TN 13 (11-11)

GN 01010.360 Special Determinations for Claims Adjudication

A. Policy on special determinations

Sometimes during the adjudication process, the adjudicator discovers conflicting information that must be resolved and documented as a special determination before final adjudication is processed. You must resolve each issue independently when several discrepancies exist. Each issue requires a special determination that should reflect your decision’s rationale. You must summarize the evidence in file, explain the relative probative value of the evidence and document a conclusion.

B. Procedure for preparing special determinations

Whenever possible, record the special determinations electronically (e.g., report of contact (RPOC), remarks (RMKS), etc.) by following instructions on section B.3 of this chapter. Also, refer to GN 00301.288 for a list of documents and the appropriate coding to include.

All special determinations that include public documentation (e.g. birth certificate, divorce decree, etc.), must be annotated in the evidence (EVID) screen with the appropriate identifying data. See GN 00301.286 and MSOM EVID 001.001 for specific information about the evidence screen.

1. Types of special determinations

There are two types of special determinations:

  • Formal, and;

  • Informal.

2. Screens and forms used for special determinations

If the RPOC screen is available, use it to record the special determination. However, determinations may be recorded using paper forms if the electronic screens are not available.

  • General Use Forms:

    • SSA-553 - Special Determination;

    • SSA-5002 - Report of Contact; or

    • SSA-924 - Folder Documentation (processing center (PC) only).

NOTE: You must electronically store all paper determinations in the Claims File Records Management System (CRFMS) or electronic DIB folder (eDIB) as per GN 00301.322.

  • Specific Use Forms:

 

FORM NAME

FORM NUMBER

POMS
REFERENCE

  • Date of Birth Determination

  • SSA-2038-F3

  • Federal Determination of Error in State Wage Reports (in limited situations)

  • SSA-4500-U6

  • OS 15020.479

  • Disability Determinations

  • SSA-831-U5

  • Reconsideration Determination

  • SSA-662

  • Evaluation of Fee Petition

  • SSA-1560-U4

  • Waiver Determination

  • SSA-635

  • NOTE: You can use these forms alone or in conjunction with the MCS screens.

3. Report of contact (RPOC)

When using the RPOC screens to record a special determination, type in capital letters:

  • “SPECIAL DETERMINATION” in the RPOC PERSON CONTACTED field and “NONE” in the RELATIONSHIP/TITLE field;

  • The date the determination is made in the DATE CONTACTED field;

  • “3” in the HOW CONTACTED field; and

  • “N/A” in the SPECIFY/OTHER SPECIFY field.

Refer to MSOM MCS 008.007 and the NOTE in GN 01010.007C.3 for more detailed information about the RPOC screen.

4. Special Determinations for wages, self employment income (SEI) and coverage issues

The Item Correction (ICOR) process of the Earnings Modernization (EM) system processes adjustments to an individual's earnings record. ICOR provides several wage and SEI determination screens for justification of the earnings action taken.

You may request the appropriate determination screen, or depending on the “Basis for Change” code, it automatically propagates. Certain “Basis for Change” codes require a determination and if selected, it automatically propagates the appropriate determination screens. If more than, one issue is involved in the earnings adjustment (e.g., an employer or employee relationship or coverage issue and an earnings adjustment), discuss each issue with the claimant and document the justification. However, be aware that only one determination screen propagates to address all pertinent issues. For more information about ICOR screens, see MSOM EM 019.001 thru MSOM EM 031.001.

If you determined that there is no need to adjust the earnings record, prepare the special determination as instructed in GN 01010.360B.2 to explain the reason for no adjustment.

5. Who prepares special determinations

Field Offices (FO) adjudicators usually prepare the special determinations for both, claims and earnings discrepancy cases. However, in some situations, the PC has information not available to the FO, in those cases; the determination will be prepared in the PC.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0201010360
GN 01010.360 - Special Determinations for Claims Adjudication - 07/13/2012
Batch run: 07/13/2012
Rev:07/13/2012