DI 11010: Initial Disability Claims Processing
TN 57 (07-16)
The field office (FO) has adjudicative responsibility for all Title II disability technical denials, pre-effectuated withdrawals, and claims not requiring a disability determination.
A. Technical denials and abatements
The FO may make a technical denial determination in the following situations. For coding of technical denial codes, see SM 00380.040 - Non-Disability Disallowance, Abatement and Withdrawal Codes-Exhibit.
1. Insured status requirements not met
For more information, see:
RS 00301.120 DIB Insured Status
RS 00301.160 Insured Status Based on Medicare Qualified Government Employment
NOTE: Ensure that all lag earnings are developed before denying a claim for uninsured status. See RS 01404.005 - Lag Period-and Lag Earnings for full instructions.
a. Earnings discrepancies
If a claimant’s record has an earnings or military service issue that affects insured status:
Develop earnings per RS 01404.003; and
Resolve the earnings issue using the Earnings Modernization 2.8 system - Item Correction Menu (EICM), see MSOM EM 010.004.
Deny the claim if the claimant does not meet the insured status requirements.
b. Claim for disability benefits filed after death
Deny claims filed after death if the number holder (NH) did not meet the insured status requirements on or before the alleged onset date (AOD) or potential onset date (POD).
c. AOD after date last insured (DLI)
For initial DIB, Freeze, and Medicare Qualified Government Employee (MQGE) claims, if the claimant’s AOD is after the DLI, and you cannot establish a POD before the DLI because of SGA-level work activity or other non-medical factors, process a technical denial.
Reminder: The POD is the earliest possible date the adjudicator should consider to establish the established onset date (EOD) based on non-medical factors. It may be the same as, earlier than, or later than the AOD. For information on POD refer to DI 25501.220.
d. Established onset date (EOD) after DLI
If the Disability Determination Services (DDS) allows a DIB, Freeze, or MQGE with an EOD after the DLI the FO should contact the DDS and:
Explain the issue to the examiner and discuss the possibility of establishing onset on or before the DLI;
If the DDS cannot establish an onset date on or before the DLI, return the case back to the DDS to revise the determination to a denial;
The FO will complete an electronic 5002 annotated with “EOD after DLI. Please reverse to a denial.” For paper claims document the paper SSA-5002 (Report of Contact) with: “EOD after DLI. Please reverse to a denial.”
NOTE: For CEF exclusions follow the instructions in DI 81010.030 Certified Electronic Folder (CEF) Exclusions and Limitations.
2. Claimant does not wish to pursue the claim or whereabouts are unknown
For FO instructions refer to DI 11018.005 Field Office Responsibilities When a Claimant Fails to Cooperate (FTC) and DI 11010.045 Claimant Cannot Be Contacted or Whereabouts Unknown or Claimant Does Not Wish to Pursue Title II Claim.
3. Claimant dies before claim sent to the DDS
If a claimant dies before the FO sends the disability claim to the DDS, abatement may be appropriate. For more information about abatement, i.e., disposing of an application without making a determination, see GN 01010.475 Abatements.
However, there may be situations in which we need more information to determine if the claim should be routed to the DDS for a medical determination. For information and instructions about these claims and the protective filing associated, see:
DI 11010.095 Claimant Dies Before Field Office (FO) Transmits Title II Claim(s), and
GN 00204.005 Claimant Dies Before Filing/Effectuation.
NOTE: Claim processing on a deceased beneficiaries record should only continue if someone is eligible to receive the deceased claimants’ underpayment. If there are, no potential claimants then follow normal abatement procedures.
4. Claimant dies after FO transfers disability claim to the DDS
When the claimant dies while the DIB, DWB, Freeze, or MQGE claim is pending at the DDS, the DDS will return the claim to the FO if the following apply:
the claimant’s death occurred during the waiting period; and
there is no possibility of an earlier onset date.
When the FO receives the case, take the following actions:
Verify the DDS examiner documented the SSA-831-U3 (Disability Determination and Transmittal), item 34 (Remarks): “Death in waiting period. No possibility of earlier onset.”
Verify the examiner signed and dated the SSA-831-U3 (Disability Determination and Transmittal).
Confirm the SSA-831-U3 (Disability Determination and Transmittal) is in the certified electronic folder (CEF) or paper folder. To access the SSA-831-U3 (Disability Determination and Transmittal) in the CEF, see the Case Documents Tab DI 81005.050.
Process the claim as an abatement according to the procedures in GN 01010.475
5. Disability applications filed by retirement or survivor insurance claimants
a. Filing 12 months or more after full retirement age
Deny DIB, freeze, or MQGE claims filed 12 months or more after full retirement age (FRA). A period of disability cannot be established if such period would have ended more than 12 months before the claimant filed an application. For coding of Modernize Claims System (MCS) denials see SM 00380.040 – Non-Disability Disallowance, Abatement and Withdrawal Codes - Exhibit.
b. MQGE claims with no prior period of disability
Deny MQGE claims if at the AOD the claimant:
is age 62 years and 7 months, and
did not have a prior period of disability that ended within 5 years before the current disability began.
c. Claims filed within 5 months of FRA
Deny claims filed by retirement or survivor insurance (RSI) claimants who allege disability within 5 months of FRA and no earlier onset is possible.
6. Prescribed period
Deny claims in which disabled widow(er)s (DWBs) do not meet the criteria (medical or non-medical) for disability within the prescribed period. For information on the prescribed period refer to DI 11005.050 - Prescribed Period and Controlling Date.
B. Procedures after the FO makes the denial determination
After you make the denial determination, review the claim and determine:
If a manual notice is needed. Prepare a notice using the Document Processing System (DPS). For detailed procedures on how to prepare notices for disability claims, see DI 11010.345; or
Use the FO Determination function to process the denial for CEF claims in the Electronic Disability Collect System (EDCS), see DI 81010.140; or
Retain the folder in the FO for paper cases per DI 11010.370; or
Route the folder to the processing center (PC) having jurisdiction based on the claim type per GN 01070.245.
C. Disability freeze
A disability determination is not necessary in situations when a favorable determination would not change the computation of a retirement insurance benefit (RIB).
Deny the freeze claim, and
Document the claim to explain why the DDS determination is not necessary.
DI 10105.025 - Basic Requirements Freeze
NOTE: For any RIB beneficiary where the benefit computation would change because of a freeze, forward the claim to DDS for a medical determination.
D. Res judicata denials
Res judicata applies at all levels of the claims process to prevent deciding on an issue that we have previously decided based on the same facts, issues, parties, and adjudicative period. For processing instructions of res judicata denials see DI 27516.001C.
It is important to address the same facts and issues and verify that the denial determination was made after the claimant last met insured status. For more information about res judicata, see GN 03101.160.
NOTE: Before using res judicata as the basis for denial, ensure all the conditions are met in DI 27516.001B Field Office (FO) Res Judicata Development and Processing.
For information about the FO’s responsibility in processing denials for Title XVI only claims, see: