I-3-1-5.Critical Case Procedures
Last Update: 8/6/24 (Transmittal I-3-197)
A. Situations that Require Expedited Processing
The Office of Appellate Operations (OAO) determines a case is “critical” and requires special expedited processing in the following situations:
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 Appeals Review Processing System (ARPS); and
A “TERI Case” flag in eView or the paper file (form SSA-2200 for paper files). If a “TERI Case” flag is added at the Appeals Council (AC) level, staff must complete form SSA-2200 and add it to eView.
For more information on what 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.
NOTE:
The presence of TERI criteria does not mandate a finding of disability. An adjudicator must evaluate the claim under the sequential evaluation process.
2. Veteran 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 ARPS; and
A “100% Perm & Total” 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.
NOTE 1:
Expedited processing procedures do not apply to claimants with a 100% P&T disability pension (as opposed to “disability compensation”) rating from the VA.
A VPAT designation is added 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).
NOTE 2:
When a VA data match identifies a claim for VPAT processing, give the claim expedited processing even if other information suggests the data match was incorrect.
NOTE 3:
The presence of a 100% P&T disability compensation rating does not mandate a finding of disability. An adjudicator must evaluate the claim under the sequential evaluation process.
3. Military Casualty/Wounded Warrior (MC/WW)
A case is designated Military Casualty/Wounded 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 a MC/WW case, but an MC/WW case can be identified at any point in the process. OAO staff can identify a MC/WW case by:
The case characteristic “MCWW” in ARPS; 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 Listing 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 DI 23022.000.
Most CAL cases are identified at the initial level of adjudication, but a new condition that develops later can also qualify for CAL processing. Subsequent identification, including at the AC, may be based solely on a claimant's allegation or on new medical evidence of a condition included on the CAL list of impairments. OAO staff will manually add the “CAL = Y” indicator in eView and the CAL case characteristic in ARPS on any CAL case upon receipt or when identified by OAO staff.
CAL cases are identified by:
The case characteristic CAL in ARPS; and
A “CAL = Y” indicator in eView.
NOTE:
Fully paper cases are not automatically considered for CAL status, because the CAL screening tool can only filter cases electronically transferred between the FO and the DDS. However, if a CAL impairment is discovered on review of a claim or when additional evidence is received, the case should be designated as CAL and critical case procedures will apply. In paper cases, attach the “Critical Case” sheet (Hearings, Appeals, and Litigation Law (HALLEX) manual I-3-1-7) with CAL clearly designated on the front of the folder.
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 OAO employees should err on the side of designating a case as “Homeless” if there is an allegation the claimant is experiencing homelessness. If a claimant alleges that they are experiencing homelessness in a phone contact, OAO staff will verify the claimant's contact information, including their mailing address and phone number. As appropriate, staff will update the information in systems to ensure OAO has the correct contact information for the claimant.
If a claimant's housing situation changes and no longer meets the above criteria, the designation can be removed or modified. See subsection B.2. below.
HMLS cases are identified by:
The case characteristic HMLS in ARPS; and
An “Critical Case” sheet (HALLEX I-3-1-7) in a paper case or, in an electronic case, by the “Homeless” flag in eView.
A case containing an “Eviction” flag in eView should be reviewed to determine if the “Homeless” flag or “HMLS” case characteristic should also be applied to the case.
6. Dire Need (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 the claimant indicates that 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 their 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 allegation that the non-receipt or interruption of benefit payments has caused the claimant a financial hardship.
NOTE:
OAO staff may also designate a case dire need when the record indicates that a dire need situation exists even when there is no allegation of dire need circumstances.
Absent evidence to the contrary, accept a claimant's or other individual's allegation of the claimant's circumstances. OAO staff will err on the side of designating the case “Dire Need.” If OAO staff later determine that the claimant's circumstances no longer meet the dire need criteria, the designation can be removed or modified. See subsection B.2. below.
