Last Update: 3/27/12 (Transmittal I-3-43)
The Office of Disability Adjudication and Review's (ODAR's) Office of Appellate Operations (OAO) designates a case requiring special processing for one of the reasons listed in subsection I-3-1-51 B. below a “critical case” to ensure that the appropriate component(s) takes prompt action on the case.
Six situations warrant instituting critical case processing procedures:
The claimant's illness is alleged to be or is identified as terminal (see subsection I-3-1-51 C. below).
The claim is 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 I-3-1-51 D. below, and POMS DI 11005.003).
The claim has been identified as a Compassionate Allowance (CAL) case (see subsection I-3-1-51 E. below).
The claimant is without, and is unable to obtain, food, medicine or shelter (dire need case, see subsection I-3-1-51 F. below);
There is an indication that the claimant is suicidal, homicidal, or potentially violent (see I-2-1-37, Claimant Threatens Violence);
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:
The Congressional and Public Affairs Branch (CPAB) uses current OAO workload data to determine the “inordinate delay” timeframe.
A critical case involving 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 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) or electronically through the Electronic Folder Flag or Appeals Review Processing System (ARPS) case characteristic [TERI], when received, and any case involving the situations and conditions described in POMS DI 11005.601C.
The presence of one of the criteria listed in DI 11005.601C. does not mandate a finding of disability. The claimant's impairment must be evaluated under the sequential evaluation process.
A critical case involving a Military Service Casualty Case (MSCC) also requires additional special handling. To provide this assistance, OAO staff will follow the TERI procedures to expedite these cases through all stages of case development and adjudication. A special Military Service Casualty Case Flag, for use in paper cases, can be found at POMS DI 11005.003H. MSCC cases include any case already identified as a MSCC case, when received, and any case subsequently identified as a case involving 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 POMS DI 11005.003.
A critical case involving a Compassionate Allowance (CAL) claim also requires additional special handling. To provide this assistance, OAO staff will follow the TERI procedures to expedite these cases through all stages of case development and adjudication.
The CAL process is a way of quickly identifying diseases and other medical conditions that invariably qualify under the Listing of Impairments (20 CFR Appendix 1 to Subpart P of Part 404—Listing of Impairments) based on minimal objective medical information. CAL will allow the Social Security Administration to target quickly the most obviously disabled individuals for allowances based on objective medical information that we can obtain quickly. Many of these claims can be allowed based on confirmation of the diagnosis alone, for example, acute leukemia, amyotrophic lateral sclerosis (ALS) and pancreatic cancer. In these cases, allowances can be made as soon as the diagnosis is confirmed or the other necessary objective medical evidence is obtained. CAL cases are identified at the initial level through an automated process (e.g., predictive modeling). Subsequent identification, including at the Appeals Council (AC) level, is based on a claimant's allegation of a condition listed on the CAL list of impairments (see POMS DI 11005.604H. or http://mwww.ba.ssa.gov/compassionateallowances/conditions.htm).
CAL cases include any case already identified as a CAL case (e.g., Electronic Folder Indicator (CAL = Y)) and/or the ARPS case characteristic (e.g., [CAL]), when received, and any case identified by OAO staff in which the claimant alleges an impairment that appears on the list in POMS DI 11005.604H.
NOTE:
Cases that are fully paper (all claims in the case are Electronic Disability Collect System (EDCS) exclusions) are not automatically considered for CAL because CAL cases are initially selected by the system through the predictive model upon EDCS transfer from the Field Office (FO) to the Disability Determination Service (DDS). However, if CAL is discovered on review of a claim (either fully paper or electronic), or upon the receipt of additional evidence, use the normal expedited procedures for a TERI case, using the Critical Case/Dire Need Flag rather than the Form SSA-2200. Clearly indicate on the flag that the case involves CAL.
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 or she needs medicine or 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); 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 or she does not have enough income or resources to meet an immediate threat to his or her health or safety.
Situations may arise that will require individual consideration and judgment with regard to designating the case as critical. Err on the side of designating the case critical. If a dire need situation becomes non-critical, the critical designation can be removed or modified.
Within ODAR Headquarters, OAO case processing branch staff and managers identify cases with critical situations and are responsible for tracking and monitoring the cases for prompt actions from beginning to end.
OAO's CPAB is responsible for designating a case as critical and initiating critical case procedures for claimants who: have a case pending with OAO; inquire about their cases through CPAB; and have a critical situation. These cases come to the attention of CPAB through a public or congressional inquiry. CPAB tracks and monitors these cases in order to provide status updates.
Critical cases (other than TERI and MSCC cases) are identified by a Critical Case/Dire Need Flag (I-3-0-93 Exhibit). Also, in CAL cases, OAO staff will annotate the Critical Case/Dire Need Flag with the term “CAL Case.” TERI cases are identified by use of the TERI Flag (See form SSA-2200 in POMS OS 15020.301). MSCC cases are identified by a MSCC Flag (POMS DI 11005.003H.)
Flags will be attached to claim files in paper claims and to the certified electronic folder (CEF) in fully electronic cases.
Within OAO, the branch chief (or his or her designee) 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 I-3-1-51B. above, to the attention of the branch chief.
Upon receipt of a flagged critical (including TERI, MSCC, or CAL) case, the branch chief will immediately commence expedited processing, as described in steps 1-3 below:
If there is indication that a critical designation was made by CPAB during the time that the case is pending in OAO, the branch chief will ensure that information about the status of the case is shared with CPAB via email to ¦¦¦ODAR OAO CPAB.
Following designation of a critical case (including TERI, MSCC, or CAL) by CPAB, the branch chief will immediately assign the case and ensure that OAO branch staff:
Flag the folder to identify the case as critical.
