DI 13050.045: Expedited Reinstatement (EXR) Title II Interview
Effective Dates: 01/14/2016 - Present TN 3 (01-07) DI 13050.045 Expedited Reinstatement Interview - Title II A. Procedure - screening for eligibility Follow these screening steps to determine if an individual is eligible for expedited reinstatement (EXR). 1. Review the MBR Query the MBR to determine if the individual was previously entitled to a disability benefit under title II (i.e., disabled number holder, disabled widow/er, or disabled child), if the entitlement has terminated and the reason for termination. A combination of three of the following MBR entries, with a LAF code of T6, T8, U, or X7, indicates entitlement was terminated due to engaging in SGA: * BENEFIT Line - A DIBCES entry in the reason for suspension/termination (RFST) field. * DIB Line - An “E” entry in the cessation disability reason (CDR) field. NOTE: A medical cessation input after the SGA cessation will overlay the CDR field. The absence of an E in the CDR field is not conclusive evidence that benefits did not terminate due to SGA. See DI 13050.085E. * DIB Line - A difference of 3 or more years between the date in the extended period of eligibility begin date (EBD) field and the date in the disability payment cessation (DBC) field. * DIB Line - A date entry in the extended period of eligibility Medicare begin date (EMD) field that is at least 78 months earlier than the Medicare Part A termination date (or 24 months earlier if the Part A termination date is prior to 10/1/00). * HI-DIB Line - A Medicare Part A termination date more than 78 months (or 24 months if termination date is prior to 10/1/00) after the Applicant's Disability date (ADC). * HISTORY Line - An RFST code entry in the SUSP/TERM field of EPESGA followed by DIBCES in subsequent lines. * SP MSG - Special message text related to SGA cessation and termination information. 2. Review other corroborating information Review the following additional sources of information to verify the termination was due to SGA and not a medical cessation or other termination: * The NDDSS may contain a record of a medical determination. An intervening medical termination that occurred after the SGA termination will NOT prevent the individual from filing for EXR. * The individual may have a termination notice or the notice may be available on an online system (ORS). * There may be a record in the MRTW, eWork systems or other locally maintained files that may be helpful. * The DCF or eWork may contain information regarding earnings or a previous SGA cessation. * There may be information on a modernized development worksheet (MDW) record. * There might be earnings posted for the appropriate years on the SEQY.
- 3. EXR filing period
Determine if the EXR request is within 60 months of the previous benefit termination month. Add 59 months to the disability benefit cessation (DBC) month to determine the ending month of the 60-month period. See DI 13050.010 for further information about the EXR request period and consideration of good cause for late filing. Also, consider the protective filing guidelines in DI 13050.015.
- 4. Establish protective writing
If an interview cannot be taken immediately, establish a protective writing through the 800 Number System and schedule an appointment in the post-entitlement (PE) appointment calendar of the individual's servicing field office (FO). Type “EXPEDITED REINSTATEMENT” in the remarks section of the PE appointment lead. Advise the individual that provisional payments/Medicare cannot begin until the completed EXR request is submitted. B. Procedure - expedited reinstatement interview – Title II
- 1. Explain EXR provisions
When the screening procedures outlined in DI 13050.045A have been completed, explain the EXR eligibility requirements to the individual and determine if he or she is eligible for EXR (see DI 13050.001B.1.). If eligible, explain the basic provisions of EXR as compared to those of filing a new application. The individual must decide whether he or she wishes to pursue EXR or an initial claim. See DI 13050.020 for a more in depth discussion of some issues to consider. If, after discussing with the individual the requirements of EXR, the individual decides not to file a request for reinstatement, discuss filing a new application for disability benefits. If a protective writing exists for EXR, it must be closed-out per DI 13050.015 and GN 00204.012. If the individual elects to file a new claim instead of EXR, state the reason for not filing EXR in the Remarks section of the initial application form. If you are unable to determine eligibility for EXR based on available evidence, proceed as if the individual is eligible and request the claims folder to confirm eligibility. 2. Obtain EXR request package Obtain a completed and signed EXR package from the individual. The EXR package will include at least the following forms: a. SSA-371, Request for Reinstatement for Title II; (see DI 13050.105). Staple this to the front of the appropriate title II supplemental paper application (i.e., SSA-16-F6 for disabled NHs, SSA-10-BK for DWBs, or SSA-4-BK for CDBs). Write “Supplement to the Request for Expedited Reinstatement” at the top of the SSA-4, SSA-10 or SSA-16 application form. NOTE: The supplemental paper application form will be completed in the same manner as it would for a new initial claim; however the date of onset to use on the EXR supplement is the previously established onset date. b. SSA-454-BK, Report of Continuing Disability Interview * Enter the month and year of the EXR request in the “Remarks” section (if protective filing exists, use the protective filing date); * Place the remark, “Possible retroactivity exists prior to