I-2-1-40.Critical Case Procedures

1. Terminal Illness (TERI)

A case is designated TERI when the claimant's illness is alleged or identified as terminal (i.e., untreatable and expected to result in death). TERI cases are identified by:

• The case characteristic TERI in the Case Processing and Management System (CPMS) or “TERI” flag in the Hearings and Appeals Case Processing System (HACPS); and

• A “TERI Case” flag (form SSA-2200) in a paper case, or, in an electronic case, by the “TERI Case” flag in eView. If a “TERI Case” flag is added at the hearings level, staff must complete form SSA-2200 and add it to eView.

A TERI designation may be added at or before the hearing level. At the hearing level, the OHO regional office (RO) monitors TERI designations to ensure the cases are expedited. For examples of TERI situations, or more information on the situations or conditions field offices (FO) and Disability Determination Services (DDS) use to designate a TERI case, see Program Operations Manual System (POMS) DI 11005.601C and DI 23020.045B.

2. Veterans Affairs 100 Percent Permanent and Total (VPAT)

A case is designated VPAT when the claimant has received a 100 percent permanent and total (100% P&T) disability compensation rating from the Department of Veterans Affairs (VA). These cases can be identified by:

• The case characteristic VPAT in CPMS or “100% P&T” flag in HACPS; and

• A “100% Perm & Total Case” flag in a paper case (POMS DI 11005.012G), or, in an electronic case, by the “Disabled Veterans rated 100% Permanent and total” flag in eView.

Add a VPAT designation after the Social Security Administration (SSA) receives verification that a claimant has a 100% P&T disability compensation rating from the VA. SSA receives verification in one of the following ways:

• Through a data match from the VA (for more information, see POMS DI 11005.007); or

• From a claimant who submits a VA notification letter verifying a 100% P&T rating (see POMS DI 23020.055).

3. Military Casualty/Wounded Warrior (MC/WW)

A case is designated Military Casualty/Wounder Warrior (MC/WW) when the claim involves any current or former member of a military service who:

• Sustained an illness, injury, or wound;

• Is alleging a physical or mental impairment, regardless of how the impairment occurred, or where it occurred (i.e., United States or on foreign soil); and

• Sustained the impairment while on active duty status on or after October 1, 2001.

For more information, including the definition of “active duty,” see POMS DI 11005.003.

Generally, the FO will identify and designate MC/WW cases, but an MC/WW case can be identified at any point in the process. MC/WW cases are identified by:

• The case characteristic MCWW in CPMS or “MC/WW” flag in HACPS; and

• A special “MC/WW flag,” found at POMS DI 11005.006, in a paper case, or, in an electronic case, by the “Military Casualty/Wounded Warrior” flag in eView.

4. Compassionate Allowances (CAL)

The CAL process identifies diseases and other medical conditions that meet or equal one or more listing in the Listings of Impairments (20 CFR Appendix 1 to Subpart P of Part 404—Listing of Impairments). For more information about the CAL initiative, see POMS DI 11005.604 and POMS DI 23022.000.

Most CAL cases are automatically identified at the initial level of adjudication. However, the DDS and hearing office (HO) can manually add a CAL indicator to a case if the system does not identify a CAL condition allegation (e.g., due to a misspelling) or if a new condition develops after the claimant files an application. Subsequent identification, including at the hearing level, may be based solely on a claimant's allegation or on new medical evidence of a condition on the CAL list of impairments. Add the CPMS or HACPS case characteristic on any CAL case upon receipt or when identified by HO staff. The OHO RO monitors CAL designations to ensure the cases are expedited. For more information on manually adding and removing a CAL indicator in eView, see POMS DI 23022.055.

CAL cases are identified by:

• The case characteristic CAL in CPMS or HACPS; and

• A “CAL = Y” flag in eView.

5. Homeless (HMLS)

A case will be designated “Homeless” if the claimant does not have a fixed, regular, and adequate nighttime residence or if the claimant expects to lose their current accommodations within 14 days and will not have a fixed, regular, and adequate nighttime residence.

The following are examples of living situations that indicate the claimant is experiencing homelessness.

