I-3-1-51.Critical Case Procedures

Last Update: 12/3/13 (Transmittal I-3-58)

A. General

The Office of Appellate Operations (OAO) in the Office of Disability Adjudication and Review (ODAR) determines a case is “critical” and requires special processing in the following situations:

1. Terminal Illness (TERI)

A case is designated critical when the claimant's illness is alleged or identified as terminal. TERI cases are identified by:

  • The case characteristic TERI in the Appeals Review Processing System (ARPS); and

  • A TERI Flag (form SSA-2200) in a paper case, or, in an electronic case, by the TERI flag in 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. Military Casualty/;Wounded Warrior (MC/;WW) Case

A case is designated critical 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, 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” flag in eView.

3. Compassionate Allowances (CAL)

The CAL process identifies 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). For more information about the CAL initiative, see POMS DI 11005.604.

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 Appeals Council (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. For a current list of CAL impairments, see POMS DI 11005.604H. The ARPS case characteristic will be added 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 flag 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 field office and the DDS. However, if CAL is discovered on review of a claim or when additional evidence is received, the case is designated CAL in ARPS and critical case procedures apply. In paper cases, attach the Critical Case/;Dire Need Flag (I-3-0-93 Exhibit) with CAL clearly designated on the front of the folder.

4. Dire Need Case (DRND)

A dire need situation exists when a claimant alleges 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; the claimant does not have any health insurance; or, the claimant indicates that access to necessary medical care is restricted because of a lack of resources.

  • The claimant lacks shelter (e.g., without utilities such that his or her home is uninhabitable, homelessness, expiration of a 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. OAO employees will 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. See I-3-1-51 B.2. below.

OAO staff may identify a Dire Need case by:

  • The case characteristic DRND in ARPS; and

  • A Critical Case/;Dire Need Flag (I-3-0-93 Exhibit) in a paper case or, in an electronic case, by the “Dire Need” flag in eView.

5. Potentially Violent

OAO staff may designate the case as critical if there is an indication that the claimant is suicidal, homicidal, or potentially violent. See instructions in Hearings, Appeals, and Litigation Law (HALLEX) manual I-1-9-15.

OAO staff may identify a potentially violent case by:

  • The case characteristic SUIC or HOMC in ARPS; and

  • A Critical Case Flag (I-3-0-93 Exhibit) in a paper case or, in an electronic case, by the “Homicidal/;Potential Violent or Suicide Threat” flag in eView.

6. Inordinate Delay

OAO may designate a case as critical if there has been an inordinate delay in processing the case and there is a public, congressional, or other high priority inquiry on the case. The Congressional and Public Affairs Branch (CPAB) uses current OAO workload data to determine the “inordinate delay” timeframe. OAO staff may identify these cases by the case characteristic DLAY in ARPS.

B. Critical Case Designation

1. Adding Critical Case Designation

CPAB is responsible for designating critical cases and monitoring the OAO pending critical case workload. OAO branch chiefs (BC) are responsible for ensuring that critical cases pending within a branch are promptly processed.

If a BC or other staff identifies a case that should be designated critical, the BC will add a critical case characteristic in ARPS and assign the case for immediate processing. However, the BC must also notify CPAB via email to |||ODAR OAO CPAB so that CPAB can track the case.

NOTE:

Due to firewall and privacy issues, CPAB will not reply by email to members of the public. If CPAB receives an email from a member of the public, CPAB will respond to the individual by telephone.

2. Removing Critical Case Designation

Critical case characteristics entered at the hearing level will automatically pass to ARPS if the case characteristic was open at the time the hearing level case was closed. However, the basis for the critical case designation may no longer be present. Additionally, OAO staff may mistakenly identify a case as critical when it does not meet the criteria. In these situations, the critical case designation may need to be removed.

NOTE:

If the erroneous critical case designation is identified after an analyst has already reviewed a case, the analyst may notify the BC so that the designation may be removed. However, the analyst will continue processing the case.

A CPAB manager may remove a critical designation when the condition(s) for the critical designation no longer applies. If a BC or staff identifies a case in which the critical case designation should be removed, the BC will close the critical case characteristic in ARPS and notify CPAB via email to |||ODAR OAO CPAB. In situations where the basis for the critical case designation is not clear, the BC will consult with a CPAB manager before closing the case characteristic.

NOTE:

For situations when it may be appropriate to remove a CAL designation, see POMS DI 23022.055D.

3. Monitoring Cases Designated as Critical

When a case characteristic is entered at either the hearing or AC levels, and the case characteristic is not closed, the case will appear on the S20 report in the AMICUS Report Menu of the ODAR Central Management Dashboard. The S20 report provides an up-to-date listing of all pending OAO cases in which there is at least one open critical case characteristic. CPAB staff and BCs must monitor the report on a regular basis to ensure that all critical cases receive prompt attention and processing.

C. Branch Case Processing

1. Assigning the Case

On receipt of a case designated critical, the BC will ensure the appropriate flags are noted in the folder and ARPS. The BC will immediately assign the case and advise CPAB of any delays in processing.

2. Notify FO

Additionally, for TERI and CAL cases first identified in the branch, the BC must 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 a Report of Contact. An electronically fillable form SSA-5002 can be found at http:/;/;co.ba.ssa.gov/;eforms/;forms/;formselector_s5002.htm. The BC will also add a REMARK in ARPS indicating that he or she notified the FO.

In the event the critical designation is later removed or the AC denies the claim, the BC will immediately notify the FO via email.

3. AC Final Action

a. Fully or Partially Favorable Decision

The BC must notify CPAB when the AC issues a fully or partially favorable decision in a TERI, MC/;WW, or CAL case by sending an email to |||ODAR OAO CPAB.

When the AC issues a fully or partially favorable decision after a court remand, see HALLEX I-4-3-43.

b. Denial, Dismissal or Unfavorable Decision

The BC must notify CPAB when the AC action is unfavorable by sending an email to |||ODAR OAO CPAB. OAO staff will follow normal procedures when releasing the final action document.

When the AC issues an unfavorable action after a court remand, see HALLEX I-4-3-43.

c. Remand

The BC must notify CPAB when the AC remands a critical case to an administrative law judge (ALJ). The AC will expedite standard procedures for releasing the remand order, and, when a paper file is involved, forward the file(s) to the hearing office by the most expeditious means practical (e.g., express mail). For paper TERI, MC/;WW, and CAL cases, clearly annotate all transmittals and envelopes “TERI”, “MCWW,” or “CAL” case.

When the AC remands to an ALJ after a court remand, see HALLEX I-4-3-43.