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. 1. 

   Ask the NH:

   • •

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

   • •

     if the NH has filed, or intends to file, an application for a disability payment; or

   • •

     if a disability claim is currently under appeal.

2. 2. 

   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 Social Security disability claim is an Internet Claim Application (iClaim) and if the NH indicated on the iClaim that they filed for a WC/PDB benefit, verify their statement in the interview that the NH filed for WC/PDB and gather all pertinent facts.

   NOTE: Request a signed Form SSA-1709 (Request for Workers' Compensation/Public Disability Benefit Information) (DI 52145.010) during the initial interview. If the claim cannot be processed through MCS, obtain Form SSA-546 (Workers' Compensation/Public Disability Benefit Questionnaire) per DI 52140.005.

3. 3. 

   Request proof of WC/PDB from the claimant at the earliest point in time possible. See the list of acceptable evidence in DI 52145.001D. Document this request for proof on the SSA-16 (Application for Disability Insurance Benefits) cover sheet/request for evidence that is stored in the Evidence Portal (EP) with the SSA-16. You may also use the Request for Information - Initial (SSA-L1043) notice in the Document Processing System (DPS) to request evidence.

4. 4. 

   For NHs who have worked in states that pay a State Disability Insurance (SDI) tax (for example, California (DI 52120.030F)) and if they have not filed for SDI, then ask "Why Not?". Document their response in the RPOC or MCS RMKS screens. Refer to DI 52135.001 for a listing of states/territories that have special features related to their public disability benefit plans.

5. 5. 

   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 they are receiving another form of disability payment.

6. 6. 

   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 (for example, carpal tunnel syndrome) 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.

7. 7. 

   If the work-related injury or illness question on the application has an answer of "No," and the response is questionable considering the alleged disability, obtain an explanation from the worker or contact the employer for verification. Use Form SSA-795 (Statement of Claimant or Other Person) or an RPOC. Document the electronic folder (EF)/eView/EP with the responses and develop, as needed, based on the worker's or employer's responses.

   IMPORTANT NOTE: Document any discussion which changes previous responses to the WC/PDB questions (as documented on the DISB screen) on an RPOC (MCS) or the Report of Contact screen (CCE/SSI Claims System) and update any Development Worksheet issues, as applicable. This is especially important when a NH files via the iClaim application process. When the NH changes their answers during the interview process, we want to make sure they understood the WC/PDB questions on the iClaim screen. We also want to be certain that we correctly identify whether the NH filed for WC/PDB benefits.

8. 8. 

   Document the conversation about the effect of WC/PDB payments in an RPOC on the disability application. It is important to remind claimants of their reporting responsibilities of WC/PDB payments during the initial interview and explain how their failure to report these payments to SSA timely may lead to an overpayment.

9. 9. 

   Address the option of filing for reduced 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 – 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 (Application for Disability Insurance Benefits)- Question #19 “Are your illnesses, injuries or conditions related to your work in any way?” or Question #21 “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?

• •

  Cover letter/request for evidence (Application for Disability Insurance Benefits)- Documents a request for proof of WC/PDB at the initial claim interview saved in the EP.

• •

  SSA-3441BK (Disability Report-Appeal) – Section 5 - Other Medical Information, Question 5, or the i3441- "Since you last told us about your other medical information, does anyone else have medical information about any of your physical or mental conditions (including emotional or learning problems) or are you scheduled to see anyone else?"

• •

  SSA-3368-BK (Disability Report-Adult) or the i3368 – Section 9 - Other Medical Information, Question 9, “Does anyone else (other than your healthcare providers) have your medical information? Examples include Department of Veterans Affairs, social services agencies, vocational rehabilitation agencies, welfare agencies, attorneys, prisons, workers' compensation, and insurance companies who have paid you disability benefits."

• •

  SSA-454-BK (Continuing Disability Review Report) – Section 6, Question 6, “Does anyone else (other than your medical providers) have your medical information or are scheduled to see anyone else? Examples include places like social services agencies, case workers, welfare agencies, attorneys, prisons, workers' compensation, and insurance companies who have paid you disability benefits.”

• •

  SSA-821 (Work Activity Report- Employee) – Question 6A, "For any job you told us about in Question 3, did you make any changes below since the DATE shown in the Identification section? Check all that apply. " 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.

If the claimant is found disabled, the FO should review and update WC/PDB information and process disability claims involving WC/PDB as follows:

1. 1. 

   Prior to processing the claim, review the folder (paper or electronic), the MCS screens, EP, and eView to determine if a technician has already requested WC/PDB proof or to check that proof/evidence is already in the claimant's file. A technician should initially request this evidence at the time of the initial claim interview. Proof should be current.

