Last Update: 2/12/09 (Transmittal I-2-73)
ODAR designates a case requiring special expedited 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.
These instructions are to guide the Hearing Office (HOs) and Regional Offices (ROs) in establishing a priority plan and procedures for processing the most serious claims first.
Use the Critical Request Evaluation Sheet (see HALLEX I-2-1-95) to evaluate the critical situation for purposes of expediting the case. The Evaluation Sheet is not to be used for determining the ultimate issue of disability.
Five (5) situations warrant instituting critical case processing procedures:
The claimant's illness is terminal (see subsection C., below) [TERI];
NOTE:
Do not attempt to verify allegations of terminal illness or Acquired Immunodeficiency Syndrome (AIDS).
The case involves a disability claim for any military service personnel injured October 1, 2001 or later regardless of how or where the disability occurred, whether in the United States or on foreign soil, provided that the individual was on active duty when the injury occurred (see subsection D., below) [MSCC];
The claimant's file is flagged as a Compassionate Allowance case (see subsection E., below) [CAL];
NOTE:
CAL cases are identified based solely on whether a claimant alleges a CAL condition. This identification is made by the Predictive Model at the initial claim level, but CAL cases can be identified at later levels if the claimant makes additional allegations or if evidence of a CAL condition is received. For a list of qualifying conditions, refer to: http://www.socialsecurity.gov/compassionateallowances/. It is important to note that while CAL cases are similar to TERI claims, not all CAL cases will involve terminal illness.
NOTE:
CAL cases should not be confused with Quick Disability Determination (QDD). QDD does not apply at the hearing level.
The claimant is without, and is unable to obtain, food, medicine or shelter [DIRE NEED];
A dire need situation exists when a person has insufficient income or resources to meet an immediate threat to health or safety, such as the lack of food, clothing, shelter or medical care.
The claimant must allege specific, immediate circumstances: (1) lack of food (i.e., without and unable to obtain food), (2) lack of medicine or medical care (e.g., the claimant expresses that he/she needs medicine/medical care but is without and unable to obtain it; the claimant does not have any health insurance, or indicates that access to necessary medical care is restricted because of lack of resources), and/or (3) lack of shelter (e.g., shut-off of utilities such that home is uninhabitable, homelessness, expiration of shelter stay, or imminent eviction or foreclosure with no means to remedy the situation or obtain shelter).
Absent evidence to the contrary, accept a person's allegation that he/she does not have enough income or resources to meet an immediate threat to his/her health or safety. If the allegation is suspect or questionable, request confirmation through the servicing SSA field office (FO) and request verification before designating the case critical. If circumstances change and the situation is no longer critical, the designation can be removed.
Situations may arise in the processing of claims that will require individual consideration and judgment with regard to the expediting of such cases. Dire need situations fall in this group. Although many disability cases could be described as “hardship” situations and many claimants have limited resources, designating all cases critical would defeat the effectiveness of any priority plan for the processing of the most serious claims. Therefore, the designator must review the known facts of a given case, and consider the estimated time in which such a case might be expected to be processed relative to the pending workload, i.e., whether additional development or consultation is required, etc. For example, if routine handling (processing in order of request for hearing date) would result in undue delay in processing a dire need case, such case should be given priority. Err on the side of expediting versus not expediting. If a dire need situation becomes non-critical, the critical designation can be removed or modified.
There is an indication that the claimant is suicidal or homicidal (see NOTE, below) [SUICIDAL/HOMICIDAL].
NOTE:
Additional guidance for suicidal or homicidal claimant situations: If a claimant threatens suicide or homicide, immediately notify, through designated channels, the Office of the Regional Commissioner with jurisdiction over the claim. (See I-2-1-37 for additional information about handling such threats.)
NOTE:
If there is congressional interest in the case, the HO must also follow the instructions and procedures found in HALLEX I-1-6-1 (Congressional Inquiries at Hearing Offices). These instructions require prompt response to the congressional or public inquiry. The congressperson can be the source of an allegation for a critical designation, and the HO must consider and respond to such requests promptly and courteously. Document all contacts in the CF and ALJ file.
A critical case involving a terminal illness (a “TERI” case) requires additional special handling. ODAR tracks a TERI case while it is within ODAR, and the SSA Regional Office also monitors these cases to ensure that they are expedited.
