Identification Number:
DI 40505 TN 1
Intended Audience:See Transmittal Sheet
Originating Office:ORDP ODP
Title:Medical Issues
Type:POMS Transmittals
Program:Disability
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM
Part DI – Disability Insurance
Chapter 405 – Processing Continuing Disability Review Cases
Subchapter 05 – Medical Issues
Transmittal No. 1, 12/18/2018

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, DPS, DTE, ICDS, IES, ISRA, PETE, RECONR, SCPS, TST;
ODD-DDS: ADJ, DHU;
RO: CDP;
OCO-ODO: BET, BTE, CLT, CR, CST, CT, CTE, CTTA, DE, DEC, DS, LSC, PAS, PCS, PETL, RCOVTA, RECONE, RECONR, RECOVR;
OQR: DE, PA, PE, TL;

Originating Component

ODP

Effective Date

Upon Receipt

Background

This transmittal is part of an ongoing activity by the Office of Disability to update POMS. It contains instructions for the Processing Centers (PCs) for cases involving a continuing disability review (CDR). The processing instructions are for both paper and electronic cases. This update does not change policy.

We changed the subchapter title from “Medically Alerted Continuing Disability Reviews” to “Medical Alerts for Continuing Disability Reviews (CDRs)”.

We made the following revisions to all sections: ·

  • Followed plain language guidelines;

  • Provided clear and detailed section titles and subsection headings;

  • Made minor changes to clarify content;

  • Shortened sentences, where possible.

Summary of Changes

DI 40505.001 Processing When Medical CDR Alert is Generated

We changed the section title from “Processing When Medical CDR Alert is Generated” to “Processing a Medical CDR When the Office of Disability Operations (ODO) Generates an Alert”.

Subsection A – Introduction to case selection for the Processing Centers (PCs)

We changed the title of the subsection from “Introduction” to “Introduction to case selection for the Processing Centers (PCs)”.

Subsections B and C – We deleted these headings and subsections. We combined the text from these subsections into Subsection A.

Subsection B – Procedure for processing CDRs

We renumbered “D” to “B”. We changed the title from “Procedure” to “Procedure for processing CDRs.”

The text in existing “B” will remain in the new “B”.

 

DI 40505.005 Routing Medically Alerted CDRs

We revised the section title from “Routing Medically Alerted CDR” to “Routing Medical Continuing Disability Reviews (CDRs)”.

Subsection A – Field Office (FO) Procedure for routing cases.

We revised the heading from “Procedure – routing forms” to “Procedure for routing cases”.

Subsection B – Procedure for routing forms

We revised the heading from “Procedure – routing” to “Procedure for routing forms”.

 

DI 40505.020 FO/DDS Deferral, or Discontinuance

We revised the section title from “Field Office and Disability Determination Services Deferral, or Discontinuance” to “Procedures for Field Office (FO) or Disability Determination Services (DDS) Deferral or Discontinuance”.

Subsection A – Introduction to deferral or discontinuance

We revised the heading from “Introduction” to “Introduction to deferral or discontinuance”. We added detail concerning the CDR mailer process and the Automated Direct Release (ADR) process.

Subsection B – Procedure for deferral or discontinuance

We revised the heading from “Procedure” to “Procedure for deferral or discontinuance”.

 

DI 40505.100 Medical Improvement Expected (MIE) Cases With Work Activity

Subsection A Policy for Medical Improvement Expected (MIE) cases

We revised the heading from “Policy” to “Policy for Medical Improvement Expected (MIE) cases.

Subsection B – Folder Review for Medical Improvement Expected (MIE) cases

We revised the heading from “Procedure” to “Folder Review for Medical Improvement Expected (MIE) cases”.

 

DI 40505.105 Title XVI Recipient Requests Reinstatement - Past Due MIE Diary - Procedure

We revised the section title from “Title XVI Recipient Requests Reinstatement – Past Due MIE Diary Procedure” to “Procedure for When a Title XVI Individual with a Past Due Medical Improvement Expected Diary Requests Reinstatement”.

 

DI 40505.110 1619 CDRs and Medical Folder Reviews (MFRs) -Related Procedures

We revised the section title from “1619 CDRs and Medical Folder Reviews (MFRs) – Related Procedures” to “1619 Continuing Disability Reviews (CDRs), Medical Folder Reviews (MFRs), and Related Procedures”.

 

DI 40505.115 Voluntary Report of Medical Improvement (MI)

Subsections A and B – We deleted the headings of subsections A and B. We combined the text into one paragraph under the main title.

 

DI 40505.120 Third Party Reports

We revised the title from “Third Party Reports” to “Third Party Report(s) May Initiate a Continuing Disability Review”.

Subsection B.2. – We added text to provide additional information about work.

 

DI 40505.125 Additional Evidence or Information Received

We deleted the word “Received” from the section title.

 

DI 40505.130 Current Evidence Required

We revised the section title from “Current Evidence Required” to “When We May Require Current Evidence”.

 

DI 40505.135 Court Requires CDR Action - Reference

We archived this section because DI 42502.001, “Court-Ordered Reviews – Reference” contains instructions for court CDRs.

