Form SSA-2930(revised) RSI/DI Quality Review Case Analysis - Sampled Number Hol

Social Security Administration

Form Approveed

OMB No. 0960-0189

RSI/DI QUALITY REVIEW CASE ANALYSIS – SAMPLED NUMBER HOLDER

NOTE TO REVIEWER: In opening the interview, explain that this case is one of a small number selected by chance for review and that the purpose of this review is to find out how well the Social Security program is working. Tell them that the review consists of asking questions about their entitlement to Social Security benefits and that we may need to talk to others who have information about their entitlement. If necessary, point out that the Social Security Administration is authorized by law to review from time to time the entitlement of beneficiaries.

This information collection meets the clearance requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. The beneficiary is not required to answer these questions unless we display a valid Office of Management and Budget control number. We estimate that it will take about 30 minutes to read the instructions, gather the necessary facts, and answer the questions. Send only comments relating to our time estimate above to: SSA, 6401 Security Blvd., Baltimore, MD 21235-6401.

I. IDENTIFYING AND REVIEW INFORMATION

A. SIC:		     			B. NH’s SSN:				     
C. Sample Selection Date (As Shown on SCL):									     
D. Review Amount on SCL: $					     
E. Review Amount Determined by QR: $								     
F.	Explanation of SCL Changes, if Any:      
G. NH’s Name (As Shown on MBR):						     
H. NH’s Address/Phone
	 Address:      
Phone:			(    )	     
I. Payee Name Address/Phone
	Name:		     
	 Address:      
Phone:			(    )	     
NH Under FRA and Entitled to RIB in Closed Year (Complete SSA-4281/SSA-4659)

II. NUMBER HOLDER

A. Identity

Type of Interview

Face-to-Face

Telephone

B. Other Names and SSNs Shown in Claims Folder/Numident

1. Other Names:	     		     
2. Other SSNs:	     		     

C. Date of Birth/Citizenship
	1. Date of Birth and Proof Code on MBR Printout:				     			     
	2. Place of Birth:		     
	3. MN:	     		FN:		     
	4. Applications Filed 12/1/96 or Later: U.S. Citizen/National Lawfully-Present Alien
	 5. Evidenc /Documentation in Claims Folder/MCS Screens:      
	 6. Evidence Needing Verificatio :      
	 7. Date of Birth Established by Desk Review:      
	 8. Citizenship/Alien Status Established by esk Review:      
	 Remarks:      

II. NUMBER HOLDER							Consolidated Review
A. Identity							A. Identity
	1. Existence Verified by:						     
		Observation		Photo ID	     
		Other:	     
	2. SSN Verified by:			SSN Card		Medicare Card
		Other:	     
B. Other Names and SSN’s Used							B. Other Names/SSN’s
		Number Holder Agrees With DR Summary					     
		Number Holder Disagrees With DR Summary
		 (Explain)      
C. Date of Birth and Citizenship/Alien Status							C. DOB and Citizenship/Alien
		Number Holder Agrees With DR Summary					     
		Number Holder Disagrees With DR Summary
		 (Explain)      
		 Evidence Obtained in Field Review:      

II. NUMBER HOLDER

D. Application

1. Benefit Type:	RIB DIB		If DIB, Established Onset Date:		     
2. Date Claim Filed:		     
3. DOE (and MOEL Option Code if RIB):				     
4. DOE Determined by Desk Review:				     
 Remarks:      

E. Multiple Entitlement Involved

YES (Complete Below)

NO

1. Claim Number on Non-sampled SSN:

     

2. Scope of Review on Non-sampled SSN:

Full Review Limited Review Not in Scope of Review

F. Other Claims Activity

1. Did the NH ever file for any other benefits (including SSI)?

YES (Explain)

NO

     

2. Does the NH have any eligible children who have not filed for benefits?

YES (Explain)

NO

     

3. Unadjudicated Claims Issues:

NONE APPLY

Unprocessed Application

Deemed Filing

Protective Filing

Open Application

Partial Adjudication

Potential Entitlement (Leads)

Delayed Claim

Misinformation

 (Explain)      

II. NUMBER HOLDER		Consolidated Review
D. Application		D. Application
	Number Holder Agrees With DR Summary	     
	Number Holder Disagrees With DR Summary
	 (Explain)      
E. Multiple Entitlement		E. Multiple Entitlement
	Number Holder Agrees With DR Summary	     
	Number Holder Disagrees With DR Summary
	 (Explain)      
F. Other Claims Activity		F. Other Claims Activity
	Number Holder Agrees With DR Summary	     
	Number Holder Disagrees With DR Summary
	 (Explain)      

II. NUMBER HOLDER

G. Underpayment on Sampled SSN Needed to Be Addressed

YES (Explain)

NO

     

H. Recovery of Overpayment in Sample Month

YES (Explain)

NO

     

I. SMI Determination

NOT APPLICABLE

The SMI determination, including the premium deduction and penalty amounts (if any), is correct.

