Compassionate Allowances(part 5)

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DI 23022.030 Identifying and Receipting Quick Disability Determination (QDD) and Compassionate Allowance (CAL) Cases

20 CFR § 404.1619 Quick Disability Determination process


20 CFR § 416.1019 Quick Disability Determination process


A. Electronic identification
1. Electronic Disability Collect System (EDCS)
When transferring a case in EDCS, the Predictive Model (PM) software determines whether the case qualifies for processing as a QDD and/or CAL case. The field office (FO) receives one of the following on-screen message boxes in EDCS:

“This case has been marked as a Quick Disability Determination case. Full non-medical development required.”, or

“This case has been marked as a Compassionate Allowance case. Full non-medical development required.”, or

“This case has been marked as a Quick Disability Determination and Compassionate Allowance case. Full non-medical development required.”

The FO must select OK to close the message box to proceed with the transfer.

NOTE: Cases that are fully-paper (all claims in the case are EDCS exclusions) are not considered for QDD/CAL. At least one of the claims must be established in EDCS for the PM to consider the case for QDD and/or CAL. The official folder may be a Certified Electronic Folder (CEF) or a paper Modular Disability Folder (MDF).

If the disability determination services (DDS) identifies CAL criteria for a fully paper claim, the DDS and FO will follow normal expedited claim procedures, such as those used for TERI cases.

If a fully electronic CAL case requires conversion to the paper process, the case must be removed from CAL processing (see DI 23022.055) and select the “other” block. Type in “conversion from electronic to paper” as the reason.

2. DDS case processing systems
All QDD and CAL cases have an associated Electronic Folder Interface (EFI) download. The EFI download contains a data element that identifies the case as QDD and/or CAL. (Until each DDS legacy system receives the appropriate upgrades, only the current QDD indicator will be visible in the DDS download.)

The DDS case processing system recognizes the QDD/CAL indicator on EFI, propagates it to the DDS case processing system screens, and uses it for special processing logic.

NOTE: Until each DDS legacy system receives the appropriate upgrades, all CAL cases are identified in the download through the QDD data element. In addition to the data element, a special message is generated in the legacy system to alert the user that CAL is involved. The message notification states: “Case has been identified as a Compassionate Allowance because of the following condition(s): .” The adjudicator will need to check eView to determine if QDD is also applicable.

B. Visual identification
The EDCS Routing Form displays “QUICK DISABILITY DETERMINATION: YES” and/or “COMPASSIONATE ALLOWANCE: YES” in large letters at the top of the page.

The QDD and CAL indicators display as separate header(s) on all eView screens, regardless of whether the case was screened by the PM or manually added. The CAL indicator allows the user to access the Compassionate Allowance page in order to view or manually add, remove, or reinstate a CAL action. If the screen shows “QDD: Y” and/or “CAL: Y”, the case is currently a QDD and/or CAL case. If the screen shows “QDD: N” and/or “CAL: N”, the case is not currently a QDD and/or CAL case. In some instances, the “QDD: N” and “CAL: Y” will appear which means it is designated as a CAL only case and vice versa.

The DDS case processing system displays a QDD or CAL indicator (if the system has the proper systems enhancements).

C. DDS identifies CAL after receipt of claim
While a QDD indicator cannot be manually added to a case, for CAL, the DDS, Office of Quality Performance (OQP), and Office of Disability Adjudication and Review (ODAR) have the capability to manually add cases to CAL processing. If an alleged or existing condition or illness that would allow CAL processing is identified, refer to DI 23022.055 for processing instructions.

D. Automatic EFI “Accept Jurisdiction” of QDD/CAL cases: receipt date
To ensure that QDD/CAL cases are processed expeditiously, the DDS case processing systems automate the “Accept Jurisdiction” EFI transaction (0123) for QDD/CAL cases.