the month of filing - see SSA-823” in the “Remarks” section of the SSA-454 to alert the DDS to the need to consider retroactive reinstatement. c. SSA-827, Authorization for Source to Release Information to the Social Security Administration Obtain one from claimant. See DI 11005.056A and DI 11005.057A. d. SSA-820/821, Work Activity Report (Self-Employed Person)/Work Activity Report (Employee) and SSA-823, Report of SGA Determination Document SGA/nonSGA during the 12-month EXR retroactive period on th eSSA 820 or 821, and record the SGA determination on the SSA-823. e. SSA-795, Statement of Claimant, indicating the individual's election choice (if applicable) regarding Medicare Part B. See HI 00801.164 for information about Medicare. NOTE: If the interview is by telephone, explain to the individual that you are sending the EXR forms to him or her for signature along with the 60-day EXR close-out notice (see DI 13050.015E). Tell the individual that he or she must return the signed forms before provisional benefits/Medicare can be paid. 3. Request the prior file Request the prior claim folder to confirm eligibility for EXR and to provide the comparison point medical records the DDS will need to make the medical determination. Follow the instructions in GN 03105.000, GN 03103.080F.5., and DI 11005.085B for retrieving a folder. If the prior folder was a certified electronic folder (CEF), convert the file to paper. For more information on how to convert a CEF to paper, see DI 81010.030C. 4. Representative payee If during the interview you determine that the individual is incapable of managing his or her own provisional benefits, develop for a representative payee. If the individual had a representative payee in the previous entitlement period, determine if a representative payee is still needed. See DI 13050.075 for more instructions about payee development. 5. Provisional benefits Start provisional benefits when appropriate (see DI 13050.025A) and send the EXR package to the servicing DDS for a medical determination per DI 13050.055. See DI 13050.075C for rep payee instructions. C. Procedure - workflow outline The following is an outline of the application and award processing procedures for title II EXR cases. 1. Title II initial development * FO screens for eligibility and takes EXR request for eligible individuals. Ensure that potentially eligible auxiliaries are identified on the “supplemental” SSA-16-F6 (a new application is required for auxiliaries, per DI 13010.610). Establish the EXR request on the DCF (per MSOM CDR 001.002, MSOM CDR 001.003, and MSOM CDR 001.016). Develop for payee as appropriate. * FO identifies all months of SGA and non-SGA in the 12-month period prior to EXR request on the SSA 820 or 821, and records the SGA determination on the SSA-823, per DI 13050.045B.2.d. The DDS will take this date into consideration when establishing the first month of EXR eligibility based on the medical evidence. SGA months should also be documented on the DCF. * FO initiates provisional benefits, beginning the month the signed EXR request was filed. See DI 13050.020 for provisional benefit information. * FO requests the prior claim folder to confirm eligibility for EXR and provide the comparison point decision medical records. * FO sends the EXR case-file to the DDS for medical determination with an EXR folder flag (see DI 13050.105, Exhibit 4). Transfer jurisdiction of the EXR event to the DDS on the DCF and create an EXR issue on the DCF development worksheet (the CDRW screen) to control for return of the case (see DI 13010.605). * DDS receipts case per DI 28057.010B, make the MIRS medical determination and complete the SSA-833. See DI 28057.020F for instructions on completing the SSA-833. * DDS faxes EXR approval to the FO so that the FO can initiate necessary non-medical development (see DI 11010.340) (or use other locally arranged alternative to expedite processing). * DDS returns EXR case file to FO. The DDS should NOT send any cases directly to OCO/PC. 2. Title II - after medical allowance * The FO transfers jurisdiction of the EXR event in the DCF back to FO. Prepare an EF-101 under District Office Final Authorization (DOFA) procedure (GN 01010.008). * The FO confirms a finding of disability (shown as a medical continuation) on the SSA-833. A code of 31 should be coded in item #20 on the SSA-833. Item #24 must show EXR MOE (MMYY). Do not terminate provisional benefits if there is current entitlement to EXR. * The onset date for EXR computation purposes remains the same as the onset date for the previously terminated period of entitlement. The PIA is computed as if the EPE termination and any provisional payments never occurred. * The MOE may be retroactive for up to 12 months, but no earlier than 01/2001. If it is determined that there was SGA in the month of filing, the determination must be reopened to a technical denial as the individual does not meet the EXR requirements (see DI 13050.001B). If there was no SGA in the month of filing but it is determined that the MOE established by the DDS cannot be used for another reason (e.g., SGA in MOE or a prior non-SGA month in the 12 month retroactive period of which the DDS was not aware), a new MOE must be established. The FO must use the MOE established by the DDS; the FO cannot change the MOE. (NOTE: The EXR filing date can be used as protective filing for a new initial claim). If the MOE established by the DDS cannot be used, the FO must send the case back to the DDS to determine a new MOE. The PSC DPB can determine a new MOE without sending the case back to the DDS when the change is based on work and earnings or incorrect retroactivity. * The FO codes any deduction, suspension, and termination