TN 9 (09-19)

DI 13015.005 Failure to Cooperate-Insufficient Evidence Decision (FTC) Suspension Procedures for Continuing Disability Reviews (CDR)- Field Office (FO)

This subchapter provides FO procedures for processing FTC suspension actions when the beneficiary or recipient does not respond to our request for necessary information in a CDR.

A. FO FTC documentation requirements in a CDR, streamlined process applies

Follow DI 13005.025 for FO development requirements when initiating a CDR. Record all development actions on a Report of Contact and save in eView, or for paper folders file the Report of Contact in the folder and fax a copy into the Non Disability Repository (NDRed).

Documentation must include:

  • Date of the initial written request (copies of the request letters must be retained in the folder, if not accessible in ORS);

  • Date the period to comply ended (including extensions);

  • If there are special handling considerations (for example, homeless or mental impairment) see DI 13005.025A for special handling considerations. Document a description of additional development efforts; and

  • Results of follow-up attempts.

B. FO FTC actions to suspend benefits

Once the FO has taken the steps outlined in DI 13005.025, documented development actions, and determined that the streamlined FTC procedures apply as explained in DI 13015.001A, take the following steps to input the FTC suspension. The FTC suspension action cannot be earlier than 35 calendar days (45 days for special handling situations) from the date of the initial CDR notice.

Note: Prior to suspending Title XVI payments ensure appropriate Goldberg/Kelly due process notice has been issued. Obtain office management approval to suspend Title XVI cases (payment status N20) per SI 02301.235J Failure to Provide Information (N20). Follow local office procedures for how to obtain the required management approval.

  1. 1. 

    Record the FO FTC determination on the Disability Control File (DCF) by selecting #4 on the IFOA screen Failure to Cooperate and the FO of jurisdiction in the "Office Responsible for Next Action" field. Refer to DI 13010.620 CDR FO Input (IFOA) Screen, MSOM CDR 001.001 Disability Control File (DCF) Overview, and MSOM CDR 001.007 CDR FO Input Screen (IFOA) for detailed input procedures.

  2. 2. 

    Enter the remark "MED CDR FTC" in the DCF remarks section, see MSOM CDR 001.009 CDR Remarks Input Screen (IRMK) for more information.

  3. 3. 

    For Title II add a special message to the MBR: "MED CDR FTC LAF S0 suspension on mm/dd/yy"

  4. 4. 

    For Title XVI enter the remark "N20 on mm/dd/yy- MED CDR FTC" by using the SSR Remarks screen (CRMK).

Allow two days for the transaction to process. The DCF FTC input places benefits in non-payment status (LAF S0 for Title II/ PS N20 for Title XVI).

If the FTC suspension processed correctly, the MBR or SSID will show "DEV CDR" and "Suspense Reason=FTC-Medical". With this coding present on the MBR or SSID, the termination should occur automatically in the 13th month. If the suspension action did not process, see instructions by title below.

If the beneficiary or recipient does not cooperate during the 12-month suspension period, disability benefits will terminate effective with the 13th month. The disability determination service (DDS) does not make a medical determination. Statutory benefit continuation does not apply.

Title II

Benefits automatically suspend (LAF S0) when the DCF input processes effective with the first month that does not cause an overpayment. If the DCF input fails to suspend benefits:

  • Do not attempt to re-enter the suspension. The DCF exception generates a Paperless action for the processing service center (PSC) to input a manual MACADE suspension action. Verify the Processing Center Action Control System (PCACS) has a suspension action pending for the PSC.

  • After 15 days, query the record to ensure the PSC's manual action processed and that notice was sent to the beneficiary. This may require a follow-up contact to the PSC via the Modernized Development Worksheet (MDW). Follow GN 01070.440D.2 for follow-up procedures.

Note: In addition to the LAF code of S0, the DEVCDR line with suspension reason FTC-Medical and suspension month start date will appear on the MBR when the FTC suspension input processes. The presence of the DEVCDR line starts the 12-month suspension count and is how the record establishes a termination action on the 13th month.

Title XVI

  • If the DCF transaction did not suspend payments, input an N20 suspension in MSICCS to suspend effective with the first month that does not cause an overpayment. For more information on N20 suspension see SI 02301.235 Failure to Provide Information (N20), and

  • The suspension notice automatically generates to the beneficiary or recipient and Title II auxiliaries when the transaction processes. Always query ORS to verify that the transaction issued a notice. If a notice was not sent, send a manual notice.

C. FTC termination after suspension

If the FTC suspension processed correctly, the record will automatically terminate in the 13th month of suspension. Once the record terminates, close out the FTC CDR issue on DCF by entering 5=SSR/MBR/STOP CDR on the IFOA screen of DCF (for more information on DCF inputs see MS 00501.007 CDR FO Input Screen (IFOA)).

Review the case in the 14th month to confirm termination. If the record did not terminate, enter the termination manually via the SSR for Title XVI and for Title II, send an MDW to the PSC requesting action to terminate the record. See MS 03901.003 MDW Worksheet (MMDW) for instructions on establishing an MDW. Alert the PSC that the FTC termination did not process in the 13th month (MM/YY) and request record be updated to show FTC termination as of MM/YY. Also, request the PSC send a notice of termination to the claimant's last known mailing address.

