DI 11055: Supplemental Security Income (SSI) Disability Cases
TN 68 (07-14)
This section provides the field office (FO) procedures for processing presumptive disability (PD) or presumptive blindness (PB) cases.
A. PD/PB procedures
Based on the claimant’s allegation(s), information, or evidence obtained during or after the claims interview, determine if a finding of PD/PB applies or is likely based on the categories in DI 11055.231. If a claimant meets one of the criteria as a potential PD/PB claim, do the following:
document the PD/PB findings;
initiate PD/PB payment;
place evidence sent by the medical source in the folder for forwarding to the Disability Determination Services (DDS), if applicable; and
transfer the case to the DDS.
If evaluation of medical evidence of record (MER) is needed, e.g., to determine listing-level severity, request MER from the medical source. For FO evaluation of MER for certain PD/PB categories, see DI 11055.240A.2. in this subsection.
1. Third-party contacts
To acquire opinions from third-party contacts regarding an alleged illness that may meet a PD/PB category, you must:
explain the PD or PB procedures to the claimant and the need to contact the source to verify the allegation to make a presumptive finding; and
ask the claimant or person filing on the claimant’s behalf for the name and telephone number of a reliable source who is able to verify the allegation to determine if a PD/PB criterion is met.
Reliable sources could be public or private schools, social agencies, the clergy, or other members of the community having knowledge of the claimant’s condition based on frequent contacts or a long-term association with the claimant. Take the following actions:
contact the appropriate source to determine if the PD/PB criterion is met;
record the information on the Modernized Supplemental Security Income Claims System (MSSICS) Report of Contact (DROC) screen or Form SSA-5002 (Report of Contact); and
upload or barcode and fax the SSA-5002 into the Electronic Disability Collect System (EDCS).
NOTE: If the official folder is a paper modular disability folder (MDF), add the SSA-5002 to the paper folder.
2. Evaluating MER for certain PD categories
When you receive MER in the FO, fax the documents into the certified electronic folder (CEF). Follow your Regional guidelines regarding page limits. For faxing instructions, see DI 81010.090.
a. Documenting MER received in the FO
b. MER received from at least one acceptable source
If MER from one or more acceptable medical sources (DI 22505.003A) is received and it permits a PD/PB decision, initiate PD/PB payments without awaiting receipt of outstanding MER from other sources.
c. Incomplete, inconclusive, or conflicting MER
If MER is incomplete, inconclusive, or if more than one piece of MER is being evaluated at the same time and the evidence conflicts as to whether or not PD/PB criteria are met, do not initiate PD/PB payments.
B. Documenting when PD/PB findings are not met
When the claimant does not meet one of the PD/PB categories in DI 11055.231 and you cannot make a PD/PB finding, you must document why the:
alleged impairment is not observable; or
observations are inconsistent with the allegations; and
PD or PB payments are not being made.
EXCEPTIONS: For claims involving human immunodeficiency virus (HIV) infection, follow the procedures in DI 11055.241. For claims involving PD category 11, 13, 14, or 16 (see DI 11055.231), the required criteria are in the category description and no further observation or confirmation is necessary.
Take the following actions prior to DDS case transfer:
Record the information on the DROC screen in MSSICS. For details about the DROC screen, see MSOM MSSICS 022.010.
Annotate on the Remarks screen of the Form SSA-3367-F5 (Disability Report – Field Office) in EDCS: “FO could not make PD/PB finding. See PD/PB flag remarks for additional information;” and
Add the PD/PB flag to the CEF and annotate on the Remarks section how you came to that conclusion.
NOTE: For claims excluded from EDCS, attach Form SSA-408 (Route Slip) to the paper MDF. Annotate “Expedite – FO PD (or PB) finding could not be made.”
C. Documenting the CEF when PD/PB findings are met
Prior to DDS case transfer, document a PD/PB finding by following the procedures:
Enter “#2” (presumptive disability) in the disability decision field on the Disability Data (ADIB) screen. For details, see MSOM MSSICS 008.010.
Enter the date when PD/PB was established in the presumptive onset date field on the ADIB screen in MSSICS. Examples to assist in determining the correct date for PD/PB are provided in DI 23535.010C.
REMINDER: Do not enter a PD or PB onset earlier than the month in which the claimant filed his or her application.
Select the PD/PB category on the SSA-3367 in EDCS.
Include payment status (i.e., non-medical eligibility factors met/not met).
If the FO determined that the claimant meets the non-medical eligibility factors, initiate the PD/PB payment immediately.
If the FO has not yet determined if claimant meets the non-medical eligibility factors, expedite the outstanding development and initiate the PD/PB payment upon completion, if applicable.
Add the “Presumptive Disability/Blind” or “Presumptive Disb” flag in EDCS and include information about the PD/PB finding in the Remarks section provided.
NOTE: Add a terminal illness (TERI) flag in addition to the Presumptive Disb flag if the case meets the criteria listed in The Disability Interview – Identifying Terminal Illness (TERI) Cases in DI 11005.601C.
D. Documenting EDCS exclusion cases and MSSICS cases when PD/PB findings are met
Complete the following steps prior to DDS case transfer when a case is excluded from electronic processing.
1. Record the PD/PB finding on the SSA-831-C3/U3 – MSSICS exclusion
For claims involving MSSICS limitations or exclusions, complete the following items on the SSA-831:
a. Items 11A and 11B
Enter “01” on line 11A; and
Enter the PD/PB category from subsection DI 11055.231 on line 11B.
b. Items 15A or 18B
Enter “PD” in Item 15A; and
Enter “PB” in Item 18B.
c. Item 34
Enter the following in Remarks: “FO PD (or PB) finding.”
If the claimant meets the non-medical criteria and you are initiating 6 months of PD/PB payments, also enter “Non-medical eligibility formally established - PD (or PB) payments initiated.”
If you are also processing an Emergency Advanced Payment (EAP), enter: “Advance in amount of $ made on (specify date).” See SI 02004.005.
2. Record PD/PB findings on the paper SSA-3367-F5
If the claimant meets a PD/PB criterion in DI 11055.231, annotate the following on the SSA-3367-F5:
check the appropriate PD/PB block in Section 8; and
record the observations/perceptions in Section 9.
3. Alert the DDS of PD/PB finding
To alert the DDS of a PD/PB finding:
attach Form SSA-408 to the front of the paper MDF; and
annotate “Expedite - PD (or PB) finding by FO.”
REMINDER: Add a terminal illness (TERI) flag in addition to the Presumptive Disb flag if the case meets the TERI criteria listed in DI 11005.601C.
E. Procedure for initiating payment
Take the following actions if a financial emergency exists:
Transmit PD/PB data on the ADIB screen in MSSICS (MSOM MSSICS 008.010);
Initiate an EAP (DI 11055.245); and
Process the EAP via the Emergency Advance Payment (UPEP) screen in MSSICS (MSOM BUSSR 003.008).