It is important during the initial interview, and any subsequent interviews, to determine if the NH has a work-related injury or illness and was entitled, is currently entitled, or will be entitled, to WC, PDB, or both.

FO disability interview considerations

The FO determines whether the NH has a work-related injury, illness or is receiving any other form of disability payment that may not be work-related.

1. a. 

   Ask the NH:

   • •

     about any other disability payment received within the 12 months that immediately precedes the first possible month of DIB payment;

   • •

     if he or she has filed, or intends to file, an application for a disability payment; or

   • •

     if a disability claim is currently under appeal.

2. b. 

   Complete the WC/PDB common screens in the MCS path if the NH has filed, or intends to file, for WC/PDB benefits. When the disability claim is an iClaim, if the NH indicated on the iClaim that they filed for a WC benefit, verify in the interview that the NH actually filed for WC. If the claim is an MCS exclusion, obtain Form SSA-546 (Workers’ Compensation/Public Disability Benefit Questionnaire) per DI 52140.005.

3. c. 

   For NHs who have worked in states that pay an SDI tax, if they have NOT filed for SDI, then ask “Why Not?”

4. d. 

   Take note of obvious or easily recognizable traumatic injuries that may have occurred at work or during normal work hours. Inquire about the NH’s current source of monthly income to determine if he or she is receiving another form of disability payment.

5. e. 

   Be aware of types of disabilities and injuries compensable under State WC/PDB laws. Many States pay WC or occupational disease benefits to workers who have conditions related to the trade. For example:

   • •

     lung diseases for textile workers and individuals who work around chemicals;

   • •

     heart disease and hypertension for high-stress occupations such as police, firefighters, or air traffic controllers;

   • •

     repetitive-stress injuries (e.g., carpal tunnel disease) for workers in repetitive motion jobs, such as computer users or sewing machine operators; or

   • •

     back injuries for individuals who are in patient care fields, etc.

6. f. 

   If the work-related injury or illness question on the application has an answer of “No,” and the response is questionable in light of the alleged disability, obtain an explanation from the worker or contact the employer for verification. Document the electronic folder (EF) with the responses and develop, as needed, based on their responses.

   IMPORTANT NOTE: Document the EF (via DW01, DW02, or Report of Contact (RPOC)) when the WC answer on the DISB screen is changed. This is especially important when a NH files via the iClaim application process. When the NH changes their answer during the interview process, we want to make sure they understood the WC question on the iClaim screen. We also want to be certain we correctly identify whether the NH filed for WC benefits. Document the file with the NH’s specific explanation for the change of the WC answer.

7. g. 

   Address the option of filing for reduced retirement insurance benefits (RIB) if the claimant is approaching age 62. Reduced RIB may be higher than DIB after WC/PDB offset. See Considering the Retirement Insurance Benefit (RIB) Option in DI 52150.030.

The following will assist you when reviewing the DIB application and related forms to determine potential offset payments:

• •

  MCS DISB screen or the iClaim (Internet Claim Application) – the questions “Are your illnesses, injuries or conditions related to your work in any way?” or “Filed or intend to file for WC/PDB?”

• •

  SSA-16-F6 (Application for Disability Insurance Benefits) question #26 “Are your illnesses, injuries or conditions related to your work in any way?” or question #27 “Have you filed, or do you intend to file, for any other public disability benefits (including workers’ compensation, Black Lung benefits, and SSI)?” If not filing, why not filing?

• •

  SSA-3441 BK (Disability Report-Appeal) – Section 3, Question F, or the i3441: “Have you been seen by other agencies for your injury or illness?”

• •

  SSA-3368-BK (Disability Report-Adult) or the i3368 – the question “Does anyone else have medical records related to your illness, injuries or conditions?”

• •

  SSA-454-BK (Continuing Disability Review Report) – the question “Does anyone else (for example, Workers’ Compensation) have medical records or information related to your illness, injuries, or conditions, within the last 12 months?”