   NOTE: We consider WC/PDB evidence of periodic payments as "current" if the proof/evidence is no more than one year old. To count this period, review the date posted on the WC/PDB evidence in the file as the starting point.

2. 2. 

   Request updated proof/evidence if the proof in the file is more than one year old. See DI 52145.001F for sources of verification, such as the NH, attorney, or other appropriate sources, and DI 52145.001D for what is considered acceptable proof. Technicians must contact the claimant first before contacting the NH's attorney, legal representative, or other appropriate sources.

3. 3. 

   Provide the claimant 10 business days (plus 5 days for mail) to respond to the request for WC/PDB proof. Technicians should also concurrently follow the verification procedures in DI 52145.001F for proof within 10 business days if the claimant will not provide verification. Utilize all methods of direct contact, including telephone, when requesting proof of WC/PDB.

   NOTE: If there is WC/PDB evidence in the file that is "not current" (i.e., over one year old), use the most recent WC/PDB evidence available to process the claim and document your attempts to obtain current WC/PDB evidence in the RPOC or MCS RMKS screen.

4. 4. 

   If the claimant does not provide WC/PDB proof/evidence or if you cannot obtain WC/PDB proof/evidence after following the verification procedures in DI 52145.001F within 10 business days (plus 5 days for mail) and all other attempts to obtain proof/evidence from sources have been documented:

   • •

     Update the MCS screens with the State maximum rate at the time of the WC/PDB injury or illness as outlined in DI 52150.045.

   • •

     Include paragraph WCPR27 on the NOT3 screen in MCS to inform the beneficiary that we will use the State maximum rate to determine offset until we receive proof/evidence of WC/PDB. See NL 00725.470 for the fill-ins for the WCPR27 paragraph.

   • •

     If the beneficiary has an attorney or non-attorney representative, include the necessary neutral language paragraphs to the beneficiary and their representative regarding the fee for representation per GN 03940.075. Enter a "Y" in the Incomplete field at the bottom of the NOT3 screen to allow the PC to add additional language as appropriate.

   • •

     Establish a 42 (WC/PDB) diary on the Decision Input (DECI) screen in MCS with a 30-day tickle on the Diary (DIAR) screen for the PC to follow up on the response to your request for proof/evidence.

If WC/PDB proof is obtained:

1. 1. 

   Update the WC/PDB information in the Modernized Claims System/Earnings Computation (MCS/EC) screens. See DI 52155.001.

2. 2. 

   Adjudicate the claim via MCS/WC per DI 52155.010.

3. 3. 

   Adjudicate and prepare the offset computations using the Interactive Computation Facility (ICF) screens for the WC/PDB action before coding the claim via A101 if the MCS/EC WC/PDB computation is incorrect or cannot process the offset computation. When preparing an EF101, adjudicate the ICF screens for the WC/PDB action before coding the EF101. For MCS/EC processing, see DI 52155.010; for A101 processing, see DI 52155.025; and for EF101 processing, see DI 52155.030.

4. 4. 

   Process and adjudicate subsequent auxiliary claims per DI 52155.015.

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 lump sum (LS) settlement),

   • •

     amount of payment,

   • •

     change in rates,

   • •

     beginning and ending dates, and

   • •

     excludable expenses.

2. 2. 

   Requests proof of WC/PDB payments at the initial interview in accordance with DI 52145.001D. For iClaims, recontact the NH and clarify the WC/PDB allegations. Document the allegations of the claim number, amounts, and sources with the NH on the DW01, DW02, or RPOC screens.

3. 3. 

   Obtains the Form SSA-1709 (Request for Workers' Compensation/Public Disability Benefit Information) with the claimant's signature and documents the request on the SSA-16 evidence request cover sheet during the initial interview.

4. 4. 

   Completes concurrent development by contacting multiple WC/PDB sources such as the WC attorney and WC carrier at the same time if the claim is approved and the NH cannot provide WC/PDB proof. The FO is responsible for initiating development of WC/PDB proof/evidence 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.

5. 5. 

   Retains all WC/PDB proof/evidence for permanent retention by faxing the documents into the EF, eView, EP, or by storing it in the paper folder per Retention of Workers' Compensation/Public Disability Benefit (WC/PDB) Proofs in DI 52145.015.

NOTE: Technicians must permanently retain WC/PDB proof. This allows for the review of the original document to verify whether the interpretation and input of the WC/PDB proof was correct.

1. 1. 

   Pay full DIB if requested in writing by the NH 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 on an SSA-795 from the NH. A repayment statement is a statement that holds the NH liable for recovery of any overpaid amount(s) of benefits that should have been offset. (See DI 52140.001F).