The claimant is staying:

• At publicly or privately operated shelters;

• In hotels or motels paid for by Federal, State, or local government programs for low-income individuals;

• In a car, park, abandoned building, bus or train station, airport, or camping ground; or

• Temporarily with a friend, family member, or another household.

These examples are not exhaustive and HO employees should err on the side of designating a case as “Homeless” if there is an allegation the claimant is experiencing homelessness. If the claimant reports that they are experiencing homelessness in a phone contact with an HO employee, the employee must verify with the claimant their mailing address, phone number, and email address, if available, and update the information in systems to ensure that the HO has the correct contact information for the claimant.

If a claimant's housing situation changes and no longer meets the above criteria, the HMLS designation or “Homeless” flag can be removed or modified. See subsection B.2. below.

HMLS cases are identified by:

• The case characteristic HMLS in CPMS or a “Homeless” flag in HACPS; and

• A “Critical Case” sheet (HALLEX I-2-1-94) in a paper case or, in an electronic case by the “Homeless” flag in eView.

A case identified by the FO or DDS as a “Homeless” case in accordance with POMS DI 11005.004 must be designated as a HMLS case at the hearing level, unless the circumstances have changed sufficiently to no longer warrant such designation. A case identified by the FO or DDS with an “Eviction” flag should be reviewed to determine if the “Homeless” flag or “HMLS” characteristic should also be applied to the case.

6. Dire Need Case (DRND)

A dire need situation exists when there is an allegation that the claimant does not possess sufficient income or resources to address an immediate threat to their health or safety, including any of the following circumstances:

• The claimant is without food and is unable to obtain it.

• The claimant lacks medicine or medical care and is unable to obtain it, or access to necessary medical care is restricted because of a lack of resources.

• The claimant lacks one or more basic utilities (heat, potable water, or electricity) at their residence such that the residence would be considered uninhabitable, and the claimant does not have the resources to turn the utilities back on.

A dire need situation also exists when there is an allegation that the non-receipt or interruption of benefit payments has caused the claimant a financial hardship.

Absent evidence to the contrary, accept a claimant's or other individual's allegation of the claimant's circumstances. HO employees will err on the side of designating the case dire need. If it is later determined that the situation no longer meets the dire need criteria, the designation can be removed or modified. See subsection B.2. below.

Dire Need cases are identified by:

• The case characteristic DRND in CPMS or “Dire Need” flag in HACPS; and

• A “Critical Case” sheet (HALLEX I-2-1-94) in a paper case or, in an electronic case, by the “Dire Need Situation” flag in eView.

A case identified by the FO or DDS as dire need in accordance with POMS DI 23020.030, must be designated as a dire need case at the hearing level, unless the circumstances have changed sufficiently to no longer warrant such designation. A case identified by the FO or DDS with an “Eviction” flag should be reviewed to determine if the “Dire Need Situation” flag or “DRND” characteristic should also be applied to the case.

7. Potentially Violent

A potentially violent situation exists if there is an indication that the claimant is suicidal, homicidal, or otherwise potentially violent. See instructions in HALLEX I-1-9-5 and I-1-9-7.

Potentially violent cases are identified by:

• The case characteristic SUIC or HOMC in CPMS, or the “Special-S” or “Special-H” flag in HACPS; and

• A “Critical Case” sheet (HALLEX I-2-1-94) in a paper case or, in an electronic case, by the “Homicidal/Potential Violent” or “Suicide Threat” flag in eView.

1. Adding a Designation

In the OHO RO, the Regional Chief Administrative Law Judge (RCALJ) or the Regional Management Officer (RMO) is responsible for designating cases as critical. The RMO is the primary point of contact for all inquiries on these cases.

In the HO, the Hearing Office Chief Administrative Law Judge (HOCALJ) or the HOCALJ's designee (e.g., Hearing Office Director, Group Supervisor, or assigned administrative law judge (ALJ) with express delegation from the HOCALJ) is responsible for designating critical cases. The HOCALJ is the ultimate point of contact for cases that require expedited processing and ensuring that procedures are followed, even if the HOCALJ has delegated designation authority to another manager.

