a) 20 CFR 411.140(d)(2) - Ticket Assignability - Portal

Portal phase-II forms for submission for OMB approval

Portal Phase-II Forms for submission for
OMB approval
Mike Kelsey
Version 1.2
Date: 07/19/2012

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Portal phase-II forms for submission for OMB approval

Revision & Approval Record
Revision History
Date
07/02/2012
07/19/2012
07/23/2012

Author
M. Kelsey
T. Ranganathan
M. Kelsey and T.
Ranganathan

Version
1.0
1.1
1.2

Change Reference
Changed COS screens
Incorporated feedback from SSA on the
COS screens

MAXIMUS Approvers
Name

Version Approved

Date

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Portal phase-II forms for submission for OMB approval

Table of Contents
1. Summary ................................................................................................................................ 4
2. Payment Request Form ........................................................................................................ 4
3. Revenue Estimator ................................................................................................................ 6
4. Supplemental Payment Form .............................................................................................. 8
5. Certification of Services (COS) Form ................................................................................. 9
6. Payment Status (detail) report ........................................................................................... 12
7. History of VR activity with beneficiaries .......................................................................... 14
8. Closure Form....................................................................................................................... 16
9. APOR Form......................................................................................................................... 18
10. BPA Change Form .............................................................................................................. 19
11. Notification of Split Payments and Allocation Notices .................................................... 24
11.1 Possible Split Payment Notice ...................................................................................... 24
11.2 Allocation Notice .......................................................................................................... 26

Table of Figures
Figure 2-1: Payment Request submission form .............................................................................. 5
Figure 3-1: Input screen for Revenue Estimator (optional self-help tool) ...................................... 6
Figure 3-2: Result screen for Revenue Estimator (optional self-help tool) .................................... 7
Figure 4-1: EN Supplemental Earnings Statement submission form ............................................. 8
Figure 5-1: EN Supplemental Earnings Statement submission form – page 1 ............................. 10
Figure 5-2: EN Supplemental Earnings Statement submission form – page 2 ............................. 11
Figure 6-1: Input screen for querying Detailed Payment Status ................................................... 12
Figure 6-2: Detailed Payment Status result screen ....................................................................... 13
Figure 7-1: Input screen for querying VR activity history ........................................................... 14
Figure 7-2: VR Activity History screen ........................................................................................ 15
Figure 8-1: Closure Request Screen ............................................................................................. 16
Figure 8-2: Closure Request confirmation screen ........................................................................ 17
Figure 9-1: APOR submission screen ........................................................................................... 18
Figure 10-1: Section 1 of BPA form ............................................................................................. 19
Figure 10-2: Section 1 of BPA form (continued) ......................................................................... 20
Figure 10-3: Section 2 of BPA form (continued) ......................................................................... 21
Figure 10-4: Section 2 of BPA Form (continued) ........................................................................ 22
Figure 10-5: Section 2 of BPA Form (continued) ........................................................................ 23
Figure 11-1: Possible Split Payment Notification ........................................................................ 24
Figure 11-2: Possible Split Payment Notification (continued) ..................................................... 25
Figure 11-3: Payment Allocation Determination Notification ..................................................... 26
Figure 11-4: Payment Allocation Determination Notification (continued) .................................. 27

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1. Summary
This document describes additional features and capabilities of the Secured Portal. The Portal
features allow vocational rehabilitation and employment support service providers, who are the
users, to submit or request information and receive reports and other information. Additionally
there are features such as file transfers and system extracts, but these are internal system
processes and therefore not presented here.

2. Payment Request Form
The Payment Request Form allows the user to submit a request for a milestone or an outcome
payment through the portal. User will specify the beneficiary for whom they have performed
services and are requesting payment. The system verifies the relationship between the provider
and beneficiary as well as makes other validations. The form allows users to enter additional
information regarding the request as freeform text such as additional information that might be
needed as justification.