The DDS case processing system Download/Receipt Queue indicates whether a claim has been marked for QDD and/or CAL processing. (If the state legacy system has not received the appropriate upgrades, QDD and CAL are identified ONLY as QDD. A special message notification is sent in the download to identify a case as CAL. The message states: “Case has been identified as a Compassionate Allowance because of the following condition(s): .” The adjudicator will need to check eView to determine if QDD is also applicable.)

The system also indicates whether an image of the signed SSA-827 (Authorization to Disclose Information to the Social Security Administration (SSA)) is stored in the Document Management Architecture (DMA). The DDS should monitor the download/receipt queue to expeditiously receipt and assign any newly transferred QDD and/or CAL claims.

The recommended 20-day time period for QDD cases starts when the DDS accepts jurisdiction of the case.

The time period for CAL cases is not limited to the 20-day processing time period; however, expedited processing procedures remain in effect for CAL cases. A case is not removed from CAL solely because evidence is not received or a favorable determination is not made within a certain time period.

The DDS accepts jurisdiction, receipts, and assigns the claim to a QDD/CAL adjudicator the same day that it posts to the Download/Receipt queue, if at all possible.

The DDS must resolve by close of business (COB) any conditions that would cause them not to receipt the claim. For example, if the claim was transferred to the wrong DDS, it should be rejected back to the FO.

NOTE: Do not automatically reject jurisdiction of cases that do not have an SSA-827 in DMA. The original document is mailed to the DDS (or destroyed, depending on local procedures) by the FO, so the FO no longer has an SSA-827 in the office to fax. Discuss any cases with a missing SSA-827 with FO management, using local procedures, before rejecting jurisdiction.

The DDS case processing system propagates the date that the DDS accepted jurisdiction of the case to the State Receipt Date (SRD) field on the NDDSS DREC mask. The SRD field cannot be modified by the DDS.

If a QDD/CAL claim is still on the Download/Receipt Queue by COB of the day it was posted to the Download/Receipt Queue (or the next business day for cases transferred on non-business days), the DDS case processing system automatically generates the “Accept Jurisdiction” EFI transaction (0123). The DDS must receipt and assign these cases expeditiously because the receipt date is the date of the system generated Accept Jurisdiction transaction.

For additional information about DDS case receipt, see DI 81020.015, Electronic Claim Receipt Process.

Compassionate Allowances(part 4)

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Code of Federal Regulations

§404.1603 Basic responsibilities for us and the State.

(a) General. We will work with the State to provide and maintain an effective system for processing claims of those who apply for and who are receiving benefits under the disability program. We will provide program standards, leadership, and oversight. We do not intend to become involved in the State's ongoing management of the program except as is necessary and in accordance with these regulations. The State will comply with our regulations and other written guidelines.

(b) Our responsibilities. We will:

(1) Periodically review the regulations and other written guidelines to determine whether they insure effective and uniform administration of the disability program. To the extent feasible, we will consult with and take into consideration the experience of the States in issuing regulations and guidelines necessary to insure effective and uniform administration of the disability program;

(2) Provide training materials or in some instances conduct or specify training, see §404.1622;

(3) Provide funds to the State agency for the necessary cost of performing the disability determination function, see §404.1626;

(4) Monitor and evaluate the performance of the State agency under the established standards, see §§404.1644 and 404.1645; and

(5) Maintain liaison with the medical profession nationally and with national organizations and agencies whose interests or activities may affect the disability program.

(c) Responsibilities of the State. The State will:

(1) Provide management needed to insure that the State agency carries out the disability determination function so that disability determinations are made accurately and promptly;

(2) Provide an organizational structure, adequate facilities, qualified personnel, medical consultant services, designated quick disability determination examiners (§§404.1619 and 404.1620(c)), and a quality assurance function (§§404.1620 through 404.1624);

(3) Furnish reports and records relating to the administration of the disability program (§404.1625);

(4) Submit budgets (§404.1626);

(5) Cooperate with audits (§404.1627);

(6) Insure that all applicants for and recipients of disability benefits are treated equally and courteously;