YES

NO (Explain)

     

J. Payment Amount

1. Amount of CMA/SM Check: $

     

, Period:

     

2. Payment Cycle Indicator (CYI):

     

3. Payment Combined with Other Benefit: YES NO

4. Check Amount Affected by Other Withholding (e.g., Medicare C/D Premiums, Voluntary Tax Withholding, Garnishment, Treasury Offset Program, etc.):

YES (Explain)

NO

     

II. NUMBER HOLDER					Consolidated Review
	G. Underpayment				G. Underpayment
		Number Holder Agrees With DR Summary			     
		Number Holder Disagrees With DR Summary
		(Explain)	     
	H. Recovery of Overpayment in Sample Month				H. Overpayment
		Number Holder Agrees With DR Summary			     
		Number Holder Disagrees With DR Summary
		 (Explain)      
	I. SMI Determination				I. SMI Determination
		Number Holder Agrees With DR Summary			     
		Number Holder Disagrees With DR Summary
		 (Explain)      
	J. Payment Amount				J. Payment Amount
		Number Holder Agrees With DR Summary			     
		Number Holder Disagrees With DR Summary:
		 (Explain)      

II. NUMBER HOLDER		NUMBER HOLDER NEVER MARRIED
K. Marital History of Sampled Number Holder
1. Current/Last Marriage to:	     
a. Age/Date of Birth:	     			b. SSN:	     
c. Date of Marriage:	     			d. Type:	     
e. Place of Marriage:	     
f. How Terminated:	     		g. Date Terminated:			     
h. Place Terminated:	     
 i. Evidence/Documentation in Claims Folder/MCS Screens:      
 j. Evidence Needing Verification:      
2. Prior Marriage to:	     
a. Age/Date of Birth:	     			b. SSN:	     
c. Date of Marriage:	     			d. Type:	     
e. Place of Marriage:	     
f. How Terminated:	     		g. Date Terminated:			     
h. Place Terminated:	     
 i. Evidence/Documentation in Claims Folder/MCS Screens:      
 j. Evidence Needing Verification:      
3. Prior Marriage to:	     
a. Age/Date of Birth:	     			b. SSN:	     
c. Date of Marriage:	     			d. Type:	     
e. Place of Marriage:	     
f. How Terminated:	     		g. Date Terminated:			     
h. Place Terminated:	     
 i. Evidence/Documentation in Claims Folder/MCS Screens:      
 j. Evidence Needing Verification:      

II. NUMBER HOLDER
K. Marital History of Sampled Number Holder
Number Holder Agrees With Marital History in DR Summary
Number Holder Disagrees With DR Summary: (Complete Below)
1. Current/Last Marriage to:	     
a. Age/Date of Birth:	     		b. SSN:	     
c. Date of Marriage:	     		d. Type:	     
e. Place of Marriage:	     
f. How Terminated:	     	g. Date Terminated:			     
h. Place Terminated:	     
i. Evidence Obtained:	     
2. Prior Marriage to:	     
a. Age/Date of Birth	     		b. SSN:	     
c. Date of Marriage:	     		d. Type:	     
e. Place of Marriage:	     
f. How Terminated:	     	g. Date Terminated:			     
h. Place Terminated:	     
i. Evidence Obtained:	     
3. Prior Marriage to:	     
a. Age/Date of Birth:	     		b. SSN:	     
c. Date of Marriage:	     		d. Type:	     
e. Place of Marriage:	     
f. How Terminated:	     	g. Date Terminated:			     
h. Place Terminated	     
i. Evidence Obtained:	     
 Consolidated Review:      

II. NUMBER HOLDER

L. Computation Information

1. Work Issues

Explanation

Wages

     

Self-Employment

     

Lag Wages/SEI

     

Gaps

     

Annual Reports

     

Other

     

2. Military Service

NONE

a. Branch of Service:

     

b. Serial Number:

     

c. Dates of Active Military Duty After September 7, 1939:

From

     

To

     

ALG/PRV/PRE

From

     

To

     

ALG/PRV/PRE

d. If MS prior to 1957, NH Receives/Eligible for Military/Civilian Federal Pension? YES NO

 e. Evidence/Documentation in Claims Folder/MCS Screens:      

 f. Evidence Needing Verification:      

3. Railroad Employment

NONE

a. Number of Service Months on Earnings Record:

     

b. Were 5 or more years of railroad work alleged?