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Figure 2-1: Payment Request submission form

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3. Revenue Estimator
The Revenue Estimator provides ENs and prospective ENs projections about the amount of
revenue they can expect based on various scenarios. For example, it provides information on the
projected dollar amount in payments that may be available to the EN based on the number of
clients they have or anticipate. The EN specifies the details of the scenario.

Figure 3-1: Input screen for Revenue Estimator (optional self-help tool)

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Figure 3-2: Result screen for Revenue Estimator (optional self-help tool)

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4. Supplemental Payment Form
The Supplemental Payment form allows service providers to submit through the Portal additional
information about beneficiaries’ reported income. Should paystubs or other documentation
submitted be incomplete, this form allows the provider to record and send us information related
to the beneficiary’s pay. The form identifies the source of the income (employer) and added
information about the income such as gross pay, various withholdings and other pay related
information. It supplements information previously submitted about a beneficiary. This form
minimizes the need to submit a paper form with this information thereby expediting the
exchange of information about beneficiaries’ pay.

Figure 4-1: EN Supplemental Earnings Statement submission form

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5. Certification of Services (COS) Form
The COS form allows the service provider to inform SSA of the services they have provided the
beneficiary and future services they will provide or assist the beneficiary in obtaining. There is a
freeform text field to allow expanded explanation of the services. The online form may be used
in lieu of the paper form to transmit the information immediately to the support desk.

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Figure 5-1: EN Supplemental Earnings Statement submission form – page 1

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Figure 5-2: EN Supplemental Earnings Statement submission form – page 2

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6. Payment Status (detail) report
The service provider can obtain through the Portal a listing of the payments in process or paid to
its organization on behalf of a certain beneficiary including the payment type and the status of
where a pending payment is in the payment process. The result returns immediately.

Figure 6-1: Input screen for querying Detailed Payment Status

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Figure 6-2: Detailed Payment Status result screen

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7. History of VR activity with beneficiaries
This screen allows a service provider to check whether a beneficiary has previously had an open
case with the state VR agency. The resulting report, which returns immediately, lists the state
VR agency, the case closure data and the closure reason.

Figure 7-1: Input screen for querying VR activity history

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Figure 7-2: VR Activity History screen

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8. Closure Form
A service provider may use this Portal form to close an open case with a beneficiary. Use of this
screen will result in the ticket being released from the service provider requesting the closure.

Figure 8-1: Closure Request Screen

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Figure 8-2: Closure Request confirmation screen

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9. APOR Form
The APOR (Annual Performance Outcome Report) form presents a series of questions for the
service provider to answer about their organization and the work they perform under the Ticket
to Work program. This information provides data for a variety of purposes, including foe
program evaluation and use in a report card for beneficiaries’ who are searching for an EN.

Figure 9-1: APOR submission screen

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10. BPA Change Form
BPA Change Form provides service providers an on-line screen to change information about
their organizations. Providers may submit their changes using this form at any time. This
information is used to update their organization’s information such as contact names and
addresses, in SSA’s records. The sample below must be coded to a screen for the Portal.
SECTION ONE
Directions: Pleaae indicate the section(s) to which you wish to make changes by entering the
information in where indicated.
Update Mailing Address:_______________________________________
Update Actual Address:________________________________________

Change Beneficiary Contact Information
Beneficiaries will be given this information in order to contact your EN. Contact Name:
_________________________________________________
Phone:

____________________

Toll Free #: ____________________
Fax:

____________________

TTY:

____________________

Email:

______________________________________________

Former contact no longer with the organization?

Yes __

No __

Figure 10-1: Section 1 of BPA form

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Change Signatory Authority Contact Information
Contact Name:

_________________________________________________

Phone:

____________________

Toll Free #:

____________________

Fax:

____________________

TTY:

____________________

Email:

______________________________________________

Former contact no longer with the organization?