(7) Be responsible for property used for disability program purposes (§404.1628);

(8) Take part in the research and demonstration projects (§404.1629);

(9) Coordinate with other agencies (§404.1630);

(10) Safeguard the records created by the State in performing the disability determination function (§404.1631);

(11) Comply with other provisions of the Federal law and regulations that apply to the State in performing the disability determination function;

(12) Comply with other written guidelines (§404.1633);

(13) Maintain liaison with the medical profession and organizations that may facilitate performing the disability determination function; and

(14) Assist us in other ways that we determine may promote the objectives of effective and uniform administration.

Compassionate Allowances(part 3)

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DI 23022.015 Compassionate Allowance (CAL)–DDS Instructions

The CAL initiative is designed to quickly identify diseases and other medical conditions that invariably qualify under the Listing of Impairments based on minimal, but sufficient, objective medical information. If the condition does not meet these strict criteria, it will not be designated as a CAL case.

All CAL-identified conditions are entered into the Predictive Model (PM) and are selected for CAL processing based solely on the claimant’s allegations listed on the SSA-3368 (Disability Report—Adult) or SSA-3820—(Disability Report—Child).

Like Quick Disability Determinations (QDD), CAL cases will receive expedited processing within the context of the existing disability determination process.

CAL cases are similar to Terminal Illness (TERI) claims, although not all CAL cases involve terminal illness. For example, a person with a spinal cord injury could qualify as a compassionate allowance – even if he or she is expected to live for many years.

DI 23022.017 Compassionate Allowance (CAL) and Quick Disability Determination (QDD): Similarities and Differences
Process CAL cases in the same manner as QDD cases. Review QDD procedures in this subchapter before processing a CAL case.

Similarities include:

Most CAL cases are identified by the Predictive Model (PM) upon Electronic Disability Collect System (EDCS) transfer to the disability determination services (DDS) at the initial classification, initial adjudicative level. CAL and QDD do not apply to Continuing Disability Review (CDR) classification cases.

CAL cases are processed in the DDS by adjudicators who meet the qualifications set forth in DI 23022.020.

Expedited processing applies to all CAL-identified cases.

CAL cases can be removed from the CAL process; however, the reasons for taking such action on a CAL case are very limited, as described in DI 23022.055B.

In certain circumstances, cases removed from the CAL process can be reinstated, as described in DI 23022.055C. This link (http://ssahost.ba.ssa.gov/ecal/Index.aspx ) will take you to the Office of Disability Programs (ODP) Compassionate Allowance website that provides more information on CAL and houses the Impairment Summaries.

Cases determined to be CAL could also meet the criteria for QDD and would be designated both QDD and CAL. For example, the case could meet the scoring criteria for QDD and also have an allegation of a CAL condition.

If the PM identifies a case as both QDD and CAL, the case can be removed from QDD yet maintain its CAL status, and vice versa.

Differences include:

The PM criteria for CAL are simpler than the criteria for QDD. A CAL case is identified solely when a claimant alleges having a disease or other medical condition that matches a disease or condition loaded in the PM (by name, synonym and abbreviation). No scoring or threshold criteria are necessary for CAL selection. For example, a case must have a high enough score from the PM to be considered a QDD. For CAL, all the PM needs to see is the allegation of a condition on the CAL list.

Designated employees in the DDS, the Office of Quality Performance (OQP), and the Office of Disability Adjudication and Review (ODAR) can manually add a CAL indicator to a case, which is not an available function in QDD process. Similar to QDD, designated employees can remove and reinstate a case from the CAL process. (See DI 23022.055). FO employees cannot add, reinstate or remove CAL cases.

NOTE: The field office (FO) workload management information (WMI) listings do not capture these manual additions, reinstatements or removals. For CAL cases that are not already identified as QDD, the FO is automatically notified when a case has been added, removed or reinstated from the CAL process, via the EDCS action items on electronic claims. FOs regularly monitor EDCS action lists to identify any case where a CAL indicator has been set after transfer so that full non-medical development of the case can be initiated.

