Last Update: 9/08/05 (Transmittal I-3-36)
OHA designates a case requiring special processing for one of the reasons listed in subsection B., below, a “critical case” to ensure that the appropriate component(s) takes prompt action on the case.
Four situations warrant instituting critical case processing procedures:
The claimant's illness is terminal (see subsection C., below);
The claimant is without, and is unable to obtain, food, medicine or shelter;
There is an indication that the claimant is suicidal or homicidal (see I-2-1-37); or
The case has been delayed an inordinate amount of time and there is a public, congressional or other high priority inquiry on the case.
NOTE:
OAO management staff will meet quarterly with Division of Congressional and Public Inquiries (DCPI) management staff to review current OAO workloads and will determine the “inordinate delay” timeframe.
A critical case involving terminal illness (a “TERI” case) requires additional special handling. OHA tracks a TERI case while it is within OHA, and the SSA Regional Office also monitors the case to ensure that it is expedited. TERI cases include any case already identified as a TERI case by the TERI Flag (form SSA-2200), when received, and any case involving:
An allegation (e.g., from the claimant or a friend, family member, doctor or other medical source) that the claimant's illness is terminal;
An allegation or diagnosis of AIDS;
A claimant registered in a Medicare designated hospice or receiving hospice care (e.g., in-home counseling or nursing care); or
A claimant with a condition which medical records indicate cannot be reversed and is expected to end in death. Such cases include (but are not limited to) those involving a claimant:
with a chronic dependence on a cardiopulmonary life-sustaining device;
awaiting a heart, heart/lung, liver or bone marrow transplant (excluding kidney and corneal transplants);
with chronic pulmonary or heart failure requiring continuous home oxygen and who is unable to care for personal needs;
with a malignant disease (e.g., cancer) who is home confined or institutionalized, unable to care for personal needs and unresponsive to therapy;
with diabetes and one or more of the following: multiple amputations due to diabetic gangrene; recurrent cardiovascular events (e.g., infarction or failure); or recurrent cerebrovascular events with neurological deficit;
with chronic liver disease (e.g., cirrhosis or hepatitis) and a history of massive gastrointestinal hemorrhage;
who is comatose for 30 days or more; or
who is a newborn with a lethal genetic or congenital defect.
The presence of one of the above criteria does not mandate a finding of disability. The claimant's impairment must be evaluated under the sequential evaluation process.
Within OHA Headquarters, the Division of Congressional and Public Inquiries (DCPI) is responsible for designating a case as critical, initiating critical case procedures, and requesting expedited payment from the SSA effectuating component, if necessary.
All OHA Headquarters components are responsible for alerting DCPI of any case, not previously identified, which appears to meet the critical case criteria; expediting and hand-carrying all cases designated as critical; and advising DCPI of completed processing actions or delays in processing.
Critical cases (other than TERI) are identified by a Critical Case/Dire Need flag (I-3-0-93 Exhibit). TERI cases are identified by form SSA-2200, a TERI flag (I-3-0-92 Exhibit).
Within OAO, the Branch Chief is responsible for ensuring that the critical case procedures are followed. All OAO branch staff are responsible for bringing any case which may meet the criteria in subsection B. or C., above, to the attention of the Branch Chief.
Upon receipt of a flagged critical (including TERI) case, the branch chief will immediately:
Ensure that DCPI is aware of the case; and
Commence expedited processing, as described below.
Upon receipt of critical case information newly raised during the time that a case is pending in OAO, the branch chief will ensure that such information is hand-carried to DCPI. (In the case of a telephone report, a report of contact describing the telephone conversation will be provided to DCPI.)
Following designation of a critical case (including TERI) by DCPI, the branch chief will immediately assign the case and ensure that OAO branch staff:
Attach to the front of the claims file (to each claims file in a concurrent case) a Critical Case flag (see I-3-0-93 Exhibit) or a TERI flag (see I-3-0-92 Exhibit), as appropriate;
Expedite processing by immediately working the case and hand-carrying it between processing stages; and
Advise DCPI of any delays in processing.
For TERI cases, OAO branch staff will also:
Ensure that the TERI flag is completed and correct, including attorney fee waiver information, if available;
Send a photocopy of the TERI flag to DCPI;
Enter “TERI Case” into the OAO tracking system; and
For TERI cases first identified in the branch, immediately notify the SSA field office to begin non-medical development.
NOTE:
When routing TERI cases to another component or office, clearly annotate transmittal slips/envelopes “TERI Case” and send the case via the most expeditious means practical (e.g., hand-carrying, express mail, SSA Central Office shuttle).
If the Appeals Council issues a fully or partially favorable decision, the branch chief will advise DCPI of the Appeals Council's action and follow DCPI's instructions on routing. DCPI will ask that the OAO Branch either mail the case to the effectuating component, or hand-carry it to DCPI so DCPI can arrange immediate payment. If the case is sent to the effectuating component, the Branch Chief will ensure that branch staff:
Hand-carry the case to the mailroom to be sent to the effectuating component, using the address supplied by DCPI, by the most expeditious means practical (e.g., express mail service, SSA Central Office shuttle); and
For TERI cases, clearly annotate all transmittals and envelopes “TERI Case.”
In a court case, if a certified administrative record (CAR) is needed because the Appeals Council is issuing a partially favorable decision (i.e., in a sentence 6 case), the Branch Chief will hand-carry the case to the Court Case Preparation and Review Branch to have the CAR prepared. If OAO is mailing the case for effectuation, the CAR will be prepared before mailing. If DCPI is arranging immediate payment, the CAR will be prepared after DCPI makes these arrangements, but before DCPI forwards the file to the effectuating component. All these actions will be taken within 24 hours of issuance of the decision.
NOTE:
The TERI case flag may not be removed. DCPI will continue to monitor processing until all retroactive benefits, if any, have been paid.
If the Council's action is unfavorable, the branch chief will notify DCPI, ensure that OAO branch staff promptly release the decision or order and follow normal procedures for distributing copies of the Appeals Council action, arranging preparation of the CAR (in a court case), and/or retaining the file(s).
If the Appeals Council issues a remand to an ALJ, the Branch Chief will notify DCPI, expedite standard procedures for releasing the remand order, and forward the file(s) to the hearing office by the most expeditious means practical (e.g., express mail). For TERI cases, clearly annotate all transmittals and envelopes “TERI Case.”
DCPI may remove the critical designation and discontinue tracking a critical case other than a TERI case when the condition(s) which formed the basis for the critical designation no longer applies. Neither DCPI nor OAO may remove TERI case flags or cancel TERI designations.