For paper cases, ensure that a Critical Case, TERI, or MSCC Flag is attached to the front of the claims file (to each claims file in a concurrent case). See I-3-0-93 for the Critical Case Flag, which is also used to designate CAL cases; Form SSA-2200 in POMS OS 15020.301 for the TERI Flag; or POMS DI 11005.003H. for the MSCC Flag.
For electronic folder cases, activate the appropriate flag(s) in eView (see DI 81010.080), as well as the CAL indicator in Compassionate Allowances cases. See also POMS DI 23022.055 for instructions on adding, removing, modifying, and reinstating CAL cases.
For both paper and electronic cases, activate the appropriate case characteristic code(s) in ARPS. The relevant case characteristics codes are:
[TERI] Terminal Illness
[MSCC] Military Service Casualty Case
[CAL] Compassionate Allowance
[DRND] Dire Need Case
[SUIC] Suicidal
[HOMC] Potentially Homicidal/Violent
[DLAY] AC Level Case – Inordinate Delay
Expedite processing by immediately working the case and hand carrying paper cases between processing stages and advise CPAB of any delays in processing if the case is being monitored by CPAB.
For TERI and MSCC cases, OAO branch staff will also:
Ensure that the paper TERI or MSCC Flag is completed in eView for fully electronic cases and completed and correct in paper cases, including representative fee waiver information, if available;
If the critical case was identified by CPAB, send a photocopy of the paper TERI or MSCC Flag to CPAB for paper cases or email to ¦¦¦ODAR OAO CPAB for fully electronic cases; and,
For TERI and CAL cases first identified in the branch, the branch chief (or designee) will immediately notify the SSA field office to begin non-medical development. The most appropriate method to notify the field office is to send an e-mail to the main local office mailbox, for example: ¦NY FO Gloversville. The branch chief will document the field office contact with a Report of Contact or Note to File and REMARKS (unhidden) in ARPS for paper cases or a message utility in eView and REMARKS (unhidden) in ARPS for electronic cases. In the event the CAL designation is later removed (see I-3-51 J (below)) or the Appeals Council denies the claim, the branch chief will immediately notify the field office via email.
If the AC issues a fully or partially favorable decision in a TERI, MSCC, or CAL case, and the case is being monitored by CPAB, the branch chief will advise CPAB of the AC's action.
In a paper, remanded court case, if the AC issues a fully favorable or partially favorable decision, the Disability Program Branch (DPB) chief will hand carry the case to the Court Case Preparation and Review Branch (CCPRB). If the case is being monitored by CPAB, the CCPRB branch chief will advise CPAB of the AC's action, and follow the above procedures for forwarding the case unless a certified administrative record (CAR) is needed because the AC is issuing a partially favorable decision (i.e., in a sentence 6 case – see HALLEX I-4-3-1 Court Remand Orders - General). The CCPRB will forward the case for effectuation. If a CAR is needed, the CAR will be prepared before forwarding the file to the effectuating component. A certified supplemental court transcript or CAR is not prepared when the AC issues a fully favorable decision following a sentence 6 remand, but a copy of the decision must be filed with the Office of General Counsel (OGC) for filing with the district court to close out the civil action. All actions, with the exception of OGC's, will be taken by the close of the next business day following issuance of the decision.
NOTE:
The TERI/MSCC case flag may not be removed.
If the Council's action is unfavorable, ensure that OAO branch staff promptly release the decision, denial notice, or dismissal order and follow normal procedures for distributing copies of the AC action. If CPAB is monitoring the case, the branch chief will notify CPAB about the AC's action(s).
In remanded court cases, the branch staff will promptly refer the case to CCPRB for expeditious release of the Council's action, preparation of the CAR in a sentence 6 Court remand case, and disposition of the file(s). If CPAB is monitoring the case, the CCPRB branch chief will notify CPAB of the AC action before the action is released.
If the AC issues a remand to an administrative law judge, 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). If CPAB is monitoring the case, the branch chief will notify CPAB that a remand order was issued. For TERI/MSCC/CAL cases, clearly annotate all transmittals and envelopes “TERI/MSCC/CAL Case.”
In remanded court cases, the branch staff will promptly refer the case to CCPRB once the AC has signed the remand order. The CCPRB branch chief will expedite procedures for processing the case as described above. If CPAB is monitoring the case, the branch chief will notify CPAB that a remand order was issued for the court case.
CPAB or OAO managers may remove the critical designation and discontinue tracking a critical case other than a TERI/MSCC case when the condition(s) which formed the basis for the critical designation no longer applies. TERI/MSCC case flags may not be removed and TERI/MSCC designations may not be cancelled.
For cases that have been designated as CAL cases, there may be appropriate reasons for removing the CAL designation and to discontinue handling such cases expeditiously. These reasons include (but are not limited to):
Medical evidence did not confirm CAL condition.
Removed to revise or correct condition(s) (there is no functionality to modify conditions – CAL indicator must be removed, corrected, and reinstated).
System mistakenly identified a CAL condition.
Certain cases that have been removed from CAL processing can be reinstated. Reasons for reinstatement include (but are not limited to):
Revised CAL condition (there is no functionality to modify conditions – CAL indicator must be removed, corrected, and reinstated).
CAL condition was mistakenly removed.
Medical evidence was received after CAL indicator was removed.
Branch chiefs will remove CAL designations from eView (both flags and CAL indicator) and close the ARPS case characteristic for CAL, when appropriate, and, if CPAB is monitoring the case, notify CPAB of the removal. See POMS DI 23022.005 for instructions on adding, removing, and reinstating CAL cases.