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Dec 18 08 7:10 PM
Jun 20 11 3:54 PM
Disability Review Mailer
Maybe this will help a Veteran out
Who is sent a mailer?
The mailer is usually sent to beneficiaries who, on the basis of
statistical analyses called profiling, indicate a low probability of medical
improvement where a full CDR was done. This group is sometimes described simply
as “LOWs”. In some instances, other groups of beneficiaries may be sent
mailers. These groups are variously referred to as “HIGHs” or “MEDIUMs”, to
differentiate between the “scores” of those who profile as potentially
productive CDRs, or when combined as a group, they may be referred to as
“non-LOWs” or “not-LOWs”.
The answers to the questions and remarks on the mailer, and
relevant attachments to the form (e.g., medical evidence, work information),
are reviewed. The responses may show that the profile has not changed, in which
case a full CDR is deferred for LOW profile cases, or a full CDR is initiated
for MEDIUM or HIGH (not-LOW) profile cases.
Alternatively, the mailer responses may show that there is reason
to conclude that the profile has changed, in which case a full CDR usually
results for mailers on LOW profile cases, or a deferral action results in the
case of the MEDIUM and HIGH (not-LOW) profile cases.
Question sequencing on
The sequence of the questions on the two forms is different. They
Health Status (Same, Better, or Worse)
Discussion with Doctor re: Ability To Work
Interest in Vocational Services
deleted as of 10/2000
The sequence of questions on Form SSA-455-OCR-SM reflects the most
current design and processing policies; however, the older Form SSA-455 may be
used. Both versions are under review by private contractors; a single sequence
of questions and redesigned mailers will be prepared following completion of
The scannable mailer includes barcoded information as well as
three lines of scannable data on the front of the mailer, immediately below the
telephone number and claim number. These scanlines contain substantial
Scanline 1 –
Field 1 – Social Security Number under which the mailer is being
Field 2 – Beneficiary Identification Code (BIC) (Title II), or
Individual Recipient Identification code (ID) (Title XVI)
Field 3 – Year of beneficiary's birth
Field 4 – Year of most recent prior CDR
Field 5 – Primary and Secondary Diagnosis Codes
Scanline 2 –
Field 1 – Medical Diary Reason/Type
Field 2 – Concurrent Entitlement information
Field 3 – Profile Type (High, Medium, or Low)
Field 4 – Profiling SCORE (9999 is highest)
Field 5 – Report Period covered by the mailer
Field 6 – Scanning Form Identification Code (SFIC) (describes if
it is a first or second request mailer, whether it is Title II, concurrent,
or Title XVI-only, and whether the beneficiary prefers a non-English language
Field 7 – Servicing Processing Center
Field 8 – Servicing State Agency/DDS code
Field 9 – Servicing Field Office (FO) Code
Scanline 3 –
Field 1 – Servicing FO City Name
Field 2 – Servicing FO State
Field 3 – Servicing FO ZIP CODE
The DE/DEC/DC reviews all responses and any remarks
or attachments, and weighs the significance of missing responses to determine
if a deferral or a full CDR is appropriate.
Following are some guidelines for decision making
when reviewing questions 1 through 6.
It is also important to consider the profile. Check
field 3 of scanline 2 of the mailer or facsimile for an H (High), M
(Medium), or L (Low), or check the profile sheet for the word High,
Medium, or Low.
When there is conflict between the codes, give the
highest priority to the code on the mailer or facsimile.
If the case is being worked from a hard paper
SSA-455, or for some other reason a profile code is not provided, query the DCF
for the profile code.
The profile ranking should be factored into the
DE/DEC/DC decision, as should the automated recommended decision on the alert.
The DE/DEC/DC is not required to follow the suggested outcome; however,
profiling has been shown to be accurate in assessing the likelihood of medical
improvement. This means that for Low cases, there must be compelling
information to refer a case for a CDR, while for Medium and High profile cases,
there must be compelling information to warrant a deferral action.
Consider the following instructions when reviewing
the mailer responses:
SSA-455-OCR-SM, Question 1 (SSA-455, Question
1)--Have you worked for someone or been self-employed?
If the answer to question 1 (1)
Your action is:
All Profiles (High, Medium, or Low)–If the BET/DT reports WORK ON THE MBR
or WORK RESOLVED or EARNINGS UNDER TOLERANCE (Title II), or EARNINGS KNOWN or
UNKNOWN EARNINGS REFERRED TO FO (Title XVI), go to question 2, but consider
the automated recommended decision, and whether work activity suggests
possible medical improvement.
All Profiles (High, Medium, or Low)-Go to question 2
All Profiles-Go to question 2
SSA-455-OCR-SM, Question 2 (SSA-455, Question
4)--Have you attended any school or work training program(s)?
If the answer to question 2(4)
High or Medium-DO CDR unless the response to question 5
or 6 (7 or 6 on SSA-455) is “YES”, or the reviewer has other information
indicating medical improvement is very unlikely.
If the response to 5 or 6 is “YES”, weigh all information, especially
responses to questions 1, 3, and 4.
Low-Go to question 3
All Profiles-Go to question 3
SSA-455-OCR-SM, Question 3 (SSA-455, Question
3)--Have you discussed work with your doctor…?
If the answer to question 3 (3)
Your action is
HAVE NOT DISCUSSED
All Profiles-Go to question 4
High or Medium-DO CDR unless theDE/DEC/DC review raises
doubt about the response (consider DIRCON to resolve).
