GN 01010: Adjudicative Policy and Standards
TN 13 (11-11)
A. Definition of DOFA exclusion
District Office Final Authorization (DOFA) refers to the action taken by the adjudicator at the Field Office (FO) level to make an adjudicative determination on a claimant’s title II application for benefits. DOFA exclusions are claims initiated at the FO via Modernized claims system (MCS), Automated 101 (A101) or Electronic Form 101 (EF101) that the FO employee cannot approve (i.e. adjudicated) because they are the processing centers (PC)s’ responsibility. In essence, claims requiring PC authorization are non-DOFA, or DOFA exclusion claims.
NOTE: The DOFA issue is all about the adjudicative signature in a particular set of circumstances. That is, whether the FO technician has the authority to approve (i.e., sign off) the specific initial determination. The system used to initiate and develop the claim (i.e., MCS, A101, or EF101) is immaterial. You can clear a non-DOFA claim to the PC without adjudicating the claim in any of these processing systems.
B. Policy on DOFA exclusions
1. FO responsibility
The FO is responsible for final authorization of all claims except those listed in GN 01010.027D of this section. Special characteristics with assigned review (RV) codes identify these categories of DOFA exclusions.
a. Single SSN is involved
When adjudicating more than one claimant on the same record (e.g., Beneficiary Identification Code (BIC)s “A,” “B” and “C”) and you discover that any of the claimants fall into the listed characteristic, treat all the claimants as one claim and exclude from DOFA.
b. Multiple SSNs are involved
If a claimant files on two or more Social Security numbers (SSN)s, review each claim independently for non-DOFA characteristics. The existence of a non-DOFA characteristic for a claimant on one SSN only affects the other claimant(s) on the same SSN.
EXAMPLE: In a retirement (RIB) – auxiliary spouse (AUXSPO) situation (e.g., a wife filing for AUXSPO benefits on her husband's SSN is also filing for RIB on her own SSN, or vice-versa), if there is a non-DOFA characteristic only on the AUXSPO claim, exclude all claimants on the AUXSPO claim from DOFA. However, process the RIB claim via DOFA. Similarly, in a RIB – survivor spouse (SURSPO) situation, process the RIB claim via DOFA even though the SURSPO claim is a DOFA exclusion.
C. Exclusions codes
FO technicians must record the non-DOFA code in MCS using the decision (DECI) screen to provide a reason why the claim is a non-DOFA. See MSOM MCS 009.013 for a complete description of the DECI screen. The DECI screen options for non-DOFA reasons are as follows:
1= PRECEDENT REQ (RV03)
2= NON-DDS JURIS (RV13)
3= ADVERSE CLM (RV02)
4= FO OPTION (RV19)
D. List of DOFA exclusions and description of exclusion codes
1. RV02 - Adverse claims
An adverse claim is an award of benefits to a new claimant or re-entitlement to benefits for a prior beneficiary that results in the non-entitlement or termination of another beneficiary previously awarded. This characteristic does not apply to adverse adjustments (i.e., post-entitlement (PE) actions where a previously awarded beneficiary's rate is only reduced).
2. RV-03 - Precedent decision, legal opinion or ruling required
Exclude the claim from DOFA if the FO needs to submit the claim to the PC or Regional Office (RO) for a new precedent decision or legal opinion. The claim is also a DOFA exclusion if you must send it to the Central Office (CO) for a decision or ruling. You must review the POMS PR section for title II opinions or the PS section for the title XVI opinions to verify existing precedents.
3. RV-13 - Non-DDS jurisdiction disability claims
This characteristic includes any disability claim routed directly from the FO to the PC for a disability determination see DI 11052.020D.
Note: ALJ and AC level disability allowances are non-DDS jurisdiction claims therefore follow non-DOFA procedures. These claims do not have an RV code annotation. Hearing offices make ALJ/AC allowance decisions and then route the claims directly to the PC.
4. RV-19 - FO Option- Claim needs coordination with another component
Coordination with the component depends in the claim situation and the component involved. See GN 01070.000 for more information.
This characteristic applies only to the situations described below.
Claimant files a new claim while an appeal is pending in a prior claim.
Exceptions: The FO may adjudicate the current claim if it is for a RIB and a prior DIB application is pending an appeal decision or if the current claim is for a Lump Sum Death Payment (LSDP) and any other type of prior claim is under appeal.
Any claim filed concurrently with a request to withdraw another claim that SSA already awarded and effectuated. Since the withdrawal requires approval and the claimant must repay the prior benefit in full, the new claim and the withdrawal request are the PC responsibility. See GN 00206.014 for more information.
Survivor claims, in which a Railroad Retirement Board (RRB) jurisdiction determination is pending, see RS 01602.202.
Life claims in which the receipt of RRB earnings information is under “delay” status and the NH is not insured with Social Security earnings alone, see RS 01602.150.
Any claim from the Veterans Administration Regional Office (VARO) in Manila, since the VARO does not have adjudicative authority.
Certain End Stage Renal Disease (ESRD) claims as defined in HI 00801.300.
Any conditional Application for Hospital Insurance (CMS-18-F5) filed for a potential Qualified Medicare Beneficiary (QMB) (see HI 00801.139 through HI 00801.140) whose Medicare entitlement is totally dependent on a favorable QMB determination by the state (i.e., a conditional application for Part A and Part B filed in a Part A buy-in State outside an enrollment period). You must fax the CMS-18-F5 and related material to the PC using a SSA-3601 routing form. The PC is responsible for preparing the SSA-A101 or EF101 since the HI and SMI effective dates must equal the Current Operating Month (COM). .
E. Procedure for processing a non-DOFA claim in the FO
When you process a non-DOFA claim in the FO, annotate the appropriate non-DOFA reason on the DECI screen in MCS and transfer the claim to the PC of jurisdiction by entering a PROC code of “N” on the INTE screen. This action creates a record request for the PC.