Last Update: 9/14/05 (Transmittal I-1-56)
In disability cases, OCO will forward (see also I-1-7-10 B.), or request other components to forward, claim folders and alerts for potential class members to OHA as follows.
In most cases, if the potential class member claim or a current claim is located in an HO, OCO will forward the alert package, with any relevant claim files, directly to the HO for processing. If the potential class member claim or a current claim is located in OHA Headquarters, OCO will forward the alert package, and any relevant claim files, to OHA Headquarters at the following address (case locator code Y46):
OHA Class Action CoordinatorThe OHA Class Action Coordinator has primary responsibility for coordinating class membership screening in OHA Headquarters, and will forward alerts and claim files, if any, to the appropriate OAO branch for screening. If a continuing disability review (CDR) alert is issued while a case is awaiting screening the OHA Class Action Coordinator (or the HO if the case is located there) will ensure that the case is screened on a priority basis before forwarding the claim file for the CDR.
Before screening an individual case, the screening component will take the actions listed below.
Determine whether a subsequent claim is pending at any administrative level or in court.
Determine whether there are additional claims within the class dates that have not been associated.
Obtain the file(s), for any:
unassociated claim(s) that fall within the class dates, and
inactive claims that postdate the class period (that potentially provide a basis for the screening decision).
If necessary, request reconstruction of any additional potential class member claim files.
EXCEPTION:
Available systems data or other information provides satisfactory proof that the particular claim would not be entitled to class relief (see I-1-7- 10 C.)
Absent a specific provision in the court order or settlement agreement, the following screening principles apply:
A claimant who received a partially favorable decision will not be screened out from class relief if all other class membership criteria are met.
If the determination or decision on a claim filed subsequent to the claim being screened applied the standard or criteria mandated by the court order or settlement agreement and adjudicated the entire time period at issue in the claim being screened, the claimant will be screened out from class relief. (To assess this, the screener must carefully review the required standard or criteria, and compare the evidence and determination or decision on the subsequent claim with the evidence in the potential class member claim.)
The term “final decision of the Commissioner” includes ALJ or Appeals Council dismissals or Appeals Council denials of requests for review, unless otherwise defined in the individual class action.
The receipt of a determination or decision on a subsequent claim that is fully favorable with respect to the time period at issue in the potential class member claim provides a basis for determining that the claimant is not a class member eligible for class relief only if the individual has received all benefits (i.e., payments or eligibility for Medicare) to which he or she could be entitled based on the potential class member claim.
A lost claim that would otherwise be reconstructed for screening and review purposes will be screened out if available systems data or other information establishes that the claim would not be subject to class relief (e.g., the Supplemental Security Record (SSR) shows that the date the claim was adjudicated is outside the class timeframe); the screener must attach pertinent documentation to the screening sheet and must annotate the screening sheet with the basis for screening out the claim (e.g., the SSR).
The OAO screener will place the original screening sheet in the claim file and, for reporting purposes, forward two copies to the OHA Class Action Coordinator at the address in I-1-7-11 A. The Coordinator will enter the information from the screening sheet into a database and will retain a copy of each screening sheet and forward a copy to the Office of Program Law (OPL) in the Office of the General Counsel.
The HO screener will place the original screening sheet in the claim file and forward, for reporting purposes, two copies directly to the OHA Class Action Coordinator at the address shown in I-1-7-11 A.
The OHA Class Action Coordinator will update the screening information to CATS, retain a copy of each screening sheet and forward a copy to OPL.
If the HO or OAO screener determines that a subsequent claim is pending at another adjudicative level, he or she will annotate this information on the screening sheet for the adjudicator's use in considering consolidation (see I-1-7-13 concerning consolidation and I-1-7-13 H. concerning notification to OPL if a subsequent or prior case is pending judicial review) or other action, and will expedite the case.
If the HO or OAO screener determined that the claimant is entitled to class relief, and there is an appeal pending judicial review on a claim filed either before or after the class claim, the screener must notify OPL because class membership may influence the action on the court case. OAO or the HO will alert the appropriate OAO Court Case Preparation and Review Branch (CCPRB) to the situation. The CCPRB will contact OPL directly and will notify the component of any action to be taken. (See I-1-7-13 H. for additional instruction to notify OPL about a screen-in if a court case is pending and overlapping periods are at issue.)
