TN 2 (02-06)

DI 13050.055 Medical Determination for Expedited Reinstatement

A. Background

When a medical determination is needed on an individual's request for expedited reinstatement (EXR), the FO will assemble the folder and, if necessary, forward the request to the appropriate DDS.

B. Procedure - FO

1. Folder Assembly

Place the EXR material in a modular disability folder (if necessary) and attach to the prior folder. See DI 70005.005 and DI 70010.001 for the appropriate folder assembly policy. If the prior folder cannot be found, follow the procedures in DI 13015.080 and DI 13015.090.

2. Collateral Estoppel

Collateral estoppel cannot be applied to EXR cases. All EXR cases that require a medical determination must be sent to the DDS. The DDS must make the medical determination that the impairment is the same as or related to the impairment that was the basis for the previous entitlement, and then make a determination that the individual is disabled based on the MIRS standard. Therefore, collateral estoppel procedures can not be applied.

3. DDS Decision Needed

If a DDS decision is needed, the FO will forward the file to DDS as follows:

  • Flag the front of the EXR folder to alert the DDS. Use the flag provided in DI 13050.105, Exhibit 4.

  • Transfer jurisdiction of the EXR case on the DCF and create an EXR issue on the DCF development worksheet (the CDRW ) screen per DI 13010.605.

  • For title II: Prepare a SSA-1418 transferring the file to the DDS, using the standard coding for transferring a medical CDR to the DDS (use type codes AM, CM or WM, as applicable).

  • For title XVI: When the DDS receipts the EXR case, the NDDSS will establish the CDR action.

  • Forward the prior file with the EXR request to the DDS.

C. Procedure - DDS

This section is intended to provide the FO with information about DDS EXR processing. For a more complete explanation refer to DI 28057.000.

  • The DDS determines whether the individual's current impairment is the same as or related to the impairment that led to the previous entitlement to, or eligibility for, disability benefits or payments. The DDS finds in the claimant's favor unless the medical evidence clearly indicates otherwise.

  • If the DDS decides that the current impairment is the same as or related to the impairment that led to the previous entitlement to, or eligibility for, disability benefits or payments, the DDS then determines if the individual is disabled based on medical improvement review standards (MIRS) and, if so, establishes the month of entitlement for title II EXR cases.

  • If the individual meets the EXR medical requirements the DDS prepares a SSA-832/833 and faxes the decision to the FO to expedite processing (or uses a locally arranged method to expedite the processing) (see DI 13050.060 for FO allowance processing).

  • If the individual does not meet the EXR medical requirements, the DDS prepares an SSA-832/833 determination that includes the reason for denial (same as or related or MIRS). The DDS includes in the file the personalized language the FO needs to issue the denial notice.

  • The DDS inputs to the NDDSS to record the decision and return the folder to the FO per DI 28057.000. The DDS should NOT send any EXR cases directly to OCO/PC.

NOTE: The DDS will not issue a decisional notice to the individual requesting EXR. The FO will issue denial notices and OCO/PC will issue award notices.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0413050055
DI 13050.055 - Medical Determination for Expedited Reinstatement - 02/16/2006
Batch run: 01/27/2009
Rev:02/16/2006