• •

  SSA-821 (Work Activity Report) – the question “I stopped working within 6 months, or I reduced my work hours and earnings…because?” This form will help identify the reason why a beneficiary stopped working. If the claimant cites that it is due to an injury or medical condition, then WC/PDB may be involved.

• •

  Medical evidence submitted by the claimant may contain information regarding WC benefits.

In addition, you may discover potential offset situations while developing income issues for a concurrent SSI claim or while reviewing the earnings record gaps with the NH. Check the NH’s answers to the questions on work history or any other forms that might indicate potential WC/PDB payments.

The FO processes disability claims involving WC/PDB as follows:

1. 1. 

   Complete Modernized Claims System/Earnings Computation (MCS/EC) screens, per DI 52155.001.

2. 2. 

   If there is a need for additional WC/PDB evidence, see DI 52145.001B. for when to defer development of WC/PDB benefits. For control guidelines, see DI 52140.001H. in this section.

3. 3. 

   Obtain and process auxiliary claims. See DI 52155.015.

4. 4. 

   Finally adjudicate claims via MCS/EC per DI 52155.010; for A101s, see DI 52155.025; or for EF101s, see DI 52155.030.

5. 5. 

   Prepare offset computations using the Interactive Computation Facility (ICF) for claims where MCS cannot process the WC/PDB offset computation (For MCS/EC processing see DI 52155.010 and for A101 processing, see DI 52155.025.)

NOTE: Adjudicate the ICF screens for the WC/PDB action before coding the claim via A101 if the MCS/EC WC/PDB computation is incorrect or not available. When preparing an EF101, adjudicate the ICF screens for the WC/PDB action before coding the EF101.

The FO:

1. 1. 

   Documents all allegations and obtains verification/proof of WC/PDB information per DI 52145.001, along with all information needed to process the WC/PDB offset, including:

   • •

     type of award (periodic payments or LS settlement),

   • •

     amount of payment,

   • •

     change in rates,

   • •

     beginning and ending dates, and

   • •

     excludable expenses.

     (For development timeframes, see DI 52140.001H. in this section).

2. 2. 

   Assists the claimant with completing Form SSA-1709 (Request for Workers’ Compensation/Public Disability Benefit Information) and obtains the NH’s signature for use when obtaining WC/PDB proof for simultaneous requests to multiple WC/PDB 3rd party resources. Secure the form early in the claim-taking process. Start a concurrent development process by contacting multiple WC/PDB resources such as the NH, WC attorney and WC carrier at the same time. The FO is responsible for developing WC/PDB proof prior to transferring the case to the PC for post-entitlement actions. Detailed instructions for the PC concurrent development process are provided in DI 52140.010B.1.

3. 3. 

   Retains all WC/PDB proof for permanent retention by faxing the documents into the EF or Non-Disability Repository for Evidentiary Documents (NDRed), or by storing it in the paper folder per Retention of Workers’ Compensation/Public Disability Benefit (WC/PDB) Proofs in DI 52145.015.

NOTE: Annotating the EVID Screen in Shared Processes or coding proof into the ICF, by itself, is not sufficient documentation. WC/PDB proof involves complex, State-specific forms and documents that may be difficult to decipher and that routinely involve a high degree of interpretation. Permanent retention is required, as explained in DI 52145.015, and allows for subsequent review of the evidence to verify if the interpretation of the proof is correct.

1. 1. 

   Pay full DIB if requested in writing by the claimant when further action is pending on the WC/PDB claim and the WC/PDB is not being paid because:

   • •

     an initial WC/PDB claim is pending;

   • •

     the WC/PDB claim is under appeal; or

   • •

     periodic payments have stopped, but further payments or a WC LS award are pending.

2. 2. 

   Obtain a repayment statement from the NH.

   • •

     For an initial MCS claim only (and any subsequent appeal on that claim), annotate the repayment statement in the Remarks (RMKS) screen of the claim for each claim on the record (NH and auxiliary) and prior to attestation via signature proxy.

