot make a capability determination, (e.g., allegation of mental disorder(s) or noticeable abnormal behavior of the claimant),

  • ask the DDS to provide a capability opinion, and

  • explain in the Remarks section on the SSA-3367.

While the DDS may provide an opinion regarding the evidence of capability, the FO is responsible for the final determination of capability. For more detailed information, see

  • DI 11055.215A. Policy for an FO request for DDS capability development

  • GN 00502.040A.3. How much consideration should I give to medical evidence?

9. Remarks Section:

Use the Remarks section

  • to add explanations, descriptions, expansion of the answers to questions, or

  • to record other pertinent information about the claim for the DDS.

a. Medicare for Qualified Government Employment (MQGE) claims

Enter the following information:

  • When applicable, alert the DDS that a claimant filed an application with the Office of Personnel Management for an annuity based on disability, or is receiving an annuity based on disability; include the Civil Service annuity claim number, see DI 11035.010;

  • When forwarding MQGE only claims to the DDS for a disability determination, annotate “MQGE claim for Medicare entitlement only”;

  • If a claimant is potentially entitled to both MQGE and DIB benefits with different DFIs, DLIs, and PODs, alert the DDS to develop evidence based on multiple onset dates.

See MQGE policy and procedures:

  • DI 11035.001 Medicare for Qualified Government Employment (MQGE) Claims Based on Disability

  • DI 11035.005 Developing Medicare for Qualified Government Employment (MQGE) Claims Using the Electronic Disability Collect System (EDCS)

  • DI 25501.365 Established Onset for Medicare Qualified Government Employment (MQGE) Claims

b. Consultative examination (CE) appointment

If the claimant expects difficulties in keeping a CE appointment, document the reason.

EXAMPLE: lack of transportation, home confinement due to disability, inability to read, no telephone to reach the claimant, or homelessness.

c. Prisoner claims

For applicable remarks to document prisoner claims, refer to

  • DI 10105.094B.2. Documenting the SSA–3367

  • DI 23530.001B.1. FO actions upon receipt of referral

d. Recontacting the claimant

If re-contacting the claimant is difficult, document the reason, see DI 11005.001A.2.

EXAMPLE: Telephone contact with a homeless claimant may be difficult, or a claimant may be on an extended trip and unavailable for contact.

e. Curtailing completion of Form SSA-3368-BK (Disability Report – Adult) or SSA-3820-BK (Disability Report – Child)

If you curtail completion of the SSA-3368-BK or SSA-3820-BK, explain why per DI 11005.020.

f. Blindness claims

In blindness, visual impairment, and low vision claims,

  • enter “If the claimant is found statutorily blind, the blind DFI is MM/DD/YYYY.”

  • you may need to provide two DFIs and two DLIs (non-blind and blind) if the claimant alleges both a physical impairment and blindness or a visual impairment, see DI 11005.071.

g. Potential parent’s benefits claims

If the DIB claimant alleges providing half support to a parent at the time of onset, enter the following statement: “Potential Parent’s Benefits - Do not use the DIB expedient when establishing the EOD,” see DI 25501.300.

h. Fraud or Similar Fault cases

Describe any fraud or similar fault issues, see DI 11006.010.

i. Medicare Waiting Period cases

If onset is more than five years after the prior termination, enter

  • “Medicare Waiting Period Determination Needed,”

  • the diagnosis code from the prior entitlement, and

  • the month of prior termination.

For more information, see DI 11010.261 Field Office Applying Prior Entitlement Months to the Medicare Waiting Period

j. COBRA cases

Annotate “COBRA case” and the date the employee must notify the health plan administrator, see DI 11080.005.

INTERVIEWER INFORMATION

  • Print the interviewer’s name, area code, and phone number

  • Print the name of the person completing the form (if different from the interviewer)

  • Date the form.

B. Form SSA-3367 supplemental instructions for specific claim types

Document information properly as it could affect the claimant’s entitlement to benefits for the claim types described in this section. For each of the following claim types provide the following:

  • supplemental claim information regarding insured status, and

  • prescribed period or controlling date, or both.

1. DIB and freeze claims with a non-blind DLI and an allegation of blindness, vision problems, or low vision

The blind DFI and blind DLI could be material to the established onset date for blindness when applicant alleges:

  • blindness,

  • vision problems, or

  • low vision

When there are both non-blind and blind allegations, provide the non-blind DLI and the blind DLI. In these claims:

  1. In item 6, Miscellaneous Information,

    • Enter the non-blind DLI in the “Non-blind date last insured (DIB/Freeze case)” field.

    • Enter the blind DLI in the “Bli