OAO staff may identify a Dire Need case by:
The case characteristic DRND in ARPS; and
An “Critical Case” sheet (HALLEX I-3-1-7) in a paper case or, in an electronic case, by the “Dire Need Situation” flag in eView.
A case containing an “Eviction” flag in eView should be reviewed to determine if the “Dire Need Situation” flag or “DRND” case 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-1-9-15 and I-1-9-17.
OAO staff may identify a potentially violent case by:
The case characteristic SUIC or HOMC in ARPS; and
An “Critical Case” sheet (HALLEX I-3-1-7) in a paper case or, in an electronic case, by the “Homicidal/Potential Violent” or “Suicide Threat” flag in eView.
8. Inordinate Delay
OAO management may designate a case as critical if there has been an inordinate delay in processing the case. In that circumstance, OAO staff will add the case characteristic DLAY in ARPS.
B. Critical Case Designation
1. Adding a Critical Designation
Critical case designations entered at the hearings level in accordance with HALLEX I-2-1-40 must be maintained at the AC level, unless the circumstances have changed sufficiently to no longer warrant such designation. Upon receipt of cases, OAO staff will check eView for presence of case flag(s) and ARPS for presence of corresponding case characteristic(s) to ensure timely processing of these cases.
If an OAO Branch Chief (BC) or other staff identifies a case that should be designated under one of the categories in HALLEX I-3-1-5 A, the BC or staff will add the appropriate flag(s) in eView and the corresponding case characteristic(s) in ARPS. DLAY cases will be identified only by adding the case characteristic in ARPS.
The BC must assign the case for immediate processing and notify the Claimant and Public Assistance Branch (CPAB) via email to ^DCARO OAO CPAB so that CPAB can track the case.
NOTE:
Multiple case designations may be added to a case. For example, if a claimant meets the criteria for both a homeless and a suicidal case designation, staff should add both the “Homeless” and “Suicide Threat” flags to eView and all applicable case characteristic(s) in ARPS.
2. Removing a Critical Case Designation
If the case is erroneously designated as critical or the condition or situation that formed the basis of the critical designation is no longer present, a CPAB manager or a BC may remove the designation. If a BC or staff identifies a case in which the critical case designation(s) should be removed, the BC will delete the flag in eView and close the case characteristic(s) in ARPS. The BC will also notify CPAB via email to ^DCARO OAO CPAB. In situations where the basis for the critical case designation is not clear, the BC will consult with a CPAB manager before deleting the flag and closing the case characteristic.
NOTE 1:
If the erroneous critical case designation(s) is identified after an analyst has already reviewed the case, the analyst may notify the BC so that the designation(s) may be removed. However, the analyst will continue processing the case.
NOTE 2:
For situations when it may be appropriate to remove a CAL designation, see POMS DI 23022.055D.
C. Branch Case Processing
1. Assigning the Case
BCs are responsible for ensuring that critical cases pending within a branch are promptly processed.
On receipt of a case designated as critical, the BC will ensure the appropriate flag(s) are maintained in eView and corresponding case characteristic(s) appear in ARPS or the paper file. The BC will immediately assign the case.
2. Notifying FO of TERI and CAL cases
When a TERI and CAL case is first identified in the branch, the BC must add the “CAL = Y” indicator or “TERI Case” flag in eView and the corresponding case characteristic in ARPS. The BC will immediately notify the FO to begin non-medical development. To notify the FO, the BC will send an e-mail to |[State Abbreviation] FO [City] and will document the contact in an SSA-5002 Report of Contact. The BC will also add a “remark” in ARPS indicating that they notified the FO.
In the event the TERI or CAL designation is later removed or the AC denies the claim, the BC will immediately notify the FO via email.
3. AC Final Action
All staff must expedite preparation and release of the action document in a critical case.
If the AC issues a fully or partially favorable decision and the case is not a certified electronic folder, the BC will alert the effectuating component using the most expeditious method practical.