EXCEPTION:
If an OAO screener determines that a claimant with an inactive OHA- jurisdiction class claim has a subsequent (current) claim pending in an HO, the screener will notify the HO Director (or designee) that he or she is transmitting the class claim.
If the screener determined, on screening an OHA-jurisdiction class claim case, that a non-OHA component has jurisdiction for readjudication, or the screener receives a CDR alert from a non-OHA component, the screener will, send any required notice and then forward the case to the non-OHA component. Screeners in OAO and HOs will notify the OHA Class Action Coordinator, either orally or in writing, of the change in jurisdiction for coordination with OPL in OGC.
The screener will forward the class claim to the effectuating component for further payment based on the date of the class claim if the three conditions listed below are met. (This is because the determination of class membership has, in effect, “reopened” the class claim regardless of the rules of administrative finality.)
The claimant is a class member entitled to relief.
A favorable or partially favorable determination or decision on a subsequent claim establishing an onset date within the time period covered by the class claim has been effectuated.
At the time of effectuation, the claim now identified as a class claim could not be reopened under the normal rules of administrative finality.
The screener will instruct the effectuating component to return the claim file(s) to the screening component on completion of its effectuation action to enable the screening component to send any required notice with respect to class membership and determine whether there are any remaining issues raised by the class member claim. If, after effectuation, the class member has received all benefits payable or any other relief to which he or she is entitled based on the class member claim, the screening component will modify any class member notice to advise the claimant that he or she is entitled to no additional relief. If there is no notice of class membership, the screening component will prepare a special notice indicating the case circumstances. If, after effectuation, the claimant is still entitled to relief, e.g., a hearing must be scheduled, the screening component will also annotate the claim file regarding the remaining issues for the adjudicator's use in preparing any further notices.
If during the screening process it becomes apparent that a favorable determination or decision on a subsequent claim was effectuated incorrectly, e.g., the effectuating component used an incorrect onset date, the screening component will:
forward the claim file(s) to the effectuating component for corrective action and any additional action required based on the determination of class membership; and
instruct the effectuating component to return the claim file(s) to the screening component on completion of its action(s) to enable the screening component to send either a notice of non-class membership or any required notice with respect to class membership and determine whether there are any remaining issues raised by the class member claim (If there is no notice of class membership, the screening component will prepare a special notice explaining the circumstances.) If the claimant is still entitled to relief (e.g., a hearing must be scheduled), the screening component will also annotate the claim file regarding the remaining issues for the adjudicator's use in preparing any further notices.
Many cases under the jurisdiction of DDSs' do not provide claimants with a separate notice of a favorable class membership determination. Occasionally an OHA component may screen a DDS-jurisdiction case for the purpose of consolidating at the OHA level (e.g., OHA plans to issue a favorable decision that is also fully favorable with respect to the class member claim). In this situation, OHA will give notice in the body of the decision that all class relief has been provided.
For OHA-jurisdiction cases, there may be a time lag between the date of screening for eligibility for class relief and the date that OHA processes the case (e.g., the date that a claim is scheduled for hearing). Therefore, at the OHA level, the screening component may give notice of eligibility for class relief at the time of screening. (Such notice may sometimes be given in connection with notice of action on a current claim.)
All individuals denied class membership or class relief will receive notice of the denial and any ensuing right to review of the denial. The notice will be tailored to the particulars of the class action and the individual claim.
When providing notice, the OHA screening component will:
Use OHA letterhead paper.
Send the original to the claimant or if the claimant is deceased, to the potential substitute party or eligible individual. If not known, send the notice in the deceased claimant's name in care of the “Next of Kin.”
Send copies to the representative (if any); class counsel (if required); and to OPL (if required in the particular case).
Place a copy of the notice in the claim file.
On release of the notice, the screening component (if it is not the adjudicating component), will forward the file(s) to the adjudicating component or to the designated location for those not entitled to class relief. (The location will be identified in the applicable TI.)