months due to SGA, Workers Compensation (WC), PDB, Windfall, etc., on the EF-101. Code EXR DIB information on the EF-101 (see DI 13050.060B for detailed processing instructions). The DAC of F must be coded on the EFBNDIB screen. * The FO enters a remark that states “Expedited Reinstatement Case – Priority Handling” in remarks section of EF-101. Add remarks to alert PC/OCO to Medicare and other special issues involved. The MOE on the EF-101 and the MOE on the SSA-833 must be the same. * The FO adjudicates and transfers the EF-101 per MSOM T2PE 009.001. The FO stores an electronic copy of the SSA-833 in eView or NDRED. The FO transfers the EXR event in the DCF to OCO/PC per DI 13010.620 and sends a copy of the EF-101 to ORS. * OCO/PC will route the EF-101 to the module (or other component/location according to local procedures) for handling. (PC employs local Paperless processes as appropriate.) Adjudicating and moving EXR EF101 to OCO/PC creates an EF101 Stub Record in the PC’s Paperless Processing Center (PPC). Do not fax the EF101 to the PC as it could result in a duplicate Action Control Record being established in PPC. * OCO/PC will perform cursory review of EF-101 under DOFA procedures and call the FO if necessary to resolve any issues. * OCO/PC will stop Provisional Benefits and process the EXR award according to DI 13050.060, adjusting for Provisional Benefits paid. OCO/PC will check to be sure the DAC of “F” (never a DAC of “X”) is coded (see SM 00856.300B.1.). * OCO/PC will send the EXR reinstatement notice to beneficiary. The EXR award notice is available in Aurora as E3956 (see NL 00703.956 for the sample notice). * OCO/PC will clear the EXR event in the DCF as a continuance per DI 13010.625. * The FO will verify that title II benefits have been reinstated (via the MBR). Review the MBR to see that there is a new DIB line with a DAC of F on the MBR. eWork cannot be used until the MBR is set up correctly (for more information on eWork processing, see eWork Help Screen Index “Correcting the MBR in EXR Cases”). The DDO should be the last day of the month prior to the EXR month of entitlement (DOED). The DOED should show the benefit reinstatement month. The DAC of “F” should be shown, which indicates the period of entitlement is due to EXR. * The FO will send the EXR folder to the National Record Center (NRC) 6000 East GeoSpace Dr., 601 South 291 HWY, Independence, MO. Include the paper SSA-833 in the folder and attach the correct cover sheet. Mark the folder “All FO/PC Actions Complete.” D. Policy - technical denial - FO responsibilities If, after going through the screening process in DI 13050.045A, or at a later date, the FO determines that the individual is or was not entitled to expedited reinstatement (EXR) because he or she does not meet the non-medical requirements for EXR (see DI 13050.001B and DI 13050.005A.2.), issue a technical denial notice to the individual and appropriate third party, stop provisional benefits (if being paid) as per DI 13050.025J and contact the individual to: * Explain the basis for non-entitlement, and * Inform the individual that he or she has the option of filing a new initial application for disability benefits, requesting a reconsideration of the EXR determination, or filing a new EXR request. Discuss the merits of each option to help the individual determine which option would be most advantageous. The request for reinstatement can be used as a protective filing for a new initial application if that is what the individual chooses to file. Process the EXR denial and take action based upon the individual's decision per DI 13050.020. A denial of expedited reinstatement is an initial determination that carries appeal rights as discussed in DI 13050.085C. However, the action taken to terminate provisional payments due to a determination being reached on the EXR request cannot be appealed. E. Procedure - technical denial – Title II 1. Individual files initial claim Document the basis for EXR non-entitlement on the RPOC screen if the application is taken on MCS or an SSA-5002 if a paper application is taken. Close out the existing EXR protective writing through normal close-out procedures (include a close-out statement in the remarks on the initial claim application, etc.). 2. Individual requests EXR * Obtain a form SSA-371, Request for Reinstatement for Title II. * Establish the EXR event in the DCF, per DI 13010.610. * Document the basis for EXR ineligibility on an SSA-553, Special Determination, or an SSA-5002, Report of Contact and annotate the Remarks screen of the DCF. * Retain supporting documentation with the above forms in a brown folder. * Annotate the MBR with a special message that reflects the following data: date the request for EXR was filed, date of denial determination, basis for denial, SSA employee identifier (such as unit code or last name) and field office code. EXAMPLE: SP MSG1 TRANS DT-07/01 EXR-FILED 06/10/01–DENIED 07/02/01-PREVIOUS ENTITLEMENT TERMINATED DUE TO MEDICAL CESSATION-UNIT DQQ FO 815 3. Notice Send an EXR denial notice to the claimant and any appropriate third parties. Refer to DI 13050.105, Exhibit 8. Retain a copy of the notice for the file. Title II EXR denial notices are contained in DPS. Include Medicare information as appropriate. Refer to DI 13050.070 for instructions on inserting the appropriate Medicare language. 4. Provisional benefits paid Terminate provisional benefits, if started. See MSOM T2PE 003.024. 5. Medicare If Medicare entitlement exists, refer to DI 13050.070. 6. DCF clearance Clear the EXR from the DCF via the IFOA screen using the SSR/MBR/OTHER CONDITIONS – STOP CDR option (see DI 13010.620D.3.).
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