 

DI 40505.200 Applicability of CDR Events and CDR Results on Both Titles

In the title, we changed “…Both Titles” to “…Title II and Title XVI”.

Subsection A – We changed “Policy principle – general rule” to “General policy principle regarding CDRs”

Subsection B – We changed “Policy principle – work issue exception” to “Policy principle regarding work issue exception”.

Subsection C – We changed “Operating policy” to “Operating policy to determine if disability continues for Title II and Title XVI cases”.

 

DI 40505.205 Title XVI File Needed for CDR?

We revised the title from “Title XVI File Needed for CDR?” to “When We May Need a Title XVI File for CDR”.

Subsection C – We deleted this subsection and moved its text as the last bullet of paragraph “B”.

 

DI 40505.210 Identifying Concurrent Cases - Deciding Need for Title XVI Determination and Title XVI Continuance Notice

We revised the title “Identifying Concurrent Cases – Deciding Need for Title XVI Determination and Title XVI Continuance Notice” to “After We Identify Concurrent Cases, We Decide Whether We Need the Title XVI Determination and the Title XVI Continuance Notice”.

Subsection A – Operating policy for concurrent cases We changed the title from “Operating policy” to “Operating policy for concurrent cases”

Subsection C – We deleted this section and renumbered subsection “D” to “C”.

Subsection C - Procedure to determine Title XVI involvement with a concurrent case –

We changed the title of this subsection from “Procedure” to “Procedure to determine Title XVI involvement in a concurrent case”.

Subsection C.2.g – We deleted the example since it is unavailable.

 

DI 40505.215 Title XVI Clear-cut Cessation Cases - Operating Policy

We changed the section title from “Title XVI Clear-cut Cessation Cases – Operating Policy” to “Operating Policy for Title XVI Clear-cut Cessation Cases”. We made minor changes to the format of the text.

 

DI 40505.220 Title II Cessation - New Title XVI Application - Related Procedure

We revised the section title from “Title II Cessation – New Title XVI Application – Related Procedure” to “Title II Cessation and New Title XVI Application”. We added more information to the text to provide more detail.

 

DI 40505.300 Diary Coding of Continuance Determinations

Subsection A – We deleted the hyphen and inserted “for” in the heading.

Subsection B – Procedure to input a medical diary to the disability control file (DCF)

We changed the heading of subsection B from “Procedure – input to MBR and SSR” to “Procedure to input a medical diary to the Introduction to non-essential material.”disability control file (DCF)”. We corrected the POMS reference from “SM 01305.825, Completion of 9 Months of TW” to “SM 01305.915D, NOTE, Diary Input Requirements When MD Transmitted – MR Diary”. We also added text for additional information.

 

DI 40505.305 Pre-effectuation Review (PER) References

We deleted the word “References” from the section title.

Subsections A and B – We deleted the headings and combined the text of the two paragraphs into one paragraph under the main title. We corrected “GN 04440.001, List of Acronyms” to “GN 04440.005, Types of Federal Quality Reviews (QR)”.

 

DI 40505.310 Nonessential Material

We changed the title from “Nonessential Material” to “Non-essential Material”. We changed the word “nonessential” to “non-essential” throughout the section. We replaced “Per” with “PER” throughout the section.

Subsection A – Introduction to non-essential material We changed the title from “Introduction” to “Introduction to non-essential material.”

Subsection B – Procedure for identifying non-essential material We changed the title from “Procedure” to “Procedure for identifying non-essential material

In “B.1.” we reformatted the content from one sentence to two sentences.

In “B.2.” we added detail for clarity.

 

DI 40505.315 Handling Continuing Disability Reviews (CDRs) When SSA Did Not Effectuate the Cessation Determination

We changed the word "Where" in the title to "When".

 

DI 40505.900 Exhibits

We changed the title from “Exhibits” to “Forms Used in Adjudication of Disability Cases”.

SSA-847-U3 (08-1986) ef (10-2004) SSA Request for Case Action

SSA-899-U2 (05-1979) Continuing Disability Review

SSA-5526-U3 (02-2005) Request for Assistance – Disability

Potential Suicide/Homicide Case Flag – See DI 81020.085, Certified Electronic Folder (CEF) Flags – for instructions on placing this flag into the CEF.

DI 40505.001 Processing a Medical Continuing Disability Review (CDR) When the Office of Disability Operations (ODO) Generates an Alert

These instructions are for processing CDR cases in the processing center (PC) only. For medical CDR processing instructions for disabled individuals with Tickets to Work, see DI 55025.010, Processing the Medical Continuing Disability Review (CDR) for Beneficiaries with Tickets.

For instructions on court cases, see DI 42502.001, Court-Ordered Reviews -- Jurisdiction.

The FO processes most 1619 CDRs and medical folder reviews (MFRs).

Before we can process a medical cessation, we must have applied the Medical Improvement Review Standard (MIRS).