Low-Go to question 4
All Profiles – Go to question 4
SSA-455-OCR-SM, Question 4 (SSA-455, Question
2)--Describe your health now as compared to…?
If the answer to question 4 (2)
All profiles-DO CDR unless the DE/DEC/DC review raises doubt
about the response (e.g., is “better”, but information shows a severe mental
impairment continues, or that inpatient care or residency in an institution
continues, or is “worse” but reports recent work activity after bypass
Consider DIRCON to resolve.
High or Medium-DO CDR unless the review raises the same
types of doubts about medical improvement as discussed for a response of
Low-Go to questions 5 and 6.
All Profiles-Go to questions 5 and 6.
All Profiles-Go to questions 5 and 6
The following chart lists instructions for
responses to questions 5 and 6 of the SSA-455-OCR-SM (questions 7 and 6 on the
SSA-455). These questions both inquire as to different types of recent medical
treatment. The DE/DEC/DC may find it efficient to consider the responses
SSA-455-OCR-SM, Question 5 (SSA-455, Question
7)--Have you gone to a doctor or clinic...?
If the answer to 5 is:
Your action on all profiles is:
Check the profile sheet for information about the prior decision.
Knowledge can be gained from the following:
Date of birth
Date of onset
Date of initial decision
Date of latest decision
Reg basis code
Vocational rule met
Assess the importance of ongoing medical treatment, or its absence, to the
status of the condition. Read carefully the “how often” and “reason for
visit” narratives and draw any conclusions.
Consider any remarks or attachments that might address whether medical
improvement is or is not indicated.
Consider whether a telephone call to the beneficiary or representative
payee will provide further details.
For LOWS, recommend a DO CDR only if the narrative/telephone call
response(s) indicates there is possible medical improvement.
For HIGHS/MEDIUMS, take a DO CDR action unless the
narrative/telephone call response(s) indicates no likelihood of medical
All Profiles-If not explained on the form, obtain by DIRCON to the beneficiary
or representative payee the reason(s) for the lack of ongoing treatment,
especially if impairment codes are:
These impairments usually require continuous medical intervention.
Recommend a full medical CDR only if the DIRCON response indicates there
is possible medical improvement.
All Profiles-Go to question 6.
SSA-455-OCR-SM, Question 6 (SSA-455, Question
6)--Have you been hospitalized or had any surgery...?
If the answer to 6 is:
Your action for all profiles is:
All Profiles-Review dates and the narrative. Check the profile sheet to
determine the impairment(s) involved.
Assess the effects of hospitalization/surgery on the impairments.
Release for DO CDR only if the narrative indicates there is possible
medical improvement. Otherwise, DEFER.
All Profiles-DEFER if response to question 5 was “Yes” and there is no indication
of possible medical improvement.
All Profiles-DO CDR if question 5 is also answered “No” or there is no
response to question 5, and nothing in remarks or on an attachment indicates
there has been recent treatment or provides a credible reason for an absence
NOTE: Regarding versions of the
SSA-455-OCR-SM with question 7 (SSA-455, Question 5), or a VR? inquiry
below the signature line -- Do not consider this response.
Call up the IPCA screen on the DCF and select event
4 “DEFER CDR”.
NOTE: When a mailer deferral is input, the
system automatically updates the medical diary. The new diary is calculated
based on the old medical data in the DCF. If the medical data in the DCF (on
the left-hand side of the QMID) is blank or zeros, the system has nothing with
which to calculate the new diary. The medical data cannot be manually updated
via 15=MODIFY MEDICAL DATA because the systems requirements were written to
prevent user input in these situations.
Enter the pertinent medical information in the
REMARK screen. Do not open a new CDR path (using the DRES) and then close it
in order to enter the medical data because this creates a new history
screen indicating a full medical review was processed (which it wasn’t) and
results in inaccurate management information (MI).
NOTE: In those Title II or concurrent Title
II-XVI cases in which unresolved earnings equal to or less than
1/2 of the yearly SGA amount were reported (EARNINGS UNDER TOLERANCE LEVEL),
the DE/DEC/DC refers the case to the BET/DT for investigation of earnings per DI 40502.001J.2.c.
The profile sheet, the MEDICAL RE-EXAM REASON
section on the Query Medical Information Data (QMID) screen on the DCF, the MR
entry on the SSR, and the first field in the second scanline on the scannable
form SSA-455-OCR-SM contain this information. There may be multiple QMID
screens; typically, the most recent iteration is used.
In the event the diary types do not agree, use the
diary type on the profile sheet in the OD-CALC MDR: field. The diary type on
the profile sheet reflects the most accurate on-line information regarding the
diary type that was set at the CPD.
The DCF QMID, SSR MR, and scanline information may
be less accurate as a result of missing or intervening systems entries, but
should be used if no value is provided on the profile sheet or the mailer.
In the event that no MDR/MR is provided on any
database, use the default MDR/MR of “3”.
The following diary types and corresponding
MIE = reset for 18 months;
MIP = reset for 3 years;
MINE = reset for 7 years.
Some MINE cases have 5-year diaries. Reset these
MINE diaries for 5 years.
Read more https://secure.ssa.gov/poms.nsf/lnx/0440502001Adult listing impairment codes https://secure.ssa.gov/apps10/poms.nsf/lnx/0426510015#g1
Elvis has left the building! Did I mention I hate tea?
Jun 20 11 10:51 PM
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