For claims involving MSSICS limitations or exclusions, manual completion of the SSA-831
is necessary. In those instances, the FO must complete Items 1-14 on the SSA-831 for
Title XVI claims transmitted to the DDS for a disability determination.
If a presumptive disability or presumptive blindness (PD/PB) determination is made
in the FO, complete additional items on the same SSA-831 as specified in DI 11055.240D.
Item 1 - destination
Check the "DDS" or "DQB" block, as appropriate, for all Title XVI disability claims
requiring a disability determination that are routed to the DDS or the Disability
Quality Branch (DQB).
Concurrent claims (Title II and Title XVI) may have the DDS, ODO, DRS (PSC), DQB,
or OIO blocks checked.
For further jurisdiction and routing instructions for certain foreign Title II disability
claims, see DI 11055.060.
Item 2 - DDS code
Enter the appropriate three-digit DDS code listed in the Detailed Office/Organization
Resource System (DOORS).
Item 3 - filing date
Enter the earliest of the following dates:
-
•
The actual month, day, and year of filing of the current application;
-
•
The protective filing date established based on an oral or written intent (for protective
filing policy and procedures, see GN 00204.010; for multi-category requests, see SI 00501.300); or
-
•
The earliest filing date, if there are two or more current applications.
NOTE: If the claimant dies before filing an application, but submits a written statement
to file, or if the FO received an oral inquiry with intent to file, someone eligible
to receive the deceased claimant's underpayment may file the application. For underpayment
policy and procedures, see GN 00204.005.
Item 4 - SSN
Enter the disabled person's own Social Security Number (SSN) for Title XVI claims.
This is the primary SSN, even though the individual may have used a different SSN
to file a Title II claim.
NOTE: If the claimant does not have an SSN, do not delay sending the Title XVI claim to
the DDS. Instead, take the following steps:
-
•
Process an application for a new Social Security Number (for data entry instructions
for Form SS-5, see RM 00407.000);
-
•
Enter "Applied For" in this block;
-
•
Immediately alert the DDS of the claimant's SSN by phone, fax, or mail when the new
SSN is generated, which is normally the following day.
Reference:
SI 00604.016, Name, Sex, Birthdate, and SSN - Question 1(a)
Item 5 - name and address of claimant
Enter the name and mailing address of the claimant.
If a proper applicant has filed on behalf of the claimant, enter the applicant's name
followed by “for,” and then the claimant's name, and the applicant’s mailing address
(see Proper Applicant GN 00204.003). Enter the name of the disabled person and proper applicant, if appropriate, in
this item exactly as shown on the disability claim.
If two or more proper applicants have filed on behalf of the claimant, the name and
address entries for the applicant should be for whichever of the applicants is the
preferred payee (see Payee Preference Lists GN 00502.105).
In situations involving a Title XVI disability claim filed after the claimant's death,
show the applicant's title and name followed by "On behalf of (claimant's title and
name) Dec'd."
Items 6 and 7
Leave blank. (Not applicable in Title XVI cases.)
Item 8 - type claim (title XVI)
Check the appropriate block as follows:
|
Abbreviation
|
Definition
|
|
DI
|
Disabled Individual
|
|
DC
|
Disabled Child
|
|
DS
|
Disabled Spouse
|
NOTE: At no time should the FO check the following blocks:
|
Abbreviation
|
Definition
|
|
BI
|
Blind Individual
|
|
BC
|
Blind Child
|
|
BS
|
Blind Spouse
|
Even though the claim is based on an alleged visual impairment, indicate "DI," "DS,"
or "DC" for all alleged visual impairments. If blindness is established, the DDS changes
this field accordingly.
Item 9 - date of birth
Indicate the established date of birth by noting the month, day, and year of birth,
e.g., 03/17/67. If the FO has not established the date of birth, use the date of birth
by which the disabled individual or child is the oldest.
Item 10 - prior action
Check the “PD” block when the Field Office is making a determination and the last
determination for the same type of benefit was a denial. Check the “PT” block when
the last determination for the same type of benefit was a termination of entitlement.
(Include the prior disability file, if in the FO, or as shown in DI 11010.260B, and complete the information on the SSA-3367 [Disability Report – Field Office],
Item 7).