A. Introduction to case selection for the Processing Centers (PCs)

The Office of Disability Operations (ODO) may select a case for a Continuing Disability Review (CDR) in one of two ways: Direct Release (DR) mailer or automated direct release (ADR). We must determine if a CDR is appropriate. We do not routinely screen out cases selected via CDR mailer. However, we must screen cases selected via ADR to determine whether we need to do a full review. For Field Office (FO) Actions for Processing and Screening Continuing Disability Review (CDR) Folders and Alerts, see DI 13005.020.

For information on the PC responsibilities in work CDRs, please refer to

DI 13010.023, Processing Center (PC) Responsibilities for Continuing Disability Reviews (CDRs) involving Work Activity.

B. Procedure for processing CDRs

1. ODO selects a case for CDR

If ODO selects a case for a CDR, the PC must attempt to locate the folder. In Title II multiple entitlement situations, the PC will locate and associate all medical disability folders. Multiple entitlement’s definition is entitlement to more than one benefit for Title II. Benefits could include any combination of Disability Insurance Benefits (DIB), Childhood Disability Benefits (CDB), and Disabled Widow’s(er’s) Benefits (DWB).

NOTE: If you find "multiple entitlements," please include “Multiple Entitlements” on all routing forms.

After ODO selects a case for a medical CDR, follow these procedures:

  1. a. 

    Folder(s) in the Processing Center (PC) or Federal Archives and Records Center (FARC) -- Obtain the folder(s).

  2. b. 

    Folder(s) in the field office (FO) -- Forward the CDR mailer to the FO, unless case control query indicates that the case has already been terminated.

  3. c. 

    For monitoring purposes, the PC will maintain a list of CDR mailers and alerts sent to the FO. The FO will notify the PC within 2 weeks of receipt of the mailer whether the folder has been located. If the FO has the folder, it will begin the CDR.

  4. d. 

    When unable to locate the folder, or it is in a location other than the PC, FARC, or FO, follow internal special search instructions.

2. ODO defers a CDR

ODO may defer a CDR if it falls into one of the following categories:

  • Reasons unrelated to disability, e.g., travel, hospitalization (short duration), weather; or

  • Life-threatening situations (with or without regional approval).

After ODO defers a CDR via the Disability Control File (DCF), Claims Technical Examiners (CTEs) or Claims Authorizers (CAs) update and reset the medical diary based on the prior medical data in the DCF. For explanation about the deferral process, see DI 28003.010, Deferrals of Continuing Disability Review (CDR) Process.

3. Suicide or Homicide cases

When processing suicide or homicide cases, resolve any doubt about suicidal or homicidal behavior. Give an explanation on an SSA-5002 (Report of Contact) for the file.

For instructions regarding flags, see DI 81020.085, Certified Electronic Folder (CEF) Flags.

DI 40505.005 Routing Medical Continuing Disability Reviews (CDRs)

A. Procedure for routing forms

1. Field Office (FO) cases

Use an SSA-5526-U3, Request for Assistance – Disability. ODO may use this form to provide information for the FO.

2. The FO will route cases to the Disability Determination Services (DDS)

The FO will use an SSA-847-U3, SSA Request for Case Action, to send the case to DDS. The Processing Center (PC) does not route cases directly to DDS.

B. Procedure for routing cases

1. Medical Improvement Expected (MIE) cases

Check block 01 medical re-exam diary (MRED) on the SA-5526-U3; forward the folder to the FO. If an individual has work activity in a MIE case, see DI 40505.100, Medical Improvement Expected (MIE) Cases with Work Activity.

2. Medical Improvement Possible (MIP) cases

Check block 03 PERIODIC REVIEW (PR) on the SSA-5526-U3; forward the folder to the FO.

3. Medical Improvement Not Expected (MINE) cases

Check block 09 PR on the SSA-847-U3; forward the folder to the DDS.

DI 40505.020 Procedures for Field Office (FO) or Disability Determination Services (DDS) Deferral or Discontinuance

A. Introduction to deferral or discontinuance

Due to the continuing disability review (CDR) mailer process described in DI 40502.000, medical CDR alerts no longer require screening. The Processing Center (PC) reviews the completed mailer and profile data sheet to decide if the Office of Disability Operations (ODO) requires a full medical CDR(s) at that time. If we do not need a full medical CDR, re-diary the case. Based on PC input, the system produces alerts only for those cases in which ODO needs full medical CDRs.

In addition to the mailer, the Automated Direct Release (ADR) system selects cases that may need a CDR. The ADR alerts require regular screening.

Both the mailer and ADR system require a folder review to determine if a

CDR is appropriate. For detailed information regarding screening procedures, see DI 13005.020A, Field Office Actions for Processing and Screening Continuing Disability Review (CDR) Folders and Alerts.

1. Defer a CDR

The FO may defer a CDR if it would be inappropriate or very inconvenient for the individual due to his or her hospitalization, travel, etc. With Regional Office (RO) approval, the FO may also defer a case in life-threatening situations. ODO can defer a case for up to 6 months. For additional information concerning deferments, see DI 13005.020J.

2. Discontinue a CDR

The DDS ordinarily completes all CDRs sent from the FO, but may discontinue a CDR if the case is particularly sensitive (for example, Acquired Immune Deficiency Syndrome (AIDS) or any other terminal impairment). For detailed information regarding screen-outs, see DI 13005.020.

