I-2-1-40.Critical Cases

Last Update: 4/9/14 (Transmittal I-2-106)

A. General

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 (i.e., untreatable, irreversible, and expected to end in death). TERI cases are identified by:

  • The case characteristic TERI in the Case Processing and Management System (CPMS); and

  • A TERI Flag (form SSA-2200) in a paper case, or, in an electronic case, by the “TERI flag” in eView.

A TERI designation may be added at or before the hearing level, and TERI designations are monitored by the ODAR regional office (RO) to ensure the case is expedited. For examples of TERI situations, or more information on the 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, including the definition of “active duty,” see POMS DI 11005.003.

Generally, the FO will identify and designate MC/WW cases, but an MC/WW case can be identified at any point in the process. MC/WW cases are identified by:

  • The case characteristic MCWW in CPMS; 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.

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 hearing level, 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 CPMS case characteristic will be added on any CAL case upon receipt or when identified by hearing office (HO) staff. CAL designations are monitored by the ODAR RO to ensure the case is expedited.

CAL cases are identified by:

  • The case characteristic CAL in CPMS; 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 CPMS and critical case procedures apply. In paper cases, attach the Critical Case/Dire Need Flag present in Hearings, Appeals and Litigation Law (HALLEX) manual I-2-1-94 with CAL clearly designated on the front of the folder.

4. Dire Need Case (DRND)

A dire need situation exists when a claimant alleges 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 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. ODAR 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 HALLEX I-2-1-40 B.3. below.

Dire Need cases are identified by:

  • The case characteristic DRND in CPMS; and

  • A Critical Case/Dire Need Flag (HALLEX I-2-1-94) in a paper case or, in an electronic case, by the “Dire Need Situation” flag in eView.

5. Potentially Violent

ODAR staff may designate the case as critical if there is an indication that the claimant is suicidal, homicidal, or potentially violent. See instructions in HALLEX I-1-9-5.

Potentially violent cases designated as critical are identified by:

  • The case characteristic SUIC or HOMC in CPMS; and

  • A Critical Case Flag (HALLEX I-2-1-94) in a paper case or, in an electronic case, by the “Homicidal/Potential Violent” or “Suicide Threat” flag in eView.

B. Adding and Removing Critical Case Designations

1. Adding a Critical Case Designation

In the ODAR RO, the Regional Chief Administrative Law Judge (RCALJ) or the Regional Management Officer (RMO) is responsible for designating critical cases. The RMO is the primary point of contact for all inquiries on TERI, MC/WW, and CAL cases.

In the HO, the Hearing Office Chief Administrative Law Judge (HOCALJ) or his or her designee (e.g., Hearing Office Director, Group Supervisor, or assigned administrative law judge (ALJ) with express delegation from the HOCALJ) is responsible for designating critical cases. The HOCALJ is the ultimate point of contact for critical cases and ensuring that procedures are followed, even if he or she has delegated critical case designation authority to another manager.

NOTE:

If a case has been assigned to an ALJ when the HO is first notified of the critical case allegation, but the assigned ALJ is absent or unavailable for more than 24 hours, the HOCALJ or an individual designated by the HOCALJ will add the critical designation. If the ALJ is on prolonged leave, see HALLEX I-2-1-55 F for situations when a HOCALJ may reassign a critical case to a different ALJ.

2. Removing a Critical Case Designation

If a case is erroneously designated as critical or the condition that formed the basis of the critical designation is no longer present, the HOCALJ or his or her designee may remove the critical designation.

If the HOCALJ or his or her designee decides to remove a critical designation, he or she must annotate the reason for the action in CPMS in the “Remarks” section.

NOTE:

If a “TERI” designation is removed, the HOCALJ or his or her designee will notify the RO of the action.

For detailed information about modifying a CAL designation, refer to POMS DI 23022.055B.

C. Case Processing

1. Identifying Critical Cases

All employees who initially screen files and mail are responsible for bringing potentially critical cases to the attention of a person with the authority to designate critical cases. If a claimant submits a critical allegation by fax or mail, the employee who is responsible for associating the mail with the case file will complete the Critical Request Evaluation Sheet in HALLEX I-2-1-95 based on the written allegation.

If a claimant calls or comes to the HO with an allegation of a critical situation while the case is pending, the employee receiving the call will obtain as much information about the situation as possible, using the Critical Request Evaluation Sheet in HALLEX I-2-1-95 as a guide. The employee will also complete a report of contact documenting the call or visit. If appropriate, the employee may have the claimant complete a Form SSA-795 describing the critical situation.

