When the DAP advocate receives the PA 731 from the eligibility worker, the DAP advocate will:
1. Review the PA 731 and enter the required data onto the DAP Client Tracking and Reporting System.
NOTE: If a Cash or Medicaid case has a PA 1663 or PA 1664 indicating the recipient is permanently disabled, the advocate must accept the case and the recipient must cooperate in pursuing SSI/SSDI.
All other referrals should be reviewed for appropriateness. Inappropriate referrals should be returned through the supervisor to the referring eligibility worker. Do not enter inappropriate referrals on the DAP data base.
2. Receive referrals from other agencies, such as the Mental Health Base Service Unit or SSA. SSA may send the information through the State Data Exchange (SDX) or may telephone about a recipient who is in the appeal process.
3. Schedule an interview with the recipient, using a Client Appointment Letter (PA 735), if either the recipient or the CAO worker has requested the advocate's help.
NOTE: The initial SSI/SSDI application process may not involve the DAP advocate. The recipient may complete the initial SSI/SSDI application on his own. In these instances, the advocate does not become involved until the recipient has been denied SSI/SSDI.
4. At the interview with the recipient the DAP advocate will:
explain the advocate's role and how it differs from that of the CAO worker's;
give the recipient a DAP Contact Card (PA 736);
emphasize the benefits to the recipient of receiving SSI/SSDI benefits;
NOTE: Remind the cash or Medicaid applicant/recipient that he must pursue benefits as a condition of eligibility.
55 Pa. Code §§ 141.21(h)(1), 181.1(d) and 183.13(b)
Complete the Appointment of Representative Form (SSA 1696-U4).
NOTE: If appointed as representative, the advocate must sign the fee waiver section of the form.
assess the recipient 's capabilities and determine if any family, friends, or other social service agency personnel are available to help him with his SSI/SSDI application; and
complete a DAP Disability Report (PA 734) to develop social, medical, and employment histories.
NOTE: The advocate should identify all terminal illness cases which meet the following criteria and notify SSA in order for them to receive priority handling.
1. Any claim involving an allegation or diagnosis of AIDS.
2. Any claim in which the claimant is in a hospice or is receiving hospice care.
3. Any conditions which medical records indicate is untreatable; that is, supportive care is being given to ease pain and suffering, but the condition cannot be reversed and is expected to end in death.
4. Any claim in which there is an allegation (e.g. from the claimant, family member, doctor or other medical source) that the illness is terminal.
1. Forward the necessary medical documentation information to the MRT using a Medical Review Team Transmittal (PA 749).
2. Promptly notify the CAO worker of the MRT decision.
During the SSI/SSDI application process, the DAP advocate will:
1. If requested, assist the recipient in the interview with the SSA worker by:
helping the recipient complete the SSI/SSDI applications, if necessary; and
helping the recipient complete the Appointment of Representative Form (SSA 1696-U4). The Appointment of Representative Form is essential for SSA to keep the advocate updated on the progress of the recipient 's SSI/SSDI application. Tell the recipient that he may appoint the advocate as representative.
NOTE: The advocate must sign the fee waiver section of the form if appointed as representative.
2. Update the DAP Client Tracking and Reporting System.
3. Maintain contact with the recipient and the SSA district office as needed regarding any appointments which SSA schedules for consultative examinations and other information which is needed.
NOTE: Occasionally the recipient may have his SSI/SSDI application rejected because SSA is not able to obtain hospital or doctor records needed to establish SSI/SSDI eligibility. When this occurs, the DAP advocate will contact the provider to facilitate the receipt of medical documentation for SSA.
If the provider charges a fee for copying the medical records, the DAP advocate will give the provider a copy of Medical Assistance PA. Code Chapter 1101-51(e), which states that providers must produce records for copying by state officials. The DAP advocate will ask to take the necessary documentation to the CAO for copying.
4. Help the recipient as needed in keeping consultative examination appointments. Arrange for or provide transportation as needed.
NOTE: If a consultative examination appointment must be changed, the DAP advocate will contact the appropriate Bureau of Disability Determination office. They will change the appointment with the physician.
NOTE: DAP staff may be reimbursed for the purchase of meals for DAP recipients who have medical appointments, hearings, etc., during meal times.
If the recipient fails to appear at the scheduled SSI/SSDI application interview, SSA notifies the DAP advocate via the PA 731 or by telephone.
The DAP advocate will schedule an interview with the recipient within 10 days of receiving notification from SSA.
Any time the recipient fails to keep an appointment with the DAP advocate, the advocate will try to determine the reason the recipient did not keep the appointment. The advocate may contact the recipient's family and friends and any community social services known to be working with the recipient.