   • •

     For all other situations in which attestation of the repayment statement via signature proxy cannot be used (non-MCS Claims, Internet claims, expedited reinstatement), the NH must sign a repayment statement (wet signature) on a paper Form SSA-795 (Statement of Claimant or Other Person) (see DI 52140.001F. in this section). If auxiliaries are involved, obtain a separate repayment statement on a paper Form SSA-795. You must document the claim.

   • •

     If the NH refuses to sign a repayment statement, document the file with a RPOC that the NH refuses to sign but understands that the receipt of WC/PDB may cause an offset of DIB and possibly an overpayment that he or she must repay.

For development control timeframes, see DI 52140.001H. in this section.

CAUTION: SSI recipients do not have the option to refuse DIB while waiting on a WC/PDB decision. They must file a DIB claim per SI 00510.005.A.1.

If the NH requests full benefits pending resolution of the WC/PDB claim or appeal:

1. 1. 

   Verify if the individual previously received WC/PDB payments and, if so, the date the payments stopped.

2. 2. 

   Explain and document on a RPOC or in the MCS application remarks screen the possibility of an overpayment and the NH’s liability for recovery of any overpaid amounts for benefits that should have been offset.

3. 3. 

   Obtain a request for full benefits and a repayment statement from the NH and any auxiliaries (per DI 52140.001E. in this section). Obtain Form SSA-795 with the pre-printed repayment statement or use the following approved language:

“I agree to report entitlement to, and changes in the amount of, workers’ compensation and other public disability benefit. I understand that such benefit may affect my Social Security payments or result in an overpayment that I may have to pay back. While my claim for (name of benefit) is pending, I wish to receive full Social Security disability insurance benefits. I hereby agree to repay promptly any overpayment created if I become entitled to (name of benefit). My (name of benefit) appeal is scheduled to be heard ___.”

NOTE: The PC cannot pay the full DIB payment without the attested language on the initial claim, a signed repayment statement, or documentation that the NH refuses to sign a repayment statement.

When the NH receives a WC/PDB LS settlement, prorate the settlement amount over a period of time to determine the offset amount.

1. 1. 

   Follow the proration procedures in Prorating WC/PDB Lump Sum Settlement in DI 52150.060.

2. 2. 

   Enter the LS figures into MCS. If you can trigger through MCS, request the LS proration paragraph on the NOT3 (MSOM MCS 009.010) screen because LS proration paragraphs are not system-generated in MCS. (MSOM ORS 002.003C.) If MCS/EC can process the WC/PDB offset computation, but you cannot trigger through MCS due to a processing limitation or exception, verify that the MCS computation is correct.

   • •

     If the MCS computation of the WC/PDB offset is correct, this information propagates to the A101 and subsequently propagates into MADCAP.

   • •

     If the MCS/EC computation is not correct, compute the offset via ICF first, before adjudicating the A101. If an EF101 is required for processing the award, compute the offset via ICF first, before adjudicating the EF101.

3. 3. 

   Fax the proof documents to the EF or NDRed. If the action is complete and the proofs are successfully added to eView, destroy the paper copy document, even if it is signed. Keep in mind that any original documents should be returned to the claimant/beneficiary. Do not fax documents into paperless if all actions are complete.

4. 4. 

   If the case requires additional PC action, fax the proofs and SSA-409 (Post-adjudicative Routing) to the appropriate PC via their paperless fax number.

5. 5. 

   If the LS data properly updates to the MBR, do not prepare a diary to remove the offset. A Regular Transcript Attainment and Selection Pass (RETAP) alert generates in the PC selecting the ending date of the LS and passes the data to the Title II Redesign (T2R) system for automatic termination of the offset.

NOTE: Exercise caution in situations when attorneys or claimants seek assistance in preparing a WC settlement prior to the WC court approving the settlement. (For example, bringing in a draft of a proposed WC settlement and asking the effect, if any, such a settlement would have on the NH's benefits; or asking specific questions regarding the proration terms used in the award.) We can supply basic information regarding how WC/PDB offset is computed, (for example, the higher of 80% of the average current earnings (ACE) or the amount of Total Family Benefit (TFB) payable in the first month of offset), and we can refer the inquiring individual to our WC/PDB offset procedures in DI 52100 (available online). However, we do not assist the attorney or claimant in determining a specific weekly rate low enough to avoid offset.