Unlike QDD, there are very few reasons for removing a case from CAL processing (DI 23022.055). Most significant is that, unlike QDD, a CAL case can be processed to a denial determination.

If a case is identified as CAL, continue to follow expedited QDD processing guidelines even if the DDS removes the case from QDD processing (e.g., if a case cannot be completed in the QDD timeframes or if the claimant moves, these are not reasons to remove a case from the CAL process).

There is a Compassionate Allowance page which can be accessed by selecting a hypertext link labeled [CAL] in the top right hand frame of the Electronic Folder (EF) in eView. The CAL link will display [CAL: Y] or [CAL: N.]

CAL cases can be identified at Initial, Reconsideration, Hearing and Appeals Council adjudicative levels.

Compassionate Allowances(part 2)

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List of Conditions
1 Acute Leukemia
2 Adrenal Cancer - with distant metastases or inoperable, unresectable or recurrent
3 Alexander Disease (ALX) - Neonatal and Infantile
4 Amyotrophic Lateral Sclerosis (ALS)
5 Anaplastic Adrenal Cancer - with distant metastases or inoperable, unresectable or recurrent
6 Astrocytoma - Grade III and IV
7 Bladder Cancer - with distant metastases or inoperable or unresectable
8 Bone Cancer - with distant metastases or inoperable or unresectable
9 Breast Cancer - with distant metastases or inoperable or unresectable
10 Canavan Disease (CD)
11 Cerebro Oculo Facio Skeletal (COFS) Syndrome
12 Chronic Myelogenous Leukemia (CML) - Blast Phase
13 Creutzfeldt-Jakob Disease (CJD) - Adult
14 Ependymoblastoma (Child Brain Tumor)
15 Esophageal Cancer
16 Farber's Disease (FD) - Infantile
17 Friedreichs Ataxia (FRDA)
18 Frontotemporal Dementia (FTD), Picks Disease -Type A - Adult
19 Gallbladder Cancer
20 Gaucher Disease (GD) - Type 2
21 Glioblastoma Multiforme (Brain Tumor)
22 Head and Neck Cancers - with distant metastasis or inoperable or uresectable
23 Infantile Neuroaxonal Dystrophy (INAD)
24 Inflammatory Breast Cancer (IBC)
25 Kidney Cancer - inoperable or unresectable
26 Krabbe Disease (KD) - Infantile
27 Large Intestine Cancer - with distant metastasis or inoperable, unresectable or recurrent
28 Lesch-Nyhan Syndrome (LNS)
29 Liver Cancer
30 Mantle Cell Lymphoma (MCL)
31 Metachromatic Leukodystrophy (MLD) - Late Infantile
32 Niemann-Pick Disease (NPD) - Type A
33 Non-Small Cell Lung Cancer - with metastases to or beyond the hilar nodes or inoperable, unresectable or recurrent
34 Ornithine Transcarbamylase (OTC) Deficiency
35 Osteogenesis Imperfecta (OI) - Type II
36 Ovarian Cancer - with distant metastases or inoperable or unresectable
37 Pancreatic Cancer
38 Peritoneal Mesothelioma
39 Pleural Mesothelioma
40 Pompe Disease - Infantile
41 Rett (RTT) Syndrome
42 Salivary Tumors
43 Sandhoff Disease
44 Small Cell Cancer (of the Large Intestine, Ovary, Prostate, or Uterus)
45 Small Cell Lung Cancer
46 Small Intestine Cancer - with distant metastases or inoperable, unresectable or recurrent
47 Spinal Muscular Atrophy (SMA) - Types 0 And 1
48 Stomach Cancer - with distant metastases or inoperable, unresectable or recurrent
49 Thyroid Cancer
50 Ureter Cancer - with distant metastases or inoperable, unresectable or recurrent