   • •

     For an initial MCS claim only (and any subsequent appeal on that claim), annotate the repayment statement in the RMKS screen of the claim for each claim on the record (NH and auxiliary) and prior to the attestation via signature proxy screen. The technician should obtain the claimant's signature by attestation.

   • •

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

   • •

     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 the NH must repay.

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 00510.005A.1.

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

1. 1. 

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

2. 2. 

   Request from the NH the expected decision date of any pending WC/PDB claim.

3. 3. 

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

4. 4. 

   Obtain a request for full benefits and a repayment statement from the NH and any auxiliaries, per DI 52140.001E. The repayment statement on the SSA-795 form must be a completely dictated, free form statement from the NH or auxiliary.

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.

If the NH requests not to receive full benefits pending resolution of the WC/PDB claim or appeal:

1. 1. 

   Obtain a written request for complete withholding of benefits due to the pending WC/PDB claim. Obtain a completely dictated, free form statement on an SSA-795 from the NH requesting a complete offset of benefits that includes language that the NH understands they will not receive a payment from SSA by voluntarily electing complete offset and such request any affect future Social Security payments resulting in an underpayment.

2. 2. 

   Use the State maximum rate to impose full offset as outlined in DI 52150.045. If the State maximum rate does not result in full offset, use an alleged rate higher than the weekly maximum to impose full offset.

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 the claim through MCS, include the applicable LS proration paragraph in NL 00725.470 on the NOT3 (MS 03509.010) screen because LS proration paragraphs are not system-generated in MCS. If MCS/EC can process the WC/PDB offset computation, but you cannot process 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 Manual Adjustment, Credit and Award Processes (MADCAP).

   • •

     If the MCS/EC computation is not correct, compute the offset via ICF first, before adjudicating the A101 as described in DI 52155.025. If an EF101 is required for processing the award, compute the offset via ICF first, before adjudicating the EF101 as described in DI 52155.030.

3. 3. 

   Fax the WC/PDB proofs and documentation to the EF (eView) or the EP. If the action is complete and the proofs are successfully faxed and verified in the EF (eView) or the EP, return the evidence to the claimant per GN 00301.275. Documents from sources other than the claimant can be destroyed unless the return was requested by the individual who submitted the documents, see GN 00301.322.

4. 4. 

   If the case requires additional PC action, fax the WC/PDB proofs to Paperless via the Store Evidence function in the EP.

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, non-attorney representatives, or claimants seek assistance in preparing a WC settlement prior to the WC court approving the settlement. For example, bringing a draft to the FO of a proposed WC settlement and the individual asking what 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, (e.g., 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 52100.000 (available online). However, we do not assist the attorney, non-attorney representative, or claimant in determining a specific weekly rate low enough to avoid offset.

When 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 the Modernized Development Worksheet (MDW) tickle dates to control for future follow-ups. For instructions for establishing the MDW, see MS 03901.003.

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 using a Processing Center Action Control System (PCACS) diary, see MS 04902.001.

For initial claims notices, see DI 52155.035.

For PE events that require use of ICF, the technician will enter the appropriate paragraphs, see NL 00720.395.

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 State maximum 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 source 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 MS 02431.001 through MS 02434.004 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 the 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 claim 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. It may be advantageous for the spouse to file for reduced RIB on their own record if they do not receive any spouses' benefits after WC/PDB offset, except for protected increases. This may leave the spouse only an age reduced benefit payable on their own record as outlined in GN 00204.035. Deemed filing applies to RIB and auxiliary (spouses) benefits at any age and when the date of birth (DOB) is January 2, 1954 or later. Subsequent auxiliary entitlement with offsets may result in higher benefits payable 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 on Form SSA-795 or the RPOC. Note the time limitations on SSA processing of appeals. See Time Limit for Filing Administrative Appeal in GN 03101.010; also see Good Cause for Extending Time Limit to File an Appeal in GN 03101.020.

2. 2. 

   Accept the NH's allegation of the new WC/PDB rate in the file if you are unable to obtain updated WC/PDB verification within 10 days (plus 5 days for mail). If no rate is given, use the State maximum rate to compute offset. See Chart of States' Maximum Workers' Compensation (WC) Benefits in DI 52150.045. Develop for proof on a post-adjudicative basis.

3. 3. 

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

4. 4. 

