GN 01010: Adjudicative Policy and Standards
TN 13 (11-11)
A. Types of adjudication and related terms
Adjudication is the application of the law to the facts and an authoritative declaration of the result (i.e. a signed determination or decision). Consider a claim adjudicated when an employee with adjudicative authority delegated from the Commissioner of the Social Security Administration completes
the appropriate electronic adjudicative decision screen,
the equivalent direct input screen, or,
signs a paper adjudicative form
2. Partial adjudication
Partial adjudication is a method of awarding benefits to a claimant before all development is complete. It is the initial determination of all issues except those still being developed.
3. Immediate payment
Immediate payment means that payment is due for the current operating month (COM) in which the claim is being adjudicated (or earlier); or Hospital Insurance / Supplement Medical Insurance (HI/SMI) entitlement exists in a monthly benefit claim.
A claimant is entitled to retirement (RIB) effective 10/2010. The first payment is due 11/03/2010 for the COM of the 10 /2010.
A claimant is in full work deduction status. Immediate payment does not exist unless the Number Holder (NH) is entitled to HI/SMI.
Exception: The immediate payment criteria do not apply to Terminal Illness (TERI) or Compassionate Allowance (CAL) claims pending disability determinations.
B. Policy on partial adjudication
The claims technician is responsible for fully developing and reviewing the claim to ensure that the claimant meets all entitlement factors prior to adjudication. You must properly document any partial award in the Modernized Claims System (MCS) screen or the claims file to ensure proper control of any outstanding issues until they are resolved.
1. When to partially adjudicate a claim
Partially adjudicate a claim if:
All factors of entitlement are met;
There is an unresolved issue pending (e.g., Military Service (MS) verification is pending);
Immediate payment is due; or
A claimant is potentially entitled to more than one benefit type or on more than one SSN and only one claim is ready for effectuation.
Reminder: It is not a partial award situation when a disability decision is still outstanding and the claimant files for another benefit type (e.g. RIB). The disability (DIB) decision is an outstanding entitlement factor for the DIB claim; adjudicate the RIB application separately from the DIB.
2. When not to partially adjudicate a claim
Do not adjudicate the following types of claims as partial awards:
Lump Sum Death Payment (LSDP) claims via MCS while a claim for monthly benefits is pending on the same social security number (SSN) (see GN 01010.250).
A claim with pending development for lag year earnings, in accordance with RS 01404.005. However, if lag earnings are not an entitlement issue (i.e. earnings are not needed for insured status), adjudicate the claim after 10 days. No diary is necessary.
Medicare-only claims involving State buy-ins or not meeting the residency requirement. However, in advance filing cases where the claimant will meet the residency requirement, you can adjudicate the claim and include a diary for verification of the 5-year residency requirement.
C. Procedure for adjudicating partial awards
1. Documenting partial awards
All adjudicative decisions must reflect the documented facts for the entitlement. We cannot establish an element of entitlement or a factor affecting payment if you do not properly document it in accordance with the Program Operations Manual System (POMS) tolerances, presumptions, or evidentiary standards.
a. MCS earning computation (EC)
You must select “DEC STAT 9” for retirement, survivor or Medicare partial claims (RSHI PARTIAL) or 10 (DIB PARTIAL) on the decision (DECI) screen;
Initiate the appropriate internal control (e.g., Modernized Development Worksheet (MDW)) and establish a diary on the DECI screen (see MSOM MCS 009.013) The DECI diary entry interfaces with the Processing Center Action Control System (PCACS) and establishes the diary in the processing center (PC).
Annotate the report of contact (RPOC) screen with the applicable diary evidence code and a detailed rationale for all issues under development. If RPOC screens are not available, prepare a paper report of contact (RC) with the diary information including the following remark “SEE RC IN FILE - PC MUST ADD DIARY REMARKS - RPOC NOT AVAILABLE” and fax it into the paperless unit of the PC of jurisdiction. This simplifies and expedites accurate diary inputs in the PC.
b. Manually processed awards
For manual awards, you must prepare an internal diary (e.g., MDW) and, request the PC to establish a diary supplying the applicable rationale and evidence Code(s).
Annotate the Automated 101 (A101) or Electronic Form 101 (EF101) Benefit Continuity Remarks/Notice (BCRN) screen with the applicable diary Evidence Code(s) and document all issues under development in detail.
The period for a diary for outstanding development input in the PC is usually 60-days unless conditions warrant a longer or shorter period and a specific date is input.
2. Partial award notices
You must annotate the applicable partial award paragraph(s) on the notice as instructed here.
Include a special paragraph on the appropriate screen for the award notice (e.g., notice (NOT) 2, NOT3, A101 BCRN screen, RPOC, etc.).
Select the dictated paragraphs needed as instructed in MSOM ORS 002.003 and NL 00725.005 for the MCS Universal Text Identifiers (UTI) for partial awards (PAYR01).
For Dual Entitlement (DE) claims, include the special paragraph stating that we will made a separate decision on the other claim, when applicable. Use the UTI “CLOR05” for MCS processing (NL 00725.005) and “B56” for manually processed awards.
The notice must include language advising the claimant that we based the determination on currently available evidence and we may be revise it based on additional evidence.
NOTE: In most cases, the first notice is not an initial determination on the unresolved issue. The PC will send another notice once the development is complete. This second notice is the final determination on that issue and must include a reconsideration paragraph. However, the first notice may be the final notice in earning record (E/R) revision cases not involving an earnings investigation (see GN 04001.040E.2).
3. Special Notice Not Required
A special notice is not required if a Primary Insurance Amounts (PIA) discrepancy is resolved prior to adjudication (see GN 01010.100).