TERI cases include any case already identified as a TERI case (in CPMS or by the special “TERI CASE” flag, Form SSA-2200), when received by the HO. Additionally, TERI cases may be identified by situation or condition. The criteria used to identify a TERI case can be referenced at POMS DI 11005.601:
NOTE:
The list shown on the TERI Flag (i.e., SSA-2200 [TERI Case]), is not intended to be all-inclusive. Use it to provide general guidance in the identification of TERI cases. Also, please note that the presence of one of the criteria does not mandate a finding of disability. The finding of disability must be based on evaluation of the claimant's impairment under the sequential evaluation process.
The procedures to expedite disability claims apply to any military service personnel injured October 1, 2001 or later regardless of how or where the disability occurred, whether in the United States or on foreign soil, provided that the individual was on active duty when the injury occurred.
The term “active duty” applies to:
Individuals on full time duty in the U.S. Army, Navy, Air Force, Marine Corps, or Coast Guard and includes active duty for training;
Students at U.S. Military, Naval, Air Force, or Coast Guard academies;
National Guard components of the U.S. Army and the U.S. Air Force ordered to active federal full time duty by the President of the United States in times of war or national emergency;
Reserve components of the U.S. Army, Navy, Air Force, Marines, and Coast Guard and includes active duty during full time training duty, annual training duty, and attendance while in the active service at a school designated as a Military Service School by law or by the Secretary concerned.
NOTE:
These cases should be processed using TERI procedures; however, these cases cannot be classified as TERI without the indication of terminal illness. A special Military Service Casualty Case (MSCC) flag has been developed. See I-2-1-96.
As with TERI cases, a critical case involving compassionate allowance (CAL) requires additional special handling. ODAR tracks a CAL case while it is within ODAR, and the SSA Regional Office also monitors these cases to ensure that they are expedited.
CAL cases include any case already identified as a CAL case (in CPMS, eView, or by specific designation on a paper folder) when received by the HO, or any previously undesignated case in which a newly identified disease or other medical condition would invariably qualify under the Listing of Impairments based on minimal objective medical information. The list of qualifying impairments can be found at: http://www.socialsecurity.gov/compassionateallowances/.
NOTE:
For Certified Electronic Folders (CEF), to determine if a previously denied claim was processed as CAL, look for the CAL:Y indicator in eView. If the HO discovers a previously undesignated case which now qualifies for CAL, the HO must change the CAL indicator in eView.
Within the Regional Office (RO), the Regional Chief Administrative Law Judge (RCALJ) or the Regional Management Officer (RMO) is responsible for designating a case as critical and ensuring that the critical case procedures are followed. All RO employees are responsible for bringing any cases which may meet the criteria in subsection B. above to the attention of the appropriate responsible official. The RMO will be the primary point of contact for all inquiries on TERI, MSCC, and CAL cases.
In the Hearing Office (HO), the Hearing Office Chief Administrative Law Judge (HOCALJ) or his or her designee (e.g., Hearing Office Director (HOD), Group Supervisor (GS) or assigned ALJ with express delegation from the HOCALJ) has this responsibility. If the case has not yet been assigned to an ALJ, the critical designation may be made by the HOCALJ, HOD or GS, as designated by the HOCALJ. If the case is assigned to an ALJ, the critical designation is made by the HOCALJ, assigned ALJ with express delegation from the HOCALJ, or by the HOD or GS, as delegated by the HOCALJ, in the absence or unavailability of the assigned ALJ (if the HOCALJ has delegated this authority to the ALJ). All HO employees are responsible for bringing any case which may meet the criteria in subsection B. above to the attention of the appropriate responsible official.
The HOCALJ is the ultimate point of contact for critical cases and issues related to critical cases. The HOCALJ has managerial authority over Administrative Law Judges (ALJs), even if the Critical Case Designator role has been delegated to another manager.
If the HO receives a designated critical case, or the HOCALJ (or designee) determines that a previously undesignated case is critical, the HO staff must attach to the front of a paper claims file (to each claims file in a concurrent case) either:
a completed Critical Case/Dire Need flag, (see HALLEX I-2-1-94), for all critical cases except TERI cases) or other visible and easily identifiable flag clearly marked and labeled “Critical Case”; or
a completed TERI CASE flag, Form SSA-2200, (unless the TERI case is already flagged when received); or
a completed Military Service Casualty Case (MSCC) Case Flag (See HALLEX I-2-1-96.)
