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How SSA grades disability update report 455 (short form) 2020-09-25

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So this is how the computer that reads a short form 455 decides whether or not to initiate a full CDR.

The link:


SSA - POMS: DI 40502.001 - Processing Center Instructions for the Continuing Disability Review Mailer Forms SSA-455 and SSA-455-OCR-SM

Processing Center Instructions for the Continuing Disability Review Mailer Forms SSA-455 and SSA-455-OCR-SM
secure.ssa.gov
secure.ssa.gov

the pertinent info:


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) is:Your action is:
YESAll 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.
NOAll Profiles (High, Medium, or Low)-Go to question 2
NO RESPONSEAll 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) is:Your action is:
YESHigh 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
NOAll Profiles-Go to question 3
NO RESPONSEAll 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) is:Your action is
HAVE NOT DISCUSSEDAll Profiles-Go to question 4
CANNOT WORKAll Profiles-Go to question 4
CAN WORKHigh or Medium-DO CDR unless theDE/DEC/DC review raises doubt about the response (consider DIRCON to resolve).

Low-Go to question 4
NO RESPONSEAll 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) is:Your action is:
BETTERAll 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 grafting).

Consider DIRCON to resolve.
SAMEHigh or Medium-DO CDR unless the review raises the same types of doubts about medical improvement as discussed for a response of “better”.

Low-Go to questions 5 and 6.
WORSEAll Profiles-Go to questions 5 and 6.
NO RESPONSEAll 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 together.
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:
YESCheck 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

  • Diaries set

  • Blindness
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 improvement.
NOAll 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:

  • 4140 (angina)

  • 4430(arterial)

  • 5710 (liver)

  • 5840 (renal)

  • 2500 (diabetes)
These impairments usually require continuous medical intervention.
Recommend a full medical CDR only if the DIRCON response indicates there is possible medical improvement.
NO RESPONSEAll 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:
YESAll 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.
NOAll Profiles-DEFER if response to question 5 was “Yes” and there is no indication of possible medical improvement.
NO RESPONSEAll 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 of treatment.
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.

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