The component responsible for discontinuing the CDR must notify the individual.

B. Procedure for deferral or discontinuance

If the FO or DDS returns a CDR to the PC, the PC must:

  • Verify the reason for return of the discontinuance (Do not review a decision just to defer.);

  • Set a new diary as appropriate (but no more than 6 months into the future) for a deferral; or

  • Return the case to the FO or DDS if the basis for discontinuing the CDR is incorrect. Explain the reason for the return on an SSA-5002, Report of Contact.

DI 40505.100 Medical Improvement Expected (MIE) Cases with Work Activity

Events other than a medical alert, for example, work activity or voluntary report of medical improvement (MI), may initiate a Continuing Disability Review (CDR). If an individual with a Medical Improvement Expected (MIE) diary alleges medical recovery, conduct a CDR. A disabled individual may voluntarily report medical improvement or recovery. Unless the report clearly indicates no medical improvement, initiate a CDR. If the diary date does not show in the Disability Control File (DCF), refer to MS 001.017.

During the trial work period (TWP), do not conduct a medical CDR in Title II-only Medical Improvement Possible (MIP) or Medical Improvement Not Expected (MINE) cases. The field office (FO) will obtain an SSA-454-BK (Continuing Disability Review Report) and other necessary CDR information and then send this information to the Processing Center (PC) for folder association and CDR action. If the PC cannot take final action, they will send the folder back to the FO for needed development. When the FO completes development, they will send the folder to the Disability Determination Services (DDS).

A. Policy for Medical Improvement Expected (MIE) cases

Return to work in a MIE case may indicate medical recovery. In this situation, the Office of Disability Operations (ODO) will initiate a medical CDR and apply current MIE diary criteria listed in DI 26525.025, MIE Criteria. If the case does not meet current MIE criteria, adjudicate it under diary criteria in effect at the time of the allowance.

If an individual with a MIE diary returns to work and meets all of the following conditions, consider a clear-cut cessation, that is, a determination without full medical development. For instructions on clear-cut cessations, see DI 28030.035, Cessation Without Full Medical Development (Clear-Cut Cessations):

  • Returns to work full-time without significant medical restrictions;

  • Acknowledges that he or she had medical improvement as of the month he or she returned to work;

  • Expects to be able to continue to work;

  • Does not want us to consider medical evidence from the last 12 months before we make a determination; and

  • Does not have a mental impairment.

The PC or DDS may prepare a clear-cut cessation.

NOTE: We do not cease Title XVI cases for work activity; however, we may prepare a Title XVI clear-cut cessation if all of the criteria meet.

B. Folder review for MIE cases

1. MIE diary appropriate

Determine if a MIE diary is appropriate. Although the diary is appropriate, work activity may require investigation regardless of the medical issue.

2. MIE diary not appropriate

If the MIE diary is not appropriate, follow these instructions:

  1. a. 

    Cancel the MIE diary; establish a medical improvement possible (MIP) or medical improvement not expected (MINE) diary as appropriate, per DI 26525.001, Scheduling Continuing Disability Reviews (CDRs) – General Policies.

  2. b. 

    Take action on Title II work activity. (For instructions, see DI 13010.023, Processing Center (PC) Responsibilities for Continuing Disability Reviews (CDRs) involving Work Activity.)

  3. c. 

    Alert the FO of earnings if it is not clear whether the individual has reported earnings.

3. MIE diary appropriate; clear-cut cessation case

If the case is a clear-cut cessation case, follow these instructions:

  1. a. 

    Prepare a clear-cut cessation determination if the case meets all the criteria per DI 28030.035, Cessation Without Full Medical Development (Clear-Cut Cessations).

  2. b. 

    Prepare cessation notice with benefit continuation language.

  3. c. 

    Release the notice to the individual.

  4. d. 

    Forward folder to the FO for appeals period. Tell the FO to handle as a medical cessation and that benefit continuation rights apply.

4. MIE diary appropriate; not a clear-cut cessation case

If the case contains a detailed report of work, but it does not meet the clear-cut cessation provisions:

  1. a. 

    Document trial work period (TWP) months and date via the disability control file (DCF). If DDS does not establish a medical cessation, they will apply a TWP.

  2. b. 

    Explain the issue on SSA-847-U3 Social Security Administration Request for Action or SSA-5526-U3 Request for Assistance - Disability if the PC has not done the CDR interview; forward the folder to FO for necessary development.

5. MIE diary appropriate; case needs work investigation

If the report of work lacks the detail necessary for an evaluation:

  1. a. 

    Forward case to the FO via SSA-847 -U3 or SSA-5526 -U3 for development and CDR interview. Explain what information the FO should obtain;

  2. b. 

    If Title XVI is involved, request income and resources (I&R) decision and necessary I&R adjustment; and

  3. c. 

    Tell the FO to forward case to DDS for a medical determination after FO completes necessary actions.