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

• •

  DI 52100.000 Workers' Compensation/Public Disability Benefit (WC/PDB) Offset - Table of Contents

• •

  DI 52110.000 Workers' Compensation (WC) Payments that May Cause Offset - Table of Contents

• •

  DI 52115.000 Federal Workers' Compensation (WC) Payments

• •

  DI 52120.000 State Specific Workers' Compensation (WC) Procedures

• •

  DI 52130.000 Federal Public Disability Benefit (PDB) Payments

• •

  DI 52135.000 State Specific Public Disability Benefit (PDB) Procedures

• •

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

• •

  DI 52140.005 Processing Center (PC) Responsibilities for Processing Workers' Compensation/Public Disability Benefit (WC/PDB) Offset

• •

  DI 52150.030 Verification of Proof of Workers' Compensation/Public Disability Benefit (WC/PDB) - Table of Contents

• •

  DI 52145.001 Verification of Proof of Workers' Compensation/Public Disability Benefits (WC/PDB)

• •

  DI 52145.010 Completion and Receipt of the Form SSA-1709 (Request for Workers' Compensation/Public Disability Benefit Information)

• •

  DI 52145.015 Retention of Workers' Compensation/Public Disability Benefit (WC/PDB) Proofs

• •

  DI 52150.025 Workers' Compensation/Public Disability Benefit (WC/PDB) Offset Ending Date

• •

  DI 52150.030 Considering the Retirement Insurance Benefit (RIB) Option

• •

  DI 52150.045 Chart of States' Maximum Workers' Compensation (WC) Benefits

• •

  DI 52150.060 Prorating a Workers' Compensation/Public Disability Benefit (WC/PDB) Lump Sum Settlement

• •

  DI 52150.070 How Changes in Family Composition Affect Workers' Compensation/Public Disability Benefits (WC/PDB) Offset

• •

  DI 52155.000 Initial Claims with Workers' Compensation/Public Disability Benefit (WC/PDB) - Table of Contents

• •

  DI 52155.001 Completing Modernized Claims System (MCS) Screens when Workers' Compensation/Public Disability Benefit (WC/PDB) Is Involved

• •

  DI 52155.005 Initial Claims and Appeals Requiring Diary Control for Workers' Compensation/Public Disability Benefit (WC/PDB)

• •

  DI 52155.010 Modernized Claims System (MCS) Earnings Computation (EC) and Workers' Compensation/Public Disability Benefit (WC/PDB)

• •

  DI 52155.015 Processing Disability Claims with Workers' Compensation/Public Disability Benefit (WC/PDB) and Auxiliaries

• •

  DI 52155.025 A101 Processing Claims with Workers' Compensation/Public Disability Benefit (WC/PDB)

• •

  DI 52155.030 EF101 Processing of Claims with Workers' Compensation/Public Disability Benefit (WC/PDB)

• •

  DI 52155.035 Initial Determination Workers' Compensation/Public Disability Benefit (WC/PDB) Notices

• •

  DI 52165.030 Interactive Computation Facility (ICF) Workers' Compensation/Public Disability Benefit (WC/PDB) Notices

• •

  GN 00204.035 Deemed Filing

• •

  GN 00301.150 Evidence of Mail Development

• •

  GN 00301.275 Retention or Return of Documents

• •

  GN 00301.322 Retention of Paper Material After Faxing into Either the eDIB Folder or Claims Folder using NDRed

• •

  GN 01040.010 Diary Codes

• •

  GN 03001.015 Notices Required Before and After Taking a Title II Adverse Action

• •

  GN 03101.010 Time Limit for Filing Administrative Appeals

• •

  GN 03101.020 Good Cause for Extending the Time Limit to File an Appeal

• •

  GN 03940.036 Fee Agreement Process - Field Office (FO) and Processing Center (PC) Procedures - Partial Adjudication Involving Deferred Development, Including Workers' Compensation (WC) or Public Disability Benefit (PDB) Information

• •

  GN 03940.075 Title II - Fee Agreement Process - Neutral Language Paragraphs - Fee Authorization Deferred

• •

  Interactive Computations Facility (ICF) Resource Page for WC/PDB Offset Computations

• •

  MS 02431.001 Workers' Compensation/Public Disability Benefit Data Collection Screens - Overview

• •

  MS 02434.004 WC/PDB Offset - Disposition - Adjudicate WC/PDB Claim (WCDA)

• •

  MS 03509.010 Notice 3 (NOT3)

• •

  MS 03901.003 MDW Worksheet (MMDW)

• •

  MS 04902.001 Processing Center Action Control System Menu - Overview

• •

  NL 00720.395 Workers' Compensation (WCP)

• •

  NL 00725.470 "WCP" UTIs - Workers' Compensation

• •

  RS 00615.110 Reduced RIB as Affected by DIB (A-HA)

• •

  SI 00510.005 Types of Other Program Benefits