Consider every individual filing a SSI claim for benefits, including children, to be a potential candidate for PD/PB benefits. The FO can make a PD/PB determination in any SSI claim in which:

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  we are likely to allow the claim on formal determination; and

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  there is an allegation listed in the PD/PB categories chart in DI 11055.231.

However, if we denied an individual’s prior claim based on medical factors, the FO or DDS may make a PD/PB finding only when:

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  the individual presents sufficient evidence;

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  there is documentation of a worsening physical or mental condition;

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  there is documentation of the existence of a new impairment; or

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  there is a strong likelihood that the claim will be medically approved.

PD/PB provisions do not apply in the following situations:

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  claimant engages in substantial gainful activity (SGA) (see DI 10501.001);

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  claimant has a history of sustained work while severely impaired, which ended for reasons not related to the impairment;

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  reconsideration or appeals cases; and

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  prerelease cases (see SI 00520.910).

The FO may make PD and PB findings based on the claimant's allegations in cases when all of the following apply:

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  the claimant filed an SSI application (not a reconsideration or other administrative appeal) based on disability or blindness; and

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  the claimant is not engaging in SGA; and

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  the claimant's impairment meets a PD/PB criterion in this subsection; and

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  observations made within the framework of a claims interview, submitted evidence, or third party information is consistent with the claimant’s allegations or contacts with other sources (applicable to categories 2-9 and 17 in DI 11055.231).

The categories of impairments in DI 11055.231 include any:

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  impairment that is likely to meet listing level severity; or

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  claim in which the impairment may, or may not, meet listing level severity, but which is likely to meet the medical-vocational profile in DI 25010.001B.

The medical and vocational information furnished by the claimant at the time of the initial application, and other facts gathered by the FO may be sufficient for a PD/PB determination.

Evidence for PD/PB determinations may include the following:

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  medical reports;

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  third-party contact information (for details, see DI 11055.240A.1.);

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  facts reported to the FO (unsubstantiated allegations do not constitute a fact); or

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  face-to-face observations (applicable to categories 2-9 and 17 in DI 11055.231).

The EAP is a special one-time payment in which the claimant receives an advance of the first month’s benefit payment if an established financial emergency exists. For more information about EAP in cases of disability and blindness, see DI 11055.245.

See Also:

SI 02004.001 Emergency Advance Payments and Immediate Payments

Do not consider payments based on PD/PB to be an overpayment if the DDS later determines that the claimant is not disabled or blind. However, if non-disability factors (e.g., excess income, SGA, or resources) cause the PD/PB payments to be incorrect, there is an overpayment, see SI 02201.010A.1.

Do not consider PD/PB payments as “first payments” for IAR purposes, see SI 02003.001C.

Do not consider PD/PB payments as past-due benefits, see GN 03920.031C.