Basic (03-86)

DI 43520.040 Completion of SSA-831-U5 by the DO Function for SGA Initial Denials - Title II Claims

When the conditions in DI 10501.025 are met, the DO or CDS SGA specialist will fully prepare the SSA-831-U5. Complete items 1 through 14 in accordance with DI 43520.030 and the additional items indicated below.

ITEM 16-DIAGNOSIS

Enter “None established.”

ITEM 19A--CLAIMANT NOT DISABLED THROUGH DATE OF CURRENT DETERMINATION

Check this block when the insured status (DIB case) or prescribed period (DWB case) requirement continues to be met through the date of the current determination.

Check this block in a CDB reentitlement claim when the claimant began engaging in SGA before the end of the reentitlement period and the reentitlement period has not expired.

ITEM 19B--CLAIMANT NOT DISABLED THROUGH (date)

Check this block when the insured status (DIB case) or prescribed period (DWB case) requirement is last met prior to the date of the current determination. Enter the date the insured status or prescribed period requirement is last met.

Check this block in a CDB reentitlement claim when the claimant began engaging in SGA before the end of the reentitlement period and the reentitlement period has expired. Enter the last day of the reentitlement period.

ITEM 19C--BEFORE AGE 22 (CDB Only)

Check this block in all CDB cases except reentitlement claims.

ITEM 20--VOCATIONAL BACKGROUND

Complete this item in DIB, freeze, and CDB cases. This block should reflect vocational background data regarding the beneficiary/recipient's customary occupation or, if not determined, the longest full-time occupation in the 15-year period prior to current adjudication. Show both the individual's occupation and the industry. Enter the 2 digit occupation code from DI 40105.005 C., Exhibit 3 most closely approximating the determined occupation. Follow this code with a dash and then enter the appropriate 2 digit industry code from DI 40105.005 C., Exhibit 4, most closely approximating the determined industry. If a CDB has never had an occupation enter “None.” If there is no vocational information in the file, and it is not needed, enter “unknown.” Vocational background information can be found on the SSA-3368-BK and SSA-3369-BK.

ITEM 22--REG.--BASIS CODE

Complete the “Reg--Basis Code” block as follows:

ITEM 24--MOB. Code

Enter one of the following codes which reflects the claimant's mobility status at the time the SSA-831-U5 is prepared. Determine the mobility status by referring to the disability background information contained on the SSA-3368-F8 /3369-F6 or any other (later) information recorded in file.

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  A--Confined in a medical institution other than a general hospital

  B--Patient in a general hospital

  C--Confined in bed at home

  D--Confined in a chair (including wheelchair)

  E--None of the above but unable to go outside

  F--Able to go outside but only with the help of another person or device

  G--Able to go outside without help

  M--Claimant is deceased

ITEM 25A--(Adjudicative Level)

Check the appropriate block to indicate the adjudicative level

ITEM 26--LIST NO.

In cases of blindness, see DI 10515.000 D.; in cases of non-blindness, see DI 10505.001.

ITEM 27--RATIONALE

See NL 00601.010.

ITEM 29--LTR./PAR.NO.

C13 paragraph

ITEM 34--REMARKS

Enter remarks for the following special situations.

ITEM 37--SSA REPRESENTATIVE

The claims representative or CDA SGA specialist will sign his or her name and in the “SSA Code” block enter “INTPSC.”.

ITEM 38--DATE

Enter the date the SSA-831-U5 is signed.

(See DI 11055.135 for title XVI and concurrent title II/title XVI.)