2. Removing a Critical Case Designation

If a case is erroneously designated as critical or the condition or situation that formed the basis of the designation is no longer present, the HOCALJ or the HOCALJ's designee may remove the designation.

If the HOCALJ or the HOCALJ's designee decides to remove such a designation, they must annotate the reason for the action in CPMS in the “Remarks” section or the “Case Notes” section in HACPS.

For detailed information about modifying a CAL designation, refer to POMS DI 23022.055C and D.

1. Identifying Critical Cases

All employees who initially screen files and mail are responsible for bringing potentially critical cases to the attention of a person with the authority to designate critical cases. If a staff person reviews a case and thinks it may meet the criteria of one of the critical categories or if a claimant submits a critical allegation by fax or mail, staff will refer the case to the person with authority to designate critical cases with a “Referral” in HACPS or a “To Do Item” in CPMS.

If a claimant calls or comes to the HO alleging a critical situation while the case is pending, the employee who receives the call or speaks to the claimant will obtain as much information about the situation as possible and document the call with a Report of Contact (form SSA-5002). If appropriate, the employee may have the claimant complete a form SSA-795, Statement of Claimant or Other Person, describing the situation.

The employee will associate all documentation with the record and notify the appropriate person of the need for a case review as follows:

• For an electronic file, the employee will use a CPMS “To Do Item” or HACPS “Referral” to alert the appropriate person of the need for a case review.

• For paper cases, the employee will hand-carry the file to a person with the authority to designate cases as critical.

2. Documenting Critical Cases

When an individual designated to do so finds expedited case processing is warranted, the individual will add the appropriate case characteristic(s) (TERI, VPAT, MCWW, CAL, SUIC, HOMC, HMLS, DRND, etc.) in CPMS, or the appropriate characteristic(s) or case flag(s) in HACPS and eView and will add a brief summary of why the case meets the criteria in HACPS case notes or CPMS remarks. Multiple critical case characteristics may be added to a case. For example, if a claimant meets the criteria for both a Homeless and a Suicidal critical case designation, staff should add both the HMLS and SUIC characteristics or case flags to the case.

If the case has congressional interest, the individual will also enter the case characteristic or flag and listing type “Congressional.”

The date critical case processing is designated will be the characteristic's or flag's “start date.”

Additionally, the designated individual will ensure that a claim(s) file for a critical case has the appropriate flag. Electronic flags are added to eView for electronic cases. For paper cases, one of the following paper flag sheets must be attached to the front of each paper claim file, as applicable:

• For all non-TERI, non-MC/WW, or non 100% P&T cases, a completed “Critical Case” sheet, found in HALLEX I-2-1-94, or other visible and easily identifiable sheet clearly marked and labeled with the appropriate case characteristic or case flag;

• A completed “TERI Case” flag, found in form SSA-2200;

• A completed “MC/WW” flag, found in HALLEX I-2-1-96; or

• A completed “100% Perm & Total” case flag, found in POMS DI 11005.012G.

3. Reviewing for On-The-Record Decision

HO management will immediately assign critical cases for on-the-record (OTR) decision review. The assigned reviewer will receive a “To Do Item” in CPMS or a “Referral” in HACPS. If an OTR decision is possible, HO management will assign the case to a decision-writer for expedited writing. If an OTR decision is not appropriate, staff will take appropriate action to expedite pre-hearing development and schedule a hearing.

4. Scheduling a Hearing, When Necessary

When a critical case is ready for scheduling, the employee responsible for workup or development will create a “To Do Item” in CPMS or a “Referral” in HACPS for the scheduling employee to expedite scheduling a hearing.

The scheduling employee will schedule critical cases in the first available open hearing slots after checking representative and expert witness availability for hearings (if applicable). If previously scheduled hearing slots become available due to cancellation or rescheduling, the slots will be offered to claimants with cases designated as critical. If there are fewer than 75 days before the hearing date, the case will be scheduled only if the claimant or the claimant's appointed representative is willing to waive the right to the 75-day advance notice of hearing in writing. For instructions regarding obtaining a waiver of advance notice of hearing, see HALLEX I-2-3-25.

5. Issuing a Decision

Staff must expedite any necessary post-hearing development and decision writing for critical cases.