DI 40505.105 Procedure When Title XVI Recipient with a Past-Due Medical Improvement Expected (MIE) Diary Requests Reinstatement

Initiate a CDR if:

  • Title XVI recipient requests reinstatement following a period of suspense for non-disability reasons; and

  • There is a past-due MIE diary on the record.

Explain the issue on an SSA-847-U3 Social Security Administration Request for Case Action or an SSA-5526-U3 Request for Assistance – Disability. If the Processing Center (PC) did not do the CDR interview, forward the folder to the FO for a CDR interview via SSA-454 Continuing Disability Review Report and any other necessary development.

DI 40505.110 1619 Continuing Disability Reviews (CDRs) and Medical Folder Reviews (MFRs) and Related Procedures

The Office of Earnings and International Operations (OEIO) processes most 1619 Continuing Disability Reviews (CDRs) and medical folder reviews (MFRs).

For additional information on CDR 1619 cases, see DI 13005.016, Continuing Disability Review (CDR) for Title XVI Section 1619 Recipients, and DI 13005.018, Field Office (FO) Actions for Section 1619 Cases. After reviewing the record, the field office is responsible for determining whether we need a CDR.

DI 40505.115 Voluntary Report of Medical Improvement

An individual may voluntarily report improvement or recovery. Unless the report clearly raises no issue of medical improvement, we will initiate a CDR. If the diary date does not show in the DCF, refer to MS CDR 001.017.

DI 40505.120 Third Party Report(s) May Initiate a Continuing Disability Review

A. Operating policy for third party reports

If a third party reports that an individual is not disabled, is not following required treatment, or has returned to work, and the report:

  • Is from someone in a position to know; and

  • Indicates a real possibility of cessation.

Then, we must investigate the situation.

B. Procedure for medical development

1. Third party report raises a medical issue

Develop for medical evidence to:

  1. a. 

    Determine if the report raises a Continuing Disability Review (CDR) issue. If cessation is unlikely, annotate the report “NAN - DI 40505.120” (that is, No Action Necessary – Third Party Reports).

  2. b. 

    Determine whether the Office of Disability Operations (ODO) has done a medical CDR in the last 6 months.

  3. c. 

    Determine if there is a clear CDR issue. If ODO has not done a CDR in the last 6 months, explain the issue on an SSA-847-U3 Social Security Administration Request for Case Action, or on an SSA-5526-U3 Request for Assistance - Disability, and forward the folder to the FO for CDR development. Do not start a CDR unless a report indicates cessation is very likely, or case was diaried as a Medical Improvement Expected (MIE).

2. Third party report of work

Perform a medical folder review (MFR) to determine whether an individual continues to have a disabling impairment when:

  1. a. 

    He or she has completed 7 or more trial work period (TWP) months;

  2. b. 

    He or she has entered, or will enter, an extended period of eligibility (EPE) or extended Medicare eligibility period; or

  3. c. 

    He or she files for premium health insurance (HI) for the working disabled.

For additional instructions regarding a medical folder review (MFR), see DI 40510.040, Medical Folder Review.

DI 40505.125 Additional Evidence or Information

A. Introductions regarding additional evidence or information

Additional information may raise a continuing disability review (CDR) issue when:

  1. 1. 

    We receive evidence in connection with a new or existing claim or case;

  2. 2. 

    Reports of work or increased earnings or responsibilities may indicate medical improvement (MI) or new vocational skills; or

  3. 3. 

    The Office of Disability Operations (ODO) receives information during a Title XVI redetermination.

B. Procedure regarding additional evidence or information

1. Duplicative report

If medical evidence is duplicative:

  1. a. 

    Discard material already considered. Write “Duplicate report; NAN - DI 40505.125” on top right hand page in file, or on the latest Disability Development Worksheet. Sign and date the “NAN” note or the latest Disability Development Worksheet.

  2. b. 

    Keep new material that confirms established impairment.

2. Report raises CDR issue

If report raises medical or work issue:

a. CDR medical issue

  • Establish CDR controls on the Disability Control File (DCF).

  • Explain the issue on an SSA-847-U3 Social Security Administration Request for Case Action or on an SSA-5526-U3 Request for Assistance – Disability if we have not done a CDR interview.

  • Forward the folder to the FO for a CDR interview.

  • After the FO completes the CDR interview, send the folder to Disability Determination Services (DDS) for CDR processing.

b. CDR work issue

For information concerning work issues, see DI 24001.005, Work Activity Development Responsibilities.

DI 40505.130 When We May Require Current Evidence

A. Operating policy for obtaining medical evidence

We may require current evidence:

  • If the previous determination appears erroneous; or

  • If advances in medical technology or vocational therapy or technology for a particular impairment raise a continuing disability review (CDR) issue.

B. Procedure for identifying an error

If the file indicates an error, see descriptions of errors per DI 28020.355, Error on the Face of the Record through DI 28020.900, Group II Exceptions.

  • Document on the disability control file (DCF) the date of completion of 9 months of the trial work period (TWP).

  • Prepare SSA-5526-U3 Request for Assistance – Disability:

    • Request the field office (FO) to initiate a CDR. After completion of necessary development, the FO will send the folder to the Disability Determination Services (DDS).