Yes __

No __

Change Payment Contact Information
EN-designated Contact to receive notices and statements and follow-up inquiries
from the Social Security Administration and the MAXIMUS EN Payment Department
Contact Name:
Phone:

_________________________________________________

____________________

Toll Free #: ____________________
Fax:

____________________

TTY:

____________________

Email:

______________________________________________
Figure 10-2: Section 1 of BPA form (continued)

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SECTION TWO
Changes to information in this section will be sent directly to your Account Manager

Change EN Contact Information
EN designated contact OTHER than the Signatory Authority to receive/answer requests from
SSA concerning the EN BPA, and authorized to make changes to the BPS.
Contact Name:
Phone:

_________________________________________________

____________________

Toll Free #: ____________________
Fax:

____________________

TTY:

____________________

Email:

______________________________________________

Former contact no longer with the organization?

Yes __

No __

Change Payment Status Report Information
EN designated contact to receive EN Payment Status Report from the MAXIMUS EN Payment
Department. This contact may be different than the EN Payment Information Contact.
Contact Name:
Phone:

_________________________________________________

____________________

Toll Free #: ____________________
Fax:

____________________

TTY:

____________________

Email:

______________________________________________

Figure 10-3: Section 2 of BPA form (continued)

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Add or Delete Service Areas
National

Serving all states amd US Territories

____(A/D)

Multi-State
State
State
State
State

_______________________________
_______________________________
_______________________________
_______________________________

Single State

____(A/D)
____(A/D)
____(A/D)
____(A/D)

_______________________________

____(A/D)

Add or Delete Counties Served
For each state you are serving select the county you wish to add or delete
State _______________________
State _______________________
State _______________________
State _______________________

Country
Country
Country
Country

______________
______________
______________
______________

___(A/D)
___(A/D)
___(A/D)
___(A/D)

Add or Delete Zip Codes Served
For each state you are serving select the zip code you wish to add or delete
State _______________________
State _______________________
State _______________________
State _______________________

Zip Code
Zip Code
Zip Code
Zip Code

______________ ___(A/D)
______________ ___(A/D)
______________ ___(A/D)
______________ ___(A/D)

Figure 10-4: Section 2 of BPA Form (continued)

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Add, Delete, or Change Doing Business As (DBA) Name
Add Name
_________________________________________________________
Change Name
_________________________________________________________
Delete Name _________________________________________________________
Add, Delete, or Change Website Address
Add Address
_________________________________________________________
Change Address
_________________________________________________________
Delete Address
_________________________________________________________
Do you want a link to this website on the Employment Network Directory?
____

Yes___

No

Add or Update Test Field
Display the following text below your EN name in the EN Directory (270 character maximum)

Change Type of Organization
Check all that apply.
___
Advocacy Group
___
Business/Employer
___
Community Based Organization
___
Education/Training
___
Faith-based Organization
___
Healthcare Provider
___
State/Local Government
___
Transportation/Transit

Add or Delete Preferred Impairment Groups Served
Impairment Group
______(drop down)
Impairment Group
______(drop down)
Impairment Group
______(drop down)
Impairment Group
______(drop down)

__ (A/D)
__ (A/D)
__ (A/D)
__ (A/D)

Add or Delete Services Offered
Service
______(drop down)
Service
______(drop down)
Service
______(drop down)
Service
______(drop down)

__ (A/D)
__ (A/D)
__ (A/D)
__ (A/D)

Add or Delete Service Locations
___A/D
Location Address:
_____________________________________________________________

Figure 10-5: Section 2 of BPA Form (continued)

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11. Notification of Split Payments and Allocation Notices
The following two notices are generated when a payment request is submitted for a beneficiary
and the beneficiary has had more than one service provider under the Ticket program. In these
instances, the payment may be split among the providers depending on the provision of services
each provided. Once an EN requests payment, the Possible Split Payment notification is sent
through the Portal to all providers who previously held the beneficiary’s ticket assignment. The
providers are asked to negotiate and propose a split for approval. The providers may opt to
contest the allocation that is approved in which case they return the notification stating this.