NOTE:
Paper cases are not initially considered for CAL because CAL cases are identified via the predictive model upon EDCS transfer. However, if CAL is discovered on review of a paper claim, or upon the receipt of additional evidence in a paper claim, clearly document on a Critical Case/Dire Need Flag that the case is CAL.
In a CEF, if the HO receives a designated critical case, or the HOCALJ (or designee) determines that a previously undesignated case is critical, the HO staff must ensure that all appropriate electronic designations have been made in eView as well as CPMS.
Take immediate action to expedite the case (including a review of the case to determine if an on-the-record (OTR) decision is appropriate), and continue to expedite all actions taken while the case is pending:
Pre-hearing analysis and workup instructions are found in HALLEX I-2-1-5. These instructions provide guidance to determine whether critical case procedures are appropriate.
All employees who initially screen cases and mail are responsible for bringing potential critical cases to the attention of the Critical Case Designator (or, if unavailable, a person with the authority to act in his/her stead).
When a paper file is involved, the screening employee shall complete the Critical Request Evaluation Sheet (see I-2-1-95) and hand-carry the file and Sheet to the Critical Case Designator (or, if unavailable, a person with the authority to act in his/her stead) for a designation. In the case of a CEF, the screening employee shall use a “To Do Item” to alert the Critical Case Designator of the need for a critical case review.
If the case is designated critical by the appropriate official, the pertinent critical case information shall be entered into the Case Processing and Management System (CPMS) with the appropriate critical case characteristic.
Employees shall hand-carry paper cases to a member of the HO Management Team to assign the case for on-the-record (OTR) decision review. When a CEF is involved, the employee shall use a “To Do Item” to alert the appropriate employee of the need for an OTR review. If an OTR decision is possible, the case shall be assigned to a decision-writer for expedited writing.
If an OTR decision is not deemed appropriate, but if the case is designated critical, it shall be expedited for pre-hearing development and scheduling.
Some critical situations will arise while the case is pending at the Hearing Office at different stages of development or “workup” — preparation of the claim file for hearing.
If the claimant calls or walks in with an allegation of a critical situation, the Hearing Office employee receiving the call or contact shall complete a record of contact (RC), SSA-5002, and obtain as much information about the situation as possible, using the Critical Request Evaluation Sheet (see I-2-1-95). If necessary and appropriate, have the claimant complete an SSA-795, http://www.socialsecurity.gov/online/ssa-795.pdfh describing his/her critical situation. In a paper case, hand-carry the completed Evaluation Sheet with any supporting documentation to the Critical Case Designator (or acting Designator) for a designation. In the case of a CEF, associate the information with the file and create a “To Do Item” for the Critical Case Designator (or acting Designator) for a designation.
If a critical allegation is received by fax or mail, the Hearing Office employee who handles the mail or is responsible for associating the mail with the case file (whether paper or electronic) shall fill out the Critical Request Evaluation Sheet based on the written allegation. Using the procedures noted above, the employee shall either attach the allegation to the Critical Request Evaluation Sheet and hand-carry the file and completed Sheet and documentation to the Critical Case Designator for a designation, or properly associate the information with the CEF and create a “To Do Item” for the Critical Case Designator (or acting Designator) for a designation.
When a critical case is ready for scheduling, the employee responsible for workup or development shall hand-carry a paper case or create a “To Do Item” in the CEF for the scheduling employee for priority scheduling.
Schedule critical cases in the first available open hearing slots after consultation with the claimant and/or his or her representative and coordination of any expert witnesses (if applicable). If previously scheduled hearing slots become available due to cancellation or rescheduling, the critical claimant(s) should be given the option of appearing for the newly available hearing slot. If there are less than 20 days before the hearing date, the claimant's case should be scheduled only if the claimant and/or his or her representative are willing to waive the right to the 20-day advance notice of hearing in writing.
Expedite critical cases for decision writing after a hearing.
Complete post-hearing development or review in an expedited manner (i.e., immediate action on requests, shorter diary follow-ups, etc.)
For paper cases, ensure that the correct flag is completed and accurate, including representative fee information, if available. To designate a TERI case, use the Form SSA-2200. MSCC cases are marked with a Military Service Casualty Case (MSCC) Case Flag (see HALLEX I-2-1-96). When CAL is discovered on a paper case, use the Critical/Dire Need flag (see HALLEX I-2-1-94), clearly documenting that the case involves CAL. For electronic folders, the HO staff must first ensure that all appropriate electronic designations have been made in eView.