    • Request DDS to make a CDR determination and, if there is a new claim, also to make an initial determination. Tell DDS that reopening the prior determination may be appropriate; and for detailed information concerning reopenings and revisions, refer to DI 27501.000, Reopenings and Revisions: Pertinent Definitions and Related Policy. If DDS finds that the prior determination is not an error, adopt it for the new claim.

After the DDS completes development, they should forward the case back to the FO.

C. New technology or therapy

We will issue developmental instructions if improved treatment methods or changes in vocational therapy or technology justify conducting a CDR(s) before the scheduled diary date.

DI 40505.135 Court Requires CDR Action - Reference

Instructions for each court case are found in DI 42502.001.

DI 40505.200 Applicability of Continuing Disability Review (CDR) Events and CDR Results on Title II and Title XVI

A. General policy principle regarding CDRs

Events that may raise a CDR issue are usually the same for Title II and Title XVI.

B. Policy principle regarding work issue exception

Substantial Gainful Activity (SGA) cessations do not apply to Title XVI.

Effective 07/01/87, under Title XVI, section 1619, SGA is not a reason for disability cessation. Also, the trial work period (TWP) and extended period of eligibility (EPE) do not apply. Treat earnings as income.

Before an individual is eligible for 1619, he or she must have a disabling impairment(s); therefore, the Office of Disability Operations (ODO) requires medical folder reviews (MFRs). The law provides that we must conduct a CDR at certain times to verify continued disability or blindness eligibility, per DI 40540.001, Section 1619 CDRs.

C. Operating policy to determine if disability continues for Title II and Title XVI cases

Medical CDR or MFR results apply to both titles, if the disability issue is the same. To determine if an individual is still disabled under the Legal Standard for Determining if Disability Continues, see DI 28005.001. For example, if a 1619 CDR results in a medical cessation, we need a Title II cessation determination even if the individual has not completed the TWP. However, if Title II benefits cease due to SGA, or if the disability issues are different, Title XVI eligibility may continue.

Likewise, if we do not find an issue during a MFR, we need SSA-899-U2s

(Continuing Disability Review), on Title II and Title XVI cases.

DI 40505.205 When We May Need a Title XVI File for Continuing Disability Review (CDR)

A. Operating policy for when we may need a Title XVI file

The Disability Determination Services (DDS) needs the comparison point decision (CPD) evidence, which is normally in the Title II folder.

DDS does not need the Title XVI file unless the CPD evidence is in that file. The situations listed in this subsection occur most likely when DDS needs the Title XVI folder:

  • In cases converted from State welfare rolls in January 1974, without a Federal disability determination.

  • In cases in which we adopted a Title II allowance from an earlier Title XVI allowance.

  • If there is no Title II entitlement, obtain the Title XVI folder.

  • Even if evidence is in the Title II file, DDS will obtain the Title XVI file if they need the State plan CPD.

B. Operating procedure for when we may need a Title XVI file

If the Title II file does not contain the CPD medical evidence:

  • Look for indications of Title XVI involvement per DI 40505.210 in this section.

  • Associate the Title XVI and Title II files, or request on an SSA-5526 Request for Assistance – Disability for the FO to do so.

  • If we cannot locate the CPD evidence, see reconstruction of the lost folders per DI 40525.075, Step Three – Preparing Duplicate Folder for CDR Lost Folder/Medical Evidence.

DI 40505.210 After We Identify Concurrent Cases, We Decide Whether We Need the Title XVI Determination and the Title XVI Continuance Notice

A. Operating policy for concurrent cases

1. Definition of concurrent

An individual who is entitled to Title II disability benefits, and

  1. a. 

    Is eligible for Title XVI payments or Medicaid; or,

  2. b. 

    In post-eligibility situations, is ineligible under Title XVI for non-disability reasons.

2. Title XVI determination and cessation notice needed

Prepare two determinations in a concurrent case whether or not we are making Title XVI payments. If a cessation results, we require two cessation notices.

3. Title XVI continuance notice not always needed

Prepare a continuance notice only if the individual receives Title XVI payments or is eligible for Medicaid under section 1619. For policy and procedure, see DI 40540.001, Section 1619 CDRs.

For Title XVI notice instructions see DI 28095.060, Continuing Disability Review (CDR) Notices for Continuances.

B. Description of a case with Title XVI involvement

A case with Title XVI involvement will generally consist of a Title II case folder with “S” or “SSI Conversion Case” cited in file. Other indications of possible Title XVI involvement:

  • In non-conversion cases, an SSA-831 (Disability Determination and Transmittal), and/or SSA-832 (Cessation or Continuance of Disability or Blindness Determination and Transmittal Title XVI), showing Title XVI involvement;

  • Other payment forms or documents indicating Title XVI involvement.

C. Procedure to determine Title XVI involvement with a concurrent case

1. Secure SSI-2 query

If a concurrent case involves Title XVI, obtain SSI-2 query with PSY field when one of the following applies:

  1. a. 

    The file does not contain an SSI query under 30 days old;

  2. b. 

    PSY code on latest query indicates Title XVI eligibility (any code other than N07, N08, N12-N17, N30-N54, T01, or T30-T51); or

  3. c. 