YES NO

4. Prior Period of Disability

NONE

a. PPD Shown on MBR:

Date of Onset:

     

Term Date:

     

b. Documentation in File:

     

c. PPD Established by Desk Review:

Date of Onset:

     

Term Date:

     

II. NUMBER HOLDER							Consolidated Review
	L. Computation Information						L. Computation Information
	1. Work Issues						1. Work Issues
	Number Holder Agrees With DR Summary						     
	     
	Number Holder Disagrees With DR Summary:
		Year		Amount on E/R		Amount Alleged
		    		     		     
		    		     		     
	 Evidence Obtained in Field Review:      
	2. Military Service						2. Military Service
	Number Holder Agrees With DR Summary						     
	Number Holder Disagrees With DR Summary:
	 (Explain)      
	Evidence Obtained in Field Review:      
	3. Railroad Employment						3. RR Employment
	Number Holder Agrees With DR Summary						     
	Number Holder Disagrees With DR Summary:
	(Explain)		     
	4. Prior Period of Disability						4. Prior Period(s) of Disability
	Number Holder Agrees With DR Summary						     
	Number Holder Disagrees With DR Summary:
	 (Explain)      

II. NUMBER HOLDER

L. Computation Information

5. Windfall Elimination Provision

COMPLETE IF NUMBER HOLDER BORN JANUARY 2, 1924 OR LATER

a. NH has 30 or More Special Minimum Coverage Years.

YES (Go to II.M.)

NO

b. NH is Entitled to a Foreign or Domestic Pension, or Lump Sum in Lieu of a Monthly

Periodic Pension, Based on Work After 1956 Not Covered by Social Security.

YES

NO (Go to II.M.)

(1) Date of First Eligibility to Pension (Month/Year):

     

(2) Date of First Entitlement to Pension (Month/Year):

     

(If either date is prior to 1986, go to 5.d.)

(3) Other Exception to WEP Applies:

YES

     

NO

(If Yes, go to 5.d.)

c. Information About the Pension

(1) Agency or Organization from Which the Pension Is Received:

Name:

     

Address:

     

(2) Period(s) of Employment Upon Which the Pension Is Based (Include Both

Employment Covered and Not Covered by Social Security):

From (Month, Year):

     

To (Month, Year):

     

From (Month, Year):

     

To (Month, Year):

     

(3) Period(s) of Employment After 1956 Not Covered by Social Security That Is Used to

Determine the Pension:

From (Month, Year):

     

To (Month, Year):

     

From (Month, Year):

     

To (Month, Year):

     

(4) Amount of the Pension for the First Month the Claimant is Concurrently Entitled to the

Pension and the Social Security Benefit:

Monthly Amount: $

     

(Obtain proof if guarantee applies.)

 d. Evidence/Documentation in Claims Folder/MCS Screens:      

 e. Evidence Needing Verification:      

II. NUMBER HOLDER	Consolidated Review
L. Computation Information	L. Computation Information.
5. Windfall Elimination Provision	5. WEP
Number Holder Agrees With DR Summary	     
Number Holder Disagrees With DR Summary:
 (Explain)      
 Evidence Obtained in Field Review:      

II. NUMBER HOLDER
	M. Current DIB Entitlement			NOT APPLICABLE (Go to II.N.)
	1. Period(s) of Disability
	a. Current Established Onset Date:	     	b. Date of Entitlement:		     
	c. Prior Period of DIB: YES (Complete Below) NO
	Effect on Current Entitlement: Waiting Period Comps Medicare Other
	     
	2. Disability-Related Work Information
	a. Earnings After Current Established Onset Date: YES (Complete Below) NO
	     
	b. Disability-Related Work Issues	Explanation
	Trial Work Period	     
	Substantial Gainful Activity	     
	Unsuccessful Work Attempt	     
	Cessation	     
	Extended Period of Eligibility	     
	Termination	     
	Expedited Reinstatement	     
	Other	     
	 c. Evidence/Documentation in File:      
	 d. Evidence Needing Verification:      