D. Additional considerations in the FTC suspension process

1. Title II additional considerations in the FTC process

a. Medicare entitlement

When Title II benefits are suspended, the beneficiary's Medicare entitlement continues, but the beneficiary will be billed separately for the monthly Medicare premiums. If the Title II benefits terminate due to FTC, the Medicare entitlement ends. The Medicare termination is effective with the end of the month after the month in which the beneficiary is notified that entitlement to benefits will end. Example: Termination of Title II benefits notice dated 10/18/2018, Medicare terminates 11/30/2018.

b. Auxiliary benefits

When the FO enters the DCF FTC action to suspend the disabled wage earner's benefits, benefits for all entitled beneficiaries on the record will also be suspended. Refer to SM 03020.050B Develop for Continuing Disability (CDIB).

c. Auxiliary benefits: Spouse (B2) or E entitled, last child in care suspended

When the FO enters the DCF FTC action to suspend benefits for a disabled minor child or an adult childhood disability beneficiary (CDB) who is the last child in care for a young spouse (B2) or widow (E), benefits must be manually suspended for the B2 or E; refer to SM 03020.050B.

d. Beneficiary in suspension status due to substantial earnings

If at the point of FTC suspension, the beneficiary is in suspense status LAF S7 due to substantial earnings from a work CDR, the DCF FTC suspension should process to add the Continuing Disability Investigation (DEV CDR) Data Line to the MBR. The presence of the DEV CDR data on the MBR triggers the termination at the 13th month. If the DEVCDR line is not present on the MBR, send a an MDW to the PSC and request the DEV CDR line be added to the MBR along with the Suspense Start- MM/YY and Suspense Reason FTC-Medical.

2. Title XVI additional considerations in the FTC process

The DCF input automatically updates the SSR with the FTC payment status (N20-Title XVI- failure to provide necessary information), refer to SM 01305.001 Payment Status Code for more information. There could be a delay of several days for this automatic update to the SSR to occur. The Medical Issue (MG) field in the Disability Data segment (DISB) of the SSR will also update with a code of "F" to show FTC status. The combination of payment status N20 with the MG code of F identifies the case as FTC. If the SSI record does not update to N20, follow manual input procedures in SI 02301.235 Failure to Provide Information (N20).

E. FTC- extended Medicare cases, streamlined process does not apply

The streamlined CDR process does not apply to extended Medicare cases where the beneficiary terminates due to work. These beneficiaries are eligible for the work incentive that extends his or her Medicare entitlement. The DDS must make a medical CDR determination to decide if entitlement to Medicare should continue.

The FO will:

  • Initiate the CDR per DI 13005.025 through DI 13005.030 and DI 81010.230 (select "paper" and do not select "key" to avoid edits at transfer);

  • Document efforts to contact the claimant per DI 13015.005A;

  • Input the transfer from the FO to the DDS in the DCF. Do not input FTC on the DCF. For information on the DCF CDR screens see, DI 13010.610 The Disability Review Establishment (DRES) Screen, DI 13010.620 The CDR FO Input (IFOA) Screen, MSOM CDR 001.016 Disability Review Establishment Screen, MSOM CDR 001.007 CDR FO Input Screen (IFOA));

  • Enter a remark on the DCF CDR Remarks Input Screen (IRMK) (MSOM CDR 001.009) such as "Medical CDR Determination needed by DDS for extended Medicare. Streamlined FTC process does not apply";

  • For electronic CDRs, include the following statement in EDCS Messages/Alerts, "Extended Medicare FTC Case- Need DDS Medical Determination. DO NOT RETURN TO FO, streamlined FTC process does not apply." For paper folder CDRs, annotate the same statement on the route slip attached to the front of the paper folder;

  • Transfer the eCDR or paper modular disability folder (MDF) to the DDS.

Note: If the beneficiary is in FTC suspension when the FO completes a work CDR resulting in termination, follow the steps above and request DDS make a continuing disability determination. Document the previous attempts to contact the claimant that led to the FTC suspension as well as any contact attempts made during the Work CDR.

F. FTC- work issue only, streamlined process does not apply

1. Title II case

When work is the sole issue, make a substantial gainful activity (SGA) determination whenever possible using any available evidence of earnings. Use all methods and sources of wage verification outlined in DI 10505.005C Determining and Verifying Gross Earnings from Employment. Refer to DI 13010.185 Due Process in Work Issue Cases, DI 13010.170 Completing the SSA-833 (Cessation or Continuance of Disability or Blindness Determination and Transmittal-Title II) for processing instructions.

If the earnings evidence is insufficient to determine that the beneficiary is engaging in SGA, proceed with the FTC cessation:

  • Provide due process per DI 13010.185 Due Process in Work Issue Cases.

  • After following the steps in DI 13010.185 for due process and the beneficiary has not submitted the requested information, cease benefits in the first month that all attempts to have the beneficiary respond have been unsuccessful.

  • Input the cessation via the Post-entitlement Online System (POS), see MSOM T2PE 003.024. Once the input processes, the MBR will display LAF T9.

2. Title XVI case

Follow procedures in SI 02302.030 Section 1619 Process and Procedures. See also DI 13005.016 CDR for Title XVI Section 1619 Recipients and DI 13005.018 Field Office Actions for Section 1619 Cases.

G. FTC- medical and work issues combined

When both work and medical issues are involved, prepare a work issue determination whenever possible based on available evidence. If the work issue determination does not result in a termination of benefits, proceed with the medical CDR. If the beneficiary does not cooperate with the FO's request for information, take the necessary steps to place the beneficiary in suspense following the procedures in DI 13015.005B.

H. Beneficiary or recipient moves to another FO jurisdiction while benefits are suspended

If the beneficiary or recipient moves to another FO jurisdiction while in suspense (and continues to not respond to the FO's request), transfer the case on the DCF to the new FO. This transfer will not reinstate benefits.

 


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DI 13015.005 - Failure to Cooperate-Insufficient Evidence Decision (FTC) Suspension Procedures for Continuing Disability Reviews (CDR)- Field Office (FO) - 05/19/2017
Batch run: 01/06/2020
Rev:05/19/2017