If the recipient continues to refuse to cooperate in the SSI/SSDI application process without good cause, the DAP advocate will:
discontinue DAP services;
send the CAO worker a PA 731 to notify him that he is discontinuing DAP services due to the recipient 's failure to cooperate without good cause; and
update the DAP Client Tracking and Reporting System.
If the DAP advocate notifies the CAO worker that a cash or Medicaid recipient is not cooperating, the CAO worker will send the recipient an Advance Notice (PA/FS 162-A) advising him that cooperation in applying for Federal benefits is a condition of eligibility for cash and Medicaid. To remain eligible for cash or Medicaid, he must contact the DAP advocate to schedule an appointment.
NOTE: The PA/FS 162-A must cite the name, address, and phone number of the advocate.
55 Pa. Code §§ 141.21(h)(1), 181.1(d) and 183.13(b)
If the recipient schedules and keeps the appointment with the DAP advocate, the advocate will immediately notify the CAO worker and follow up with a new PA 731 to ensure that the recipient remains eligible. The advocate will send the original to the CAO worker and keep a copy in the DAP file.
If the recipient does not schedule and keep the appointment, the CAO worker will:
close the case if it is a one-person budget or remove the non-cooperating individual from the budget group after the PA/FS 162-A expires; and
record the facts in the case file.
If SSA approves SSI/SSDI, the DAP advocate will:
update the DAP Client Tracking and Reporting System; and
notify the CAO worker with a PA 731. Attach any available verification.
If SSA denies the initial application, the first appeal step is a hearing before an Administrative Law Judge (ALJ). The cash/medical recipient must appeal an initial denial through the ALJ stage, unless the DAP worker and/or lawyer has determined the recipient does not have a reasonable chance of being determined eligible for SSI/SSD.
If the recipient refuses to cooperate with the DAP advocate during the ALJ process, the DAP advocate will advise the CAO caseworker, who will send a 162A to close.
For the ALJ process, the DAP advocate will:
1. Interview the recipient and discuss the SSI/SSDI appeal process including:
Complete the Request for Hearing Form (HA 501-U5), the Authorization to Disclose Information to the Social Security Administration (SSA 827) and Disability Report – Appeal (SSA 3441-BK).
NOTE: The ALJ appeal must be submitted to SSA within 60 days of initial denial.
Explain the advocate's role and the difference between the advocate and the CAO worker, if this is the first contact with DAP.
Give the recipient a DAP contact card.
Complete the DAP Disability Report (PA 734) or other disability questionnaire to develop social, medical, and employment histories.
2. Contact SSA to obtain copies of consultative examination reports, Social Security denial letters, and justifications.
3. If needed, seek advice as to whether to pursue an appeal by forwarding the SSA information and the DAP file to the MRT for review and recommendation. The MRT will recommend whether or not the recipient should pursue the appeal any further. Include the following forms in the referral:
MRT Transmittal (PA 749). The MRT may return this form if it needs additional information. The MRT will also note its decision on this form. The DAP advocate keeps the original with the MRT's determination. A copy should be kept in the ongoing eligibility case record.
A copy of the SSA Denial Notice (SSA 4268-C4), including consultative examination reports, the denial letter, and the justification for the denial.
A copy of the DAP Disability Report (PA 734).
Copies of medical documentation in the DAP case record. The CAO will keep the originals in the case record.
The following forms should also be included if they are contained in the SSA case record. They are usually stapled to the front of the record:
SSA 3368-BK (disability report).
SSA 3369-BK (vocational report).
SSA 5002 - record of phone contacts with the recipient, friends, agencies, etc.
SSA 4734-U8 or SSA 4734-F4 - Mental or Physical Residual or Functional Capacity Assessment.
SSA 2506-BK - Psychiatric Review Technique.
DD 164 - Psychiatric Activities Assessment.
any other doctor or hospital reports the advocate does not have.
Send the information to:
Medical Review Team
410 Second Avenue
Jessup, PA 18452
When the MRT receives the SSA and DAP information, the MRT will:
1. Review the information to determine if the MRT agrees or disagrees with SSA's decision that the recipient is not disabled.
2. Recommend additional medical or psychiatric examinations, if appropriate, by either regular Medicaid providers or specialists outside the Medicaid program.
NOTE: If enough information is available, the MRT may certify the recipient as disabled as well as recommend that he pursue the appeal.