    The latest query shows one of the codes in sentence “b” (i.e., ineligibility) but later evidence indicates Title XVI eligibility.

2. Actions based on Supplemental Security Record (SSR) codes

When sending a concurrent case for a continuing disability review (CDR), tell the Disability Determination Services (DDS) whether we need a Title XVI determination and notice as follows:

  1. a. 

    DS Field Appears - Treat as Title II only, regardless of PSY code. (Social Security Administration (SSA) has made Title XVI initial denial determination.)

  2. b. 

    PSY Codes N07, N08, N12-N17, N27, N30-N54, T01, or T30-T51 - Treat as Title II only.

  3. c. 

    PSY Code C01 (Current Pay) – Prepare concurrent determinations and notices for Title II and Title XVI.

  4. d. 

    PSY Code NO1 - Individual may or may not be receiving Medicaid under section 1619(b). Obtain SSID. Look in CMPH field for column T (Medicaid social services test):

    • If column T shows a, b, or f, the individual is eligible under 1619(b). Prepare Title XVI determination and continuance notices.

    • If column T shows any code other than a, b, or f, the individual is ineligible. Prepare Title XVI determination but do not prepare a continuance notice .

      NOTE: If an individual is in N01 for any reason and the case is concurrent, we should always make decisions on both titles. We cannot adopt cessations and if Title II terminates based on the medical cessation, the Title XVI can go to C01.

  5. e. 

    For PSY Codes E01, N02-N06, N09-N11, N20, or S4-S20, we require Title XVI determination; but we do not require Title XVI continuance notice.

  6. f. 

    For PSY Codes H10-H90 or S21, phone the FO for status (system does not know). If still H10-H90 or S21, Title XVI determination needed; however, Title XVI continuance notice not needed.

  7. g. 

    PSY Code N19 (Voluntary termination): Obtain SSID query. Look in CMPH field for date N19 first appeared in PS segment. Individual went in N19 first day of month and year shown.

    When the individual is in N19 status:

    • 60 or more days treat as Title II only.

    • 60 Days or less, prepare Title XVI cessation determination; however, do not prepare Title XVI continuance notice.

  8. h. 

    For PSY Code M01 (Force Pay; individual may or may not be in pay), obtain SSID. Look in CMPH field (last entry for Payment Status is T31) for date M01 first appeared in PS segment. Look for same month and year in PMTH field, and read over to SMA and FMA segments for that month and year.

    When to prepare Title XVI determination and notice:

    • If there is any money amount shown in either FMA or SMA segment, prepare Title XVI determination and continuance notice.

    • If there is zero money amount shown, prepare Title XVI determination but not continuance notice.

  9. i. 

    For PSY Codes T20 or T22, individual received duplicate Title XVI payments based on same or different Social Security Numbers (SSNs). Check folder to determine what SSNs are involved. If you cannot tell, call the FO and ask. Obtain SSI queries on all SSNs and take action as appropriate.

DI 40505.215 Operating Policy for Title XVI Clear-cut Cessation Cases

The Office of Disability Operations (ODO) does not cease Title XVI cases due to work. However, a clear-cut cessation applies if all of the clear-cut cessation criteria in DI 28030.035 meet (Cessation Without Full Medical Development – Clear-Cut Cessations).

DI 40505.220 Title II Cessation and New Title XVI Application

A Title II medical cessation may be possible or likely (for example, case forwarded to the Disability Determination Services (DDS) for extended period of eligibility (EPE) severity determination). The Processing Center (PC) is aware that there is a new Title XVI claim. In this situation, to avoid premature adoption follow PC and field office coordination instructions, per DI 40510.055, Title II Medical or SGA Cessations – New Title XVI Application.

DI 40505.300 Diary Coding of Continuance Determinations

A. Procedure for diary coding the determination

For the following continuance determinations, establish and record diary information on the SSA-832 Cessation or Continuance of Disability or Blindness Determination and Transmittal) Title XVI, or SSA-833 Cessation or Continuance of Disability or Blindness Determination and Transmittal) Title II, according to DI 26525.001(Scheduling Continuing Disability Reviews (CDRs) – General Policies:

  • Disability Determination Services (DDS) Medical Continuances - if DDS has not set a diary, or DDS diary must be revised;

  • Processing Center (PC) Jurisdiction Continuances;

  • PC or field office (FO) substantial gainful activity (SGA) Continuances and Reinstatements; or

  • Administrative law judge (ALJ), Appeals Council (AC), and Court Reversal(s) to a Continuance(s).

B. Procedure to input a medical diary to the disability control file (DCF)

The SSA-832 or SSA-833 establishes a diary on the DCF. To establish or correct a diary after the disability examiner has input the determination, contact the FO, per SM 01305.915D (Diary Requirements When MD Transmitted – MR Diary). Only the FO has the ability to change the diary after DDS input.

DI 40505.305 Pre-effectuation Review (PER)

State Disability Determination Services (DDS) Title II continuances are subject to selection for PER in the processing center (PC) unless we select them for quality assurance review.

