Request for Reconsideration--Paper and MCS/SSI Claims System

RECONSIDERATION REQUEST 1/ FEDRO
Ln
No
1
2
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10
11

0
1
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1 2 3 4 56 7 890 1 2 34 5 678 9 0 12 3 456 7 8 90 1 234 5 6 78 9 012 3 4 56 7 890 1 2 34 5 678 9 0 12 3 456 7 8 90 1 234 5 6 78 9
C M C S R E CON S I DE R ATI O N R E QUE S T (R C N1)
OR FE D R O (FD R 1 )S D 3
0
N H S S SSS S S SS
S S S SS SS S S SS S SSS
C L SS S S SS S SS
SS S SS S SS S SSS S S S
L
U
C RO S S R E F ER E NCE
S SN: S SS S SSS S S
BIC: SS
SS N : S S S SS S SSS
BI C : S S
M
A PP E LLA N T ( I F O T H ER THA N CL M T O R RE P ): X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XX
N
A DD R ESS : XX X XXX X X XX X XXX X X XX X XXX
XX X XXX X X XX X XXX X X XX X XXX
*
XX X XXX X X XX X XXX X X XX X XXX
XX X XXX X X XX X XXX X X XX X XXX
O
C ITY : XX X XXX X X XX X XXX X X XX
S T AT E : X X
ZIP : 99 9 99
PH O NE: 9 99 999 9 99 9
N
C OU N TRY : XX X XXX X X XX X XXX X
CON S U L C ODE : 99 9
E
B IC : XX
S POU S E S S N: 9 9 99 9 999 9
CAS E TY P E: 9 1. INI T I AL ENT
E XP L ANA T I ON PRO V I DE D (Y / N ): X
RE Q UES T E D ( Y/N ) : X

12
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16
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19
20
21
22
23
24

R
E
S
E
R
V
E
D

A PP E AL C L AI M TY P E : 9 9
1 . R SI
RSI
5 . SS I BL I N D/ T ITL E II
SS B C
2 . D ISA B I LI T Y W O R KE R OR C HI L D D I WC
6 . SS I DI S A BI L ITY / T IT L E I I SS D C
3 . D ISA B I LI T Y W I D OW ( ER)
D I WW
7 . HE A LTH I NS ENT
HI E
4 . S SI A G ED / TIT L E I I
S S AC
8 . OT H ER X X XX X XXX X X XX X XXX X X XX X XX
I SS U E: X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XX
R EA S ON R E QU E STE D : X X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XX
X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X
X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X
X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X
A DD I TIO N A L E VID E N CE (Y/ N / F) : X
* * * ** * *** * * ** * (LI N E 2 3 RE S E RV E D F O R A P PLI C A TI O NS I N FO R MAT I O N) * *** * * ** * *** * * ** *
* * * ** * *** * * ** * (LI N E 2 4 RE S E RV E D F O R O P ERA T I NG SYS T E MS INF O R MA T ION ) * ** * *** * * **
*THE TITLE OF THIS SCREEN WILL CHANGE BASED ON THE SELECTION MADE ON THE
NAPP (APPEALS ESTABLISHMENT SCREEN)

The key to the highlight values is:
Yellow Mandatory
Green Conditional
Blue
Optional

8
0
4

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23
24

0
1
C
0
L
U
M
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*
O
N
E
R
E
S
E
R
V
E
D

1
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5
6
7
7
234567890123456789012345678901234567890123456789012345678901234567890123456789
MCS
RECONSIDERATION REQUEST 2 OR FEDRO 2
SD3
NH SSSSSSSSS
SSSSS SSSSSSSSSS
CL SSSSSSSSS
SSSSS SSSSSSSSSS
SSI APPEAL: 9

1. CASE REVIEW

2. INFORMAL CONFERENCE

3. FORMAL CONFERENCE

IF CLAIMANT REQUESTS OPTION 2 