3. Notify the advocate of its decision within 20 days.
If the MRT agrees with SSA that the recipient is not disabled, the DAP advocate will:
1. Send the CAO worker a PA 731 notifying him of the decision.
2. Send the recipient a DAP Termination Letter (PA 737).
3. Update the DAP Client Tracking and Reporting System.
4. Terminate DAP activity.
NOTE: If the MRT denies disability, the advocate may decide either to continue the appeal process or to discontinue DAP services. The advocate may continue to provide services if he feels that the recipient is disabled by SSI standards and that he can make a substantive case for approving disability benefits.
4. Advise the recipient of his right to have either the DAP advocate or an attorney represent him in his appeal.
NOTE: If the advocate represents the recipient, the advocate may not testify at the hearing. An advocate may testify if an attorney represents the recipient.
5. Assist the recipient in obtaining an attorney through the local legal services program or a private attorney if applicable.
Refer the DAP recipient to a Legal Services Program for legal representation by completing a DAP/LSP Referral Form (PA 1579). DHS has a contract with the Pennsylvania Legal Services Center, parent organization of the local legal services programs, to provide legal representation for DAP recipients at the ALJ Hearing.
The Legal Services Office will accept or reject the referral within 30 days by returning the LSP/DAP Referral Confirmation (PA 1580).
NOTE: Private attorneys who represent category D cases in which DHS receives reimbursement are eligible for fee reimbursement. The amount shall be 25 percent of the amount received from or on behalf of the recipient as payment on the department’s claim. Requests for fee reimbursement should be sent to AWFIRM.
NOTE: If the recipient requests an ALJ hearing and legal representation is not immediately available, the advocate should attach a note to the Request for Hearing (HA 501-U5) explaining that he will not be representing the recipient and that another SSA 1696-U4 will be filed shortly. He should also explain the reason for the delay.
6. Work with the attorney, if one is chosen, to prepare for the ALJ hearing. Have the recipient sign the HIPPA release form to disclose information to the attorney. If the advocate is representing the recipient, coordinate the date, time, and place of the hearing. Arrange testimony by community MH/MR professional staff, attending physician, and others that the ALJ has requested to testify.
NOTE: The ALJ determines who will testify at the hearing and advises the advocate.
7. If the ALJ requests it or if the DAP advocate feels that it would help, the advocate can obtain documentation to support the disability claim by requesting a history of the Medicaid services provided to the recipient. The DAP advocate can request information from the PROMISe paid claim history file. The claims include:
medical services;
dental services;
long term care;
inpatient care; and
prescription drugs.
If the Administrative Law Judge approves SSI/SSDI, the DAP advocate will:
update the DAP Client Tracking and Reporting System; and
notify the CAO worker with a PA 731.
If the ALJ denies SSI/SSDI, the next step is a review by the Appeals Council. The DAP advocate and/or attorney should review the evidence and make a determination if further appeal is warranted. To appeal to the Appeals Council, the DAP advocate will:
update the DAP Client Tracking and Reporting System; and
file a Request for Review of Hearing Decision Order (HA 520-U5).
NOTE: The Appeals Council Review may take 2-3 years. DAP staff should file a second application with SSA if there are any changes in the recipient’s disability and/or new medical documentation.
If the DAP advocate and/or attorney determines further appeal is not warranted, the DAP advocate will:
1. Update the DAP Client Tracking and Reporting System.
2. Notify the CAO worker on a PA 731.
3. Notify the recipient that DAP activity has been terminated.
4. Terminate DAP activity.
If the Appeals Council approves SSI/SSDI, the DAP advocate will:
update the DAP Client Tracking and Reporting System; and
notify the CAO worker with a PA 731.
If the Appeals Council upholds the ALJ's denial, the next level of the appeal process is the United States District Court.
The DAP advocate will:
1. Update the DAP Client Tracking and Reporting System.
2. Notify the CAO worker with a PA 731.
3. Review the evidence and decide whether it is likely that the recipient will receive a favorable decision from the US District Court.
4. If there is a probability of approval, notify the recipient of the need for an attorney. If the recipient does not already have an attorney, help him find one.
NOTE: It is the recipient's decision whether or not to appeal to the US District Court.
5. Work with the attorney who is chosen to prepare for the hearing.
NOTE: Explain to recipient that the filing fee for U.S. District Court can be waived.
6. Help the recipient go to the SSA office to sign the Appointment of Representative Form (SSA 1696-U4) naming the attorney as representative.
If the US District Court approves SSI/SSDI, the DAP advocate will:
update the DAP Client Tracking and Reporting System; and
notify the CAO worker with a PA 731.
If the US District Court denies SSI/SSDI, the DAP advocate will:
1. Update the DAP Client Tracking and Reporting System.
2. Notify the CAO worker with a PA 731.
3. Notify the recipient that DAP activity has been terminated.
4. Discontinue DAP activity.
Reissued September 19, 2012, replacing March 16, 2012