Enter the appropriate case characteristic (TERI, MSCC, or CAL) in the Case Processing and Management System (CPMS); and
Clearly mark “TERI Case,” “MSCC Case,” or “CAL Case” on any transmittal forms or envelopes used to forward the claim or any information to another component. For automatically generated transmittals, verify that TERI, MSCC, or CAL identification is noted.
In CPMS, select the appropriate critical case characteristic (TERI, MSCC, CAL, Suicidal, Homicidal, Dire Need Case, etc.) and also note that the case is “Critical” for listing type. For cases with congressional inquiries, the case characteristic and listing type of “Congressional” should also be entered into CPMS.
The date of designation should be entered under “Start Date”.
The HO Management Team is to monitor and track the HO's progress in processing critical cases. HOs may alter normal case processing procedures if such action will expedite payment of benefits (e.g., splitting a concurrent case to issue a favorable SSI decision when the title II claim requires development).
Each HO will maintain a list of its critical cases for internal monitoring, tracking and reporting purposes. The HO may also be required to issue reports to other components from time to time for review or information purposes. The list must show the date (month/day/ year) the case was designated as critical, the claimant's name and social security number, the designating office, the reason for the critical designation, and the current status of the case. If applicable, the reasons why the status of a particular case has not changed for an inordinate period of time (i.e., beyond benchmarks) should be captured in the “Remarks” section in CPMS.
Each RO will monitor the HO's list of critical cases (within their jurisdiction) and the HO's compliance with critical case handling procedures. If the RO itself is handling a critical case, RO staff will follow the procedures set forth in I., above, to track the case in the RO.
When an ALJ is prepared to issue a final disposition on a critical case, proceed as follows:
If the ALJ issues a fully or partially favorable decision on a critical case, the HO will:
Expedite preparation and release of the decision; and
Send the file to the effectuating component. For paper cases, use the most expeditious method practical to send the file to the effectuating component (e.g., express mail).
For paper cases, use the following addresses for critical cases not involving terminal illness (Critical Cases) and critical cases involving terminal illness (TERI cases) being sent to the Office of Disability Operations (ODO) for effectuation:
|
Critical Cases |
TERI Cases |
|
SSA ODO, Critical Case Unit 1500 Woodlawn Drive Baltimore, Maryland 21241 |
SSA ODO, TERI Case Unit 1500 Woodlawn Drive Baltimore, Maryland 21241 |
For all other cases (including TERI cases being sent to Program Service Centers), use the standard effectuating component addresses.
If the ALJ issues a dismissal or an unfavorable decision, the HO will:
Expedite preparation and release of the decision or order; and
Follow standard procedures for claims file routing.
HO or RO staff may remove the critical designation and discontinue tracking a case other than a TERI case when the condition(s) which formed the basis for the critical designation no longer applies. Offices may not remove TERI case flags or cancel TERI designations.
If an HO or RO decides to discontinue monitoring a critical case (other than TERI) or remove a critical designation, the reason for the action must be annotated in CPMS in the “Remarks” section.
NOTE:
Although rare, there may be occasions to remove a case from CAL processing. For information in addition to that noted below, refer to DI 23022.055B.
Reasons for removal include (but are not limited to):
The medical evidence did not confirm a CAL condition. For example, a claimant may allege a new CAL condition when requesting a hearing. However, the designation may be removed if a review of the medical evidence does not support the allegation.
The designation is removed to revise or correct condition(s). There is no functionality to modify conditions. As a result, a case must be removed from CAL and then reinstated where the updated CAL conditions applicable to the case will be selected.
The system mistakenly identified a CAL condition. Occasionally, the system may pick up a particular CAL condition but, upon further review, it is discovered the condition is not a CAL condition for the claimant. For example, the allegation may belong to another family member as recorded in the remarks section.
However, certain cases that have been removed from CAL processing can be reinstated. Reasons for reinstatement include (but are not limited to):
A CAL condition needs revision. There is no functionality to modify conditions. As a result, a case must be removed from CAL and then reinstated.
A CAL condition is mistakenly removed.
Previous MER did not substantiate the CAL condition but subsequent MER received after removal confirms the CAL condition.