II. NUMBER HOLDER		Consolidated Review
	M. Current DIB Entitlement	M. Current DIB Entitlement
	1. Period(s) of Disability	1. Period(s) of Disability
	Number Holder Agrees With DR Summary	     
	Number Holder Disagrees With DR Summary
	 (Explain)      
	2. Disability-Related Work Information	2. Disability-Related Work Info
	Number Holder Agrees With DR Summary	     
	Number Holder Disagrees With DR Summary
	 (Explain)      
	 Evidence Obtained in Field Review:      

II. NUMBER HOLDER
3. Worker’s Compensation/Public Disability Benefit (WC/PDB)
a. NH Filed for WC/PDB: YES NO (Go to II.M.4)
b. Status of Claim: Awarded (Complete Below) Denied Pending
c. Employer Name and Address		Payer Name and Address
     		     
 d. Describe Type of Payments Received:      
e. WC/PDB Affects Review Period Payment: YES NO
 (Explain)      
 f. Documentation in Claims Folder/MCS Screens:      
 g. Evidence Needing Verification:      
4. Child-Care Dropout (Less than 3 Regular Drop-Out Yrs): YES NO (Go to II.N)
a. Child Under Age 3 Lived With NH During a Year That NH Had No Earnings:
YES NO
 b. Documentation in Claims Folder/MCS Screens:      
 c. Evidence Needing Verification:      

II. NUMBER HOLDER	Consolidated Review
3. Worker’s Compensation/Public Disability Benefit (WC/PDB)	3. WC/PDB
Number Holder Agrees With DR Summary	     
Number Holder Disagrees With DR Summary:
 (Explain)      
 Evidence Obtained in Field Review:      
4. Child-Care Dropout Years	4. Child-Care Dropout
Number Holder Agrees With DR Summary	     
Number Holder Disagrees With DR Summary:
 (Explain)      
 Evidence Obtained in Field Review:      

II. NUMBER HOLDER
	N. Fugitive Felon
	a. Are there any unsatisfied felony warrants for NH’s arrest or for violations of probation/parole?
	YES NO (Go to II.O)
	 b. Evidence/Documentation in Claims Folder/MCS Screens:      
	 c. Evidence Needing Verification:      
	O. Criminal Activities
	NH Not Involved in Any Criminal Activities Listed Below
	Removal (formerly Deportation)			Subversive Activities
	Offenses Against the National			Confined for a Criminal Offense
		Security (Hiss Act)
	Disability Determination Based on a Condition That Occurred During the Commission of a
		Felony After October 19, 1980
	Disability Determination Based on a Condition That Occurred During Confinement for a Felony
		Conviction
	 Evidence/Documentation in Claims Folder/MCS Screens:      
	 Evidence Needing Verification:      
	P. Representative payee
	Does the claims folder indicate an unresolved representative payee issue (need for payee change,
	etc.) for the sampled number holder?
	YES (Explain) NO
	     

II. NUMBER HOLDER						Consolidated Review
	N. Fugitive Felon					N. Fugitive Felon
		NH states/desk review summary shows that there are no unsatisfied felony warrants for arrest or for violations of probation/parole.				     
		YES		NO (Explain)
		     
		 Evidence Obtained in Field Review:      
	O. Criminal Activities					O. Criminal Activities
		If any of the criminal activities listed in II.O. of the desk				     
		review summary are involved, discuss and resolve below.
		     
	P. Representative Payee					P. Representative Payee
		There is an indication that an unresolved representative				     
		payee issue exists (need for payee change, etc.) for the sampled number holder.
		YES (Explain)	NO
		     

II. NUMBER HOLDER

Q. Consolidated Review Summary

Desk and field review findings are in agreement.

Desk and field review findings are not in agreement. Indicate the section(s) where the

disagreement exists.

Section A

Section B

Section C

Section D

Section E

Section F

Section G

Section H

Section I

Section J

Section K

Section L

Section M

Section N

Section O

Section P

Additional Development/Findings/Remarks:

     

Signature of Reviewer(s)

     

Date:

     

Desk Reviewer

     

Date:

     

Field Reviewer

     

Date:

     

Consolidated Reviewer

Form SSA-2930-BK (xx-xxxx)

Destroy All Prior Editions

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