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

SOCIAL SECURITY ADMINISTRATION

Form Approved
OMB No. 0960-0189

RSI/DI QUALITY REVIEW CASE ANALYSIS – SAMPLED NUMBER HOLDER

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)

Form SSA-2930-BK (01-2012) EF (01-2012)
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DESK REVIEW
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:
4. Applications Filed 12/1/96 or Later:

FN:
U.S. Citizen/National

Lawfully-Present Alien

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

6. Evidence Needing Verification:

7. Date of Birth Established by Desk Review:
8. Citizenship/Alien Status Established by Desk Review:

Remarks:

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FACE-TO-FACE/TELEPHONE REVIEW
II. NUMBER HOLDER
A. Identity

Consolidated Review
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:

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DESK 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
NONE APPLY

3. Unadjudicated Claims Issues:
Uprocessed Application

Deemed Filing

Protective Filing

Open Application

Partial Adjudication

Potential Entitlement (Leads)

Delayed Claim
(Explain)
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Misinformation

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FACE-TO-FACE/TELEPHONE REVIEW
II. NUMBER HOLDER
D. Application

Consolidated Review
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 F. Activity

F. Other Claims Activity

Number Holder Agrees With DR Summary
Number Holder Disagrees With DR Summary:
(Explain)

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DESK REVIEW
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:

$

, Sample Month:

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)

Form SSA-2930-BK (01-2012) EF (01-2012)
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NO

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FACE-TO-FACE/TELEPHONE REVIEW
II. NUMBER HOLDER
G. Underpayment
Number Holder Agrees With DR Summary

Consolidated Review
G. Underpayment

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
Number Holder Agrees With DR Summary

I. SMI Determination

Number Holder Disagrees With DR Summary:
(Explain)

J. Payment Amount
Number Holder Agrees With DR Summary

J. Payment Amount

Number Holder Disagrees With DR Summary:
(Explain)

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DESK REVIEW
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:

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FACE-TO-FACE/TELEPHONE REVIEW
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:

Form SSA-2930-BK (01-2012) EF (01-2012)
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DESK 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

YES

NO

d. If MS prior to 1957, NH Receives/Eligible for Military/Civilian Federal Pension?
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?

4. Prior Period of Disability
a. PPD Shown on MBR:

YES

NO

NONE
Date of Onset:

Term Date:

Date of Onset:

Term Date:

b. Documentation in File:
c. PPD Established by Desk Review:

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FACE-TO-FACE/TELEPHONE REVIEW
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. Railroad Employment

Number Holder Agrees With DR Summary
Number Holder Disagrees With DR Summary:
(Explain)

4. Prior Period of Disability

4. Prior Period of Disability

Number Holder Agrees With DR Summary
Number Holder Disagrees With DR Summary:
(Explain)

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DESK REVIEW
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:
(If Yes, go to 5.d)

YES

NO

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:

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FACE-TO-FACE/TELEPHONE REVIEW
II. NUMBER HOLDER
L. Computation Information
5. Windfall Elimination Provision

Consolidated Review
L. Computation Information
5. WEP

Number Holder Agrees With DR Summary
Number Holder Disagrees With DR Summary:
(Explain)

Evidence Obtained in Field Review:

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DESK REVIEW
II. NUMBER HOLDER
M. Current DIB Entitlement

NOT APPLICABLE (Go to II.N.)

1. Period(s) of Disability
a. Current Established Onset Date:
c. Prior Period of DIB:

b. Date of Entitlement

YES (Complete Below)

Effect on Current Entitlement:

Waiting Period

NO
Comps

Medicare

Other

2. Disability-Related Work Information
a. Earnings After Current Established Onset Date:

b. Disability-Related Work Issues

YES (Complete Below)

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:

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NO

FACE-TO-FACE/TELEPHONE REVIEW
II. NUMBER HOLDER
M. Current DIB Entitlement
1. Period(s) of Disability

Consolidated Review
M. Current DIB Entitlement
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:

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DESK REVIEW
II. NUMBER HOLDER
3. Worker’s Compensation/Public Disability Benefit (WC/PDB)
a. NH Filed for WC/PDB:
b. Status of Claim:

YES

NO (Go to II.M.4)

Awarded (Complete Below)

c. Employer Name and Address

Denied

Pending

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:

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FACE-TO-FACE/TELEPHONE REVIEW
II. NUMBER HOLDER
3. Worker’s Compensation/Public Disability Benefit (WC/PDB)

Consolidated Review
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:

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DESK 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)

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NO

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FACE-TO-FACE/TELEPHONE REVIEW
II. NUMBER HOLDER
N. Fugitive Felon

Consolidated Review
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

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CASE SUMMARY
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 exits.
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

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Privacy Act Statement
Collection and Use of Personal Information

Sections 205(a), 228(a), 1614(a) and 1836 of the Social Security Act, as amended, allow us to collect this
information. Furnishing us this information is voluntary. However, failing to provide all or part of the information
may prevent us from verifying your eligibility for benefits.
We will use the information to check data for accuracy and to verify documentation used to establish your
eligibility for benefits. We may also share your information for the following purposes, called routine uses:
1. To third party contacts in situations where the party to be contacted has, or is expected to have, information
relating to the individual’s capability to manager their affairs or eligibility for or entitlement to benefits
under the Social Security program when the data are needed to establish the validity of evidence or to verify
the accuracy of information presented by the individual; and
2. To contractors and other Federal agencies, as necessary, for the purpose of assisting the Social Security
Administration (SSA) in the efficient administration of its programs. We will disclose information under
the routine use only in situations in which SSA may enter into a contractual or similar agreement with a
third party to assist in accomplishing an agency function relating to this system of records..
In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For
example, where authorized, we may use and disclose this information in computer matching programs, in which our
records are compared with other records to establish or verify a person’s eligibility for Federal benefit programs and
for repayment of incorrect or delinquent debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices (SORN) 60-0040,
entitled Quality Review System; and, 60-0090, entitled Master Beneficiary Record. Additional information and a
full listing of all our SORNs are available on our website at www.socialsecurity.gov/foia/bluebook.

Form SSA-2930-BK (01-2012) EF (01-2012)
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