11.1 Possible Split Payment Notice
MAXIMUS Ticket to Work Program
EN Payment Department
P.O. Box 1433
Alexandria, Virginia 22313
March 24, 2010

JOHN DOE
ABC, INC
123 NOTHING RD
ANYWHERE, VA 22314
Re: Potential eligibility to Split EN Payments on Behalf of Ticket-holder listed below.
Based on Ticket history, this ticket has been assigned to more than one EN at different times. The
other EN(s) involved: ACME
Our records show that you held or hold a ticket assignment for the Ticket-holder named below.
Therefore, you and the other EN(s) named above may be entitled to a possible split payment for this
Ticket holder. If you believe you are entitled to split payments on behalf of this Ticket-holder based
on the services you provided, please send us the information requested on the next page within 30
days of the date of this letter. This information may be faxed or mailed. No evidence of earnings is
required. Not submitting a split payment request within 30 days will indicate that your agency is not
interested in pursuing possible split payments.
Name of Ticket-holder: JANE SMITH
Ticket Number: TW 1
Figure 11-1: Possible Split Payment Notification

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To request split payments, please provide the following information:
1. Service Records – Detail services provided to Ticket holder as well as dates of service.
2. Completed Payment Request form for the following claim(s).
_________________________________________________________________
3. Form SSA-1401 – Complete this form to indicate the results of the negotiation between
EN organizations involved and payment percentage allocation determination or request to
have PM negotiate payment percentage allocation determination.
If You Have Any Questions
As our valued partner in the Ticket to Work Program, we appreciate your interest and commitment.
We look forward to working with you to serve your needs. We invite you to visit the
www.yourtickettowork.com and www.ssa.gov/work websites regularly for program updates,
general information, and training opportunities.
If you have any questions regarding the Ticket to Work Program, please contact us at 1-866-9493687 or TDD 1-866-833-2967 or via fax at 703-683-3289. You can also write to us at the
following address:
MAXIMUS Ticket to Work
EN Payment Department
P.O. Box 1433
Alexandria, VA 22313

Sincerely,
MAXIMUS Ticket to Work Program
EN Payment Department
Enclosure:
Form SSA-1401
Figure 11-2: Possible Split Payment Notification (continued)

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11.2 Allocation Notice
MAXIMUS Ticket to Work Program
EN Payment Department
P.O. Box 1433
Alexandria, Virginia 22313
August 3, 2012

JOHN DOE
ABC, INC
123 NOTHING RD
ANYWHERE, VA 22314

Re: Request to Split EN Payments on Behalf of Ticket-holder listed below.
We have reviewed the information submitted and approved the payment allocation as follows:
Name of Ticket-holder: JANE SMITH
Ticket Number:

TW 1

Allocation Determination:
Future payments may be subject to periodic reviews to ensure that the payment percentages
reflect current contribution of services.
EN Name and DUNS
Number

Percentage

Payment Type

Figure 11-3: Payment Allocation Determination Notification

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If You Disagree

If you disagree with the approved payment percentage, you may ask us to reconsider it.
Please submit additional information within 30 days of the date of this letter with your
request explaining what you believe should be the payment percentage for each EN and
why you believe the percentages should be different.
If You Have Any Questions
As our valued partner in the Ticket to Work Program, we appreciate your interest and
commitment. We look forward to working with you to serve your needs. We invite you
to visit the www.yourtickettowork.com and www.ssa.gov/work websites regularly for
program updates, general information, and training opportunities.
If you have any questions regarding the Ticket to Work Program, please contact us at 1866-949-3687 or TDD 1-866-833-2967 or via fax at 703-683-3289. You can also write
to us at the following address:
MAXIMUS Ticket to Work
EN Payments Department
P.O. Box 1433
Alexandria, VA 22313

Sincerely,
MAXIMUS Ticket to Work Program
EN Payments Department

Figure 11-4: Payment Allocation Determination Notification (continued)

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