Effective Dates: 09/18/2026 - Present Previous | Next

TN 21 (09-26)

RS 02801.001 Critical Case Criteria and Exclusions

A. Introduction

This section provides information and guidance on Title II critical cases. When a beneficiary is adversely affected because payment is not made timely, a case will be treated as critical if it meets the requirements in this section. A critical case, requires priority handling and must be developed and processed expeditiously. For information about other types of cases identified for priority handling, refer to DI 23020.001.

B. Policy

A Title II critical case exists when:

  • •

    a beneficiary who is entitled to benefits has not received a due payment;

  • •

    there is a dire need or adverse public relations potential; and

  • •

    an exclusion outlined in RS 02801.001B2 does not apply.

For the definition of dire need, refer to DI 23020.030.

IMPORTANT: Cases that meet the terminal illness (TERI) criteria are also considered critical. For information on TERI cases, refer to DI 11005.601.

1. Situations in which a critical case may exist

A critical case for Title II may exist for situations in which there is:

  1. a. 

    an initial claim for benefits, where all factors of entitlement are met;

  2. b. 

    a reinstatement of payment for benefits that were in a suspense status and evidence has been submitted to prove the suspense no longer applies;

  3. c. 

    a delayed or interrupted payment due to a processing error;

  4. d. 

    an adverse determination has been reversed on appeal;

  5. e. 

    an alleged non-receipt of an issued payment. Refer to RS 02801.001B.2.c in this section for the critical case non-receipt exclusions;

  6. f. 

    a disability to survivor conversion case that has not successfully processed through the Manual Adjustment Credit and Award Process (MADCAP) after two attempts; or

  7. g. 

    a MADCAP adjustment action for nonpayment to payment status that has not successfully processed after three attempts.

References: 

 

2. Critical case exclusions

Some cases are excluded from Title II critical case processing because they are not considered critical payment situations. A critical case does not exist for situations in which there is:

  1. a. 

    an issue or discrepancy where no payment is due. For example, a Medicare issue with no Title II payment problem, Social Security Number (SSN) issues or earning discrepancies, requests for explanation of benefit or overpayment amounts;

  2. b. 

    a request for a recomputation, recalculation, and/or delayed retirement credits where only the amount of payment is in question;

  3. c. 

    an alleged non-receipt for a payment that represents only a retroactive cost-of living increase payable to all beneficiaries, a lump-sum death payment, or an underpayment due a deceased beneficiary;

  4. d. 

    a conditionally adjudicated or non-adjudicated claim;

  5. e. 

    payment of the family maximum; or

  6. f. 

    a tax refund offset.

References: 

 

C. Procedure-applying the critical case criteria

When applying the critical case criteria, technicians must consider the merits of each case and determine if the issue with the case can be resolved through routine processing, by using direct input in the applicable system. For cases that cannot be resolved using direct input, technicians will use the Critical Payment System (CPS) to replace the delayed payment. CPS is primarily used to:

  • •

    make Title II critical payments-a payment issued by the Treasury Department and received by the beneficiary in two-to-five days; and

  • •

    record Title II immediate payments (IP)-a debit card is issued immediately in the field office because of a dire need situation requiring payment faster than the two-to-five days of a Treasury issued payment. For more information on the criteria for an IP, refer to RS 02801.010.

For more information on CPS, refer to SM 00635.000 and MS 07901.001.

While most critical cases are identified and processed in the FO, these cases are also processed in the teleservice center (TSC) and the processing center (PC). For TSC instructions on processing critical cases, refer to TC 15001.040. For PC and FO instructions, refer to RS 02803.000.

NOTE: If the FO needs to transfer a critical case to the PC for necessary action, such as when a CPS exclusion exists or for certain appellate reversals, complete a Modernized Development Worksheet (MDW) 2560HP (High Priority Payment Center Request) request. For information about modes of requesting assistance, refer to GN 01070.228.

NOTE: For critical cases where benefit payment offset (BPO) applies, subtract any BPO amount before issuing a CPS payment. Additionally, CPS payments cannot be issued to pay back excess BPO payments. For more information, refer to GN 02410.300.

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0302801001
RS 02801.001 - Critical Case Criteria and Exclusions - 09/18/2026
Batch run: 09/18/2026
Rev:09/18/2026