Cases we select for PER require disability examiner review. For types of cases we review, see GN 04440.005A.2 (Types of Federal Quality Reviews (QR).

DI 40505.310 Non-essential Material

A. Introduction to non-essential material

The Disability Determination Services (DDS) should identify non-essential material and document it on a Disability Development Worksheet or on an SSA-5002 Report of Contact. Attach the non-essential material to a Non-essential Material flag. See DI 20503.010 Exhibit – Sample Non-essential Material Flag.

B. Procedure for identifying non-essential material

1. Non-Pre-effectuation review (PER) case

Discard non-essential material and flag after DDS completes all reviews. Retain Worksheet as a permanent part of the file.

2. PER case

After the processing center completes the PER, follow DI 40505.310B.1. in this section.

DI 40505.315 Handling Continuing Disability Reviews (CDRs) When the Social Security Administration (SSA) Did Not Effectuate the Cessation Determination

 

A. Operating policy for when the SSA did not effectuate the cessation determination

1. Uneffectuated medical cessations (UMC) and overdue medical cessations (OMC)

There is no time limit on correcting an error in processing a determination.

As a rule, if we notified an individual of a CDR cessation and he or she has not appealed, process the cessation. For special instructions concerning UMC cases and OMC cases, see DI 13015.265 for field office (FO) procedures and DI 28075.200 for DDS procedures.

UMC cases are Disability Determination Services (DDS) medical cessation determinations made before January 01, 2006, and because of administrative error, we did not effectuate the determination at the time DDS made the determination.

OMC cases are DDS medical cessation determinations made on or after January 01, 2006. Due to an administrative error, we did not effectuate the determination for more than 2 months after the month of termination or date of the cessation notice, whichever is later.

2. Notice of action

Before we can process a cessation, we must have applied the medical improvement review standard (MIRS). For UMC cases, we must send a due process notice to the individual to explain the action that we are taking. However, for OMC cases, we do not need to send a due process notice before we stop checks because the individual has already received a cessation notice.

B. Procedure to process overdue medical cessation (OMC) and uneffectuated medical cessation (UMC) cases

1. OMC cases

Forward all OMC cases to the FO and request the FO to:

  • Send the notice per Payment Termination not Effectuated in DI 13010.197F, Special Situations in Work Continuing Disability Reviews; and

  • Process the case per Special Instructions for Processing UMC and OMC Cases in DI 13015.265B.

Process OMC appeals by following cessation procedures. If the individual wants to appeal, the FO considers whether good cause exists for late filing and if the individual requests, for benefit continuation.

2. UMC cases

If you discover a UMC case in the Processing Center (PC):

  • Obtain the UMC flag shown in DI 13015.265C;

  • Place it on top of the folder and forward it to the FO;

  • Request the FO to process the case per Special Instructions for Processing UMC and OMC Cases in DI 13015.265C.

Do not terminate benefits on any UMC case for which the DDS made the medical cessation determination prior to January 1, 2006.

The FO initiates a new CDR on all UMC cases. Do not attempt to identify cases where SSA has already terminated benefits. However, if we receive any type of protest (for example, Congressional contact or a request for waiver of the overpayment) on a UMC case that has been previously terminated, forward the case to the FO for processing per Special Instructions for Processing Overdue Medical Cessation and Uneffectuated Medical Cessation Cases in DI 13015.265.

If you receive a UMC case and the folder is:

  • In the PC, return it to the FO under cover of the flag shown in DI 13015.265C. Request the FO to process the case per Uneffectuated Medical Cessation Special Instructions for Processing Overdue Medical Cessation and Uneffectuated Medical Cessation Cases in DI 13015.265.

  • Not in the PC, send a modernized development worksheet (MDW) to the FO to indicate we did not process the termination action. Request the FO to process per Special Instructions for Processing Overdue Medical Cessation and Uneffectuated Medical Cessation Cases in DI 13015.265.

NOTE: These special UMC procedures do not apply after the DDS makes a new CDR determination. For example, if the new CDR determination (made after January 01, 2006) again results in a cessation determination, terminate benefits based on the new CDR cessation date and process any subsequent appeal. In addition, these instructions do not apply to OMC cases for which the DDS made the cessation determination on or after January 01, 2006.

DI 40505.900 Forms Used in Adjudication of Disability Cases

A. SSA Request for Case Action

SSA-847-U3 (09-1986; ef 10-2004) SSA Request for Case Action

Form SSA-847-U3 SSA Request for Case Action

B. Continuing Disability Review

SSA-899-U2 (05-1979) Continuing Disability Review

To view this form, go to SSA-899-U2.

 

C. Request for Assistance - Disability

SSA-5526-U3 (02-2005) Request for Assistance – Disability

Form SSA-5526-U3 Request for Assistance

 

D. Potential Suicide/Homicide Case Flag

Potential Suicide/Homicide Case flag -- See DI 81020.085, Certified Electronic Folder (CEF) Flags, for instructions for placing this flag into the CEF.

Potential Suicide/Homicide Case Flag

 


DI 40505 TN 1 - Medical Issues - 12/18/2018