The FO develops for WC/PDB evidence according to DI 52145.001 and establishes appropriate controls as outlined below.

Where the next follow-up will be less than 6 months from the date the FO initially identifies the issue that needs to be controlled, use MDW tickle dates to control for future follow-ups. For instructions for establishing the MDW, see MSOM MDW 001.003.

If the next follow-up will be due 6 months or more from when the control was initially established, responsibility then transfers to the Processing Center (PC) and the control will be set up via a PCACS diary (see MSOM MCS 009.015 and MSOM PCACS 009.002).

For initial claims notices, see DI 52155.035.

For PE events that require use of ICF, enter the appropriate paragraphs:

For ICF WC/PDB notices, see DI 52165.030.

Send a due-process notice (per GN 03001.015) informing the claimant that we will use the maximum state rate to impose offset per DI 52150.045 unless we receive evidence IF:

• •

  there is no WC/PDB proof available;

• •

  there is no previously proven rate;

• •

  you have taken and documented every available avenue to secure proof, but

• •

  a response has not been received.

The ICF Resource Page has instructions for using ICF in subsequent auxiliary claims with WC/PDB. See MSOM ICFT2 031.001 through MS ICFT2 036.010 and the ICF Tool - Interactive Computations Facility (ICF) Resource Page for WC/PDB Offset Computations.

A subsequent auxiliary claim is an MCS/EC processing limitation if the auxiliary entitlement requires an adjustment to the NH’s WC/PDB offset. In these situations, compute the offset in ICF and process the case via A101/EF101.

If you cannot process the case via MCS/EC:

1. 1. 

   Compute WC/PDB offset via ICF for your claimant, the NH, and any other already entitled auxiliaries; apply offset to the auxiliaries first, then to the NH.

2. 2. 

   Consider changes to the TFB with the addition of subsequent auxiliaries per instructions in DI 52150.070 How Changes in Family Composition Affect WC/PDB Offset.

3. 3. 

   Process the case via A101/EF101.

4. 4. 

   Prepare notices for your claimant, the NH, and any entitled auxiliary per instructions in DI 52140.001I. in this section.

See Also:

Processing DIB Claims with WC/PDB and Auxiliaries in DI 52155.015.

NOTE: Offset may apply to auxiliaries even though the NH’s benefit is not offset. If deemed filing does not apply and if the spouse does not receive any benefit after WC offset except for protected increases, it may not be advantageous for the spouse to file if he or she receives a reduction for age. Subsequent auxiliary entitlement may result in higher benefits payable after offset (or full DIB benefits payable) to the NH.

If a NH requests an appeal for a DIB claim involving WC/PDB:

1. 1. 

   Update the WC/PDB allegation. Note the time limitations on SSA processing of appeals. See Time Limit for Filing Appeal in GN 03101.010; also see Good Cause for Extending Time Limit in GN 03101.020.

2. 2. 

   Accept allegations of the WC/PDB rate in file if you are unable to obtain updated WC/PDB verification quickly. If no rate is given, use the State maximum rate to compute offset. See the Chart of States Maximum WC Benefits in DI 52150.045. Develop for proof on a post-adjudicative basis.

3. 3. 

   Follow-up to ensure you receive the verification/proof.

4. 4. 

   For instruction on setting controls, see DI 52140.001H. in this section.

• •

  DI 52120.000 - State Specific Workers’ Compensation (WC) Procedures

• •

  DI 52135.000 - State Specific Public Disability Benefit (PDB) Procedures

• •

  DI 52115.000 - Federal Workers’ Compensation (WC) Payments

• •

  DI 52130.000 - Federal Public Disability Benefit (PDB) Payments

• •

  DI 52110.000 - Workers’ Compensation (WC) Payments That May Cause Offset

• •

  DI 52140.005 - Form SSA-546 Workers’ Compensation/Public Disability Benefit Questionnaire

• •

  DI 52150.030 - Considering the Retirement Insurance Benefit (RIB) Option