DI 52155: Initial Claims with Workers' Compensation/Public Disability Benefit (WC/PDB)
During the interview, question all claimants filing for disability benefits about WC/PDB.
Are they receiving WC/PDB?
Has the claimant received WC/PDB in the recent past?
Has the claimant filed?
Does the claimant expect to file in the future?
This is a very error prone issue.
Follow the instructions in DI 52140.001 to identify potential WC/PDB offset situations during the disability interview and when reviewing the application.
A. Obtain WC/PDB information in the disability interview
The MCS DISB screen asks if the number holder (NH) filed or intends to file a claim for WC/PDB. This question must be answered completely. It is not sufficient to only ask if the NH was injured on the job. This also applies when a paper SSA-16 application is submitted. If a claim was or will be filed, ascertain the carrier and WC attorney (if applicable) and document MCS (even if payment has not yet been made or if the NH does not know the amount of the payment).
After identifying receipt of WC/PDB, ask the NH if the payment is reduced for any medical expenses, attorney fees etc., that may be excluded from offset.
1. NH provides alleged WC/PDB rate
Complete WC/PDB screens in MCS or obtain paper Form SSA-546 (Workers’ Compensation/Public Disability Benefit Questionnaire).
Obtain a signed paper Form SSA-1709 (Request for Workers’ Compensation/Public Disability Benefit Information) from the NH if the NH is unable to provide evidence of the WC/PDB benefit they allege.
Verify WC/PDB payments from outside sources only if the NH cannot or will not provide verification.
2. WC/PDB rate unknown
If the NH is receiving WC but provides no proof and alleges no rate, impose offset at the State maximum using the chart in DI 52150.045 - States’ Maximum WC Benefits Chart.
Develop for proof of WC/PDB post-adjudicatively.
Be sure to follow-up to determine if proof is eventually received.
3. NH not filing for WC/PDB
Inform the NH that entitlement to WC/PDB may affect the amount of Social Security disability insurance benefits payable to the NH and his or her family.
Explain that, in attesting to the application, the NH is agreeing to the reporting responsibilities if WC/PDB is paid in the future.
4. Discrepant WC/PDB answers
If the work-related question is answered “yes,” but the filing question is answered “no”:
Obtain an explanation from the NH or the employer.
Determine if a claim will be filed if the NH has not filed a WC claim.
Document MCS RPOC screen or the EF with the responses.
5. NH alleges Sick Pay
If the NH alleges sick pay but the impairment appears to be work-related, obtain verification/proof from the employer to determine the true nature of the payments. Document the EF with your findings.
6. WC/PDB claim denied
If the WC/PDB was denied less than one year prior to the first possible month of offset and no appeal was filed:
Document MCS RPOC screen or the EF with the responses.
Use the DIAR screen to record the reason for the denial.
If the claim requires an A101 or EF101, annotate the reason for the WC/PDB denial on the Remarks screen.
B. Complete the WC/PDB common screens in MCS
When a response is provided on the DISB screen indicating the NH has filed or intends to file for WC/PDB, the WC/PDB Claim Data (WPCL—MSOM COMMON 001.003) screen comes into the MCS claims path.
Complete the WPCL with all available information regarding the first WC or PDB claim. Additional screens are brought into the path according to how this screen is completed.
Complete the WC/PDB Claim Data Employer/Payer Name and Address (WPAD—MSOM COMMON 001.004) screen for all WC/PDB claims. Include as much information as possible regarding the employer as well as the address, contacts and information about the company or entity that is paying the WC/PDB.
Additional screens will come into the path as applicable:
WC/PDB Periodic Payments (WPPR—MSOM COMMON 001.005)
WC/PDB Periodic Payments Ongoing Expenses (WPOX—MSOM COMMON 001.006)
One-Time Only Excludable Expenses for Periodic Payments (WPEX—MSOM COMMON 001.007)
WC/PDB Lump Sum Award Data (WPLS—MSOM COMMON 001.008)
When the screens are completed for the first claim, the WC/PDB Selection Menu (WPMU—MSOM COMMON 001.002) appears in the path. If additional claims need to be added, enter Y in ADD NEW OCCURRENCE at the bottom of the screen.
After all claims are entered into the WC/PDB COMMON screens, the WPMU screen is used to select a specific claim for correction or update.
Once the WC/PDB COMMON Screens are established in MCS, they can also be viewed in the T2 SHARED DATA SCREENS.
For information about accessing T2 Shared data, see MSOM ICD 005.003.
There are occasions where it will be necessary to delete WC/PDB data from the claims path. Some examples are:
After loading the information, you find that the benefit is clearly NOT WC/PDB.
The WC/PDB event was in the past and, after doing the computation, you find the LS proration does not extend into this claim period.
The WC was repaid by a third party settlement.
The WC award was annulled on appeal.
To delete a specific claim, select the claim from the WPMU. On the WPCL enter Y after DELETE THIS CLAIM.
C. Preparing the repayment statement on the Remarks Screen (RMKS)
Any time you have an indication that the NH filed or intends to file for WC/PDB, include a repayment statement in the application or a signed SSA-795 with a repayment statement in file. Explain in the repayment statement that:
All changes in WC/PDB payments must be reported to Social Security immediately, and
The NH understands that failure to report changes could result in overpayment of benefits and that any overpayment must be repaid.
NOTE: See DI 52140.001F. for sample language for the repayment statement.