DI 42548.008: Claim Review
Effective Dates: 04/08/2013 - Present
- TN 1 (11-00)
- DI 42548.008 Claim Review
- A. Policy
- 1. Timeframes
- All denials/terminations adjudicated during the period covered by Hyatt (7/7/81-11/14/91) must be considered except those claims described in DI 42548.001B.3.
- 2. Place and level of review
- The place and level of review of Hyatt claims is outlined as follows:
- * DDS review:
- * Class members whose claims were decided last by the DDS are reviewed in the North Carolina DDS (NCDDS);
- * The claim is adjudicated at the reconsideration level; and
- * The next level of appeal after DDS review is the ALJ hearing. See DI 42548.015 for a detailed description of appeal rights.
* ODAR Review - claims decided last by an ALJ, the Appeals Council, or Federal court are returned to ODAR for a new hearing by an ALJ with full appeal rights. * Claims Consolidation - See DI 42548.009 for routing instructions when a current claim is pending in the DDS or ODAR. (OCO is not responsible for retrieving and consolidating folders pending in the DDS or ODAR.)
- NOTE: Class members with more than one class claim, will have their claims adjudicated by an ALJ if at least one of the claims was finally decided by an ALJ, the Appeals Council, or a Federal court.
- B. Procedure
- 1. No record of filing
- Take the following action if there is no record of filing a claim on the DDBQ, MBR or SSR under the SSN provided by someone who seeks relief under Hyatt.
- * Send a copy of Exhibit 4, DI 42548.095 to the responder. Send a copy of the notice and the alert-query package to the OPB/LS.
- * Use the OPB/LS address as the return address on the envelope:
- Office of General Counsel Correspondence Control Staff Altmeyer Room 617 6401 Security Blvd. Baltimore, Maryland 21207 Attn: Class Action Coordinator
- * If a response to the letter mistakenly comes into OCO/PSC forward to OPB/LS.
- 2. Lost folders
- Take the following action when one or more claims for a responder cannot be found.
- * Review systems information to determine if queries clearly establish that the Hyatt III relief is clearly inappropriate, i.e., no application for DIB filed, no final medical denial/termination decision by a NC adjudicator [DDS /ALJ/AAJ] between 07/07/81 and 11/13/91 based on fraud, SGA, or any other exclusions identified in DI 42548.001B.3.
- * Forward the holder and any available folders to Litigation Staff at the address shown in DI 42548.008B.1.b. with an SSA-559 explaining why claimant meets the exclusions. The FO must reconstruct any missing class member claims.
- * Take the following actions where any class member claim must be reconstructed by the FO.
- * * Prepare an SSA-559 to the FO and identify the claim(s) that must be reconstructed .
- * Staple the SSA-559 to the front of the folder.
- * Annotate the alert “UTL prior claim – FO (FO code) requested to reconstruct.”
- * Scan Reconstruction information into CATS and add servicing FO code to alert location.
- * Send the case to the servicing FO for reconstruction of the disability material.
- 3. Late responders
- Annotate CATS alerts for individuals who respond more than 125 days after the notice date will be annotated “Late Responder - Good Cause
- Development Necessary.”
- * If good cause is established follow DI 42548.009B.
- * If good cause is not found, request the FO to notify the claimant and, if necessary, make a “good cause” determination in accordance with GN 03101.020.
- * If good cause is not established, the FO sends “Good Cause Denial” notice (DI 42548.095, Exhibit 9) and returns title II folders to the appropriate PC for return to the permanent storage location.
- NOTE: It can be assumed that individuals with mental impairments have good cause established.
- 4. Subsequent partially favorable determination/decision
- If the determination/decision on a subsequent claim results in a partially favorable determination/decision as to the Hyatt III claim, a new Hyatt III determination/decision is still needed to reopen and adjudicate the earliest Hyatt III claim. This means that if claimant files a subsequent claim alleging:
- * the same onset date in the subsequent claim as alleged in the earliest Hyatt III claim, regardless of whether or not he/she later amends the onset date in the subsequent claim to a later date; or
- * a later onset date in the subsequent claim than alleged in the earliest Hyatt III claim,
Forward the Hyatt III claim to either ODAR or the DDS for adjudication. See DI 42548.009 for the case routing.
- REMEMBER THAT THE HYATT III DETERMINATION/DECISION CANNOT RESULT IN A LESS FAVORABLE DISABILITY ONSET THAN THE SUBSEQUENT CLAIM.
- NOTE: ANY ADDITIONAL BENEFITS DUE CLAIMANT UNDER HYATT III AS A RESULT OF THE PARTIALLY FAVORABLE DETERMINATION/DECISION ON THE SUBSEQUENT CLAIM, WILL BE PAID AFTER THE EARLIER CLAIM IS REOPENED AND A NEW DETERMINATION/DECISION IS ISSUED.
- 5. Subsequent fully favorable determination/decision – no reopening
If the determination/decision on the subsequent claim established disability beginning with the earliest onset date alleged in the earliest Hyatt III claim, even if the determination/decision on the subsequent claim reopened the Hyatt III claim, forward the folder to the DDS/ODAR for completion of the Hyatt III Favorable Determination/Decision Worksheet and Transmittal. See DI 42548.095, Exhibit 14.
x← This means that the line was removed and was added – in other words, the "Effective Dates" line at the top of the document has been updated to reflect that the new version is effective as of the date the change was made.