All documentation will be associated with the record and the employee will notify the appropriate person of the need for a critical case review as follows:

  • For an electronic file, the employee will use a “To Do Item” to alert the appropriate person of the need for a critical case review.

  • For paper cases, the employee will hand-carry the file to a person with the authority to designate cases as critical.

2. Documenting Critical Cases

When an individual designated to do so finds critical case processing is warranted, he or she will add the appropriate case characteristic (TERI, MCWW, CAL, SUIC, HOMC, DRND, etc.) in CPMS. If the case has congressional interest, the individual will also enter the case characteristic and listing type “Congressional.” The date critical case processing is designated will be the characteristic's “start date.”

Additionally, the designated individual will ensure that a claim(s) file for a critical case has the appropriate flag. Electronic flags must be entered into eView for electronic cases. For paper cases, one of the following paper flags must be attached to the front of each paper claim file, as applicable:

  • For all non-TERI or non-MC/WW cases, a completed Critical Case/Dire Need flag, found in HALLEX I-2-1-94, or other visible and easily identifiable flag clearly marked and labeled “Critical Case”;

  • A completed TERI case flag, Form SSA-2200; or

  • A completed MC/WW case flag, found in HALLEX I-2-1-96.

NOTE:

For concurrent claims, the flag must appear on the front of each claim file.

3. Reviewing For On-The-Record Decision

HO management will immediately assign critical cases for on-the-record (OTR) decision review. When an electronic file is involved, the assigned reviewer will receive a “To Do Item” in CPMS. Paper cases will be hand-carried for OTR review. If an OTR decision is possible, the case will be assigned to a decision-writer for expedited writing. If an OTR decision is not appropriate, staff will take appropriate action to expedite pre-hearing development and schedule a hearing.

4. Scheduling a Hearing, When Necessary

When a critical case is ready for scheduling, the employee responsible for workup or development will create a “To Do Item” in CPMS or hand-carry a paper case to the scheduling employee for priority scheduling.

The scheduling employee will schedule critical cases in the first available open hearing slots after consultation with the claimant, representative, and any expert witnesses (if applicable). If previously scheduled hearing slots become available due to cancellation or rescheduling, the slots will be offered to claimants with designated critical cases. If there are less than 20 days before the hearing date, the case will be scheduled only if the claimant and/or his or her representative are willing to waive in writing the right to the 20-day advance notice of hearing.

5. Issuing a Decision

Staff must expedite decision writing and any necessary post hearing development for critical cases.

a. Fully or Partially Favorable Decisions

If the ALJ issues a fully or partially favorable decision on a critical case, the HO will:

  • Expedite preparation and release of the decision; and

  • Send the file to the effectuating component, using the most expeditious method practical (e.g., express mail).

Except for paper cases sent to the Office of Disability Operations (ODO), HO staff will use the standard effectuating component addresses. For paper cases sent to ODO for effectuation, HO staff will use the following addresses:

Critical Cases

TERI Cases

SSA
ODO, Critical Case Unit
1500 Woodlawn Drive
Baltimore, Maryland 21241
SSA
ODO, TERI Case Unit
1500 Woodlawn Drive
Baltimore, Maryland 21241

b. Dismissals and Unfavorable Decisions

If the ALJ issues a dismissal or an unfavorable decision, the HO will:

  • Expedite preparation and release of the decision or order; and

  • Follow standard procedures for claim(s) file routing.

D. Monitoring Cases Designated as Critical

The HO Management Team will monitor and track the HO's progress in processing critical cases. HOs may alter normal case processing procedures if such action will expedite payment of benefits (e.g., splitting a concurrent case to issue a favorable SSI decision when the title II claim requires development).

Each HO will maintain a list of its critical cases for internal monitoring, tracking, and reporting purposes. The HO may also be required to issue reports to other components occasionally for review or information purposes. The list must show the date (month/day/ year) the case was designated as critical, the claimant's name and social security number, the designating office, the reason for the critical designation, and the current status of the case. If applicable, the reasons why the status of a particular case has not changed for an inordinate period of time (i.e., beyond benchmarks) will be captured in the “Remarks” section in CPMS.

Each RO will monitor the lists of critical cases and compliance with critical case handling procedures for the HOs within its jurisdiction. If the RO itself is handling a critical case, RO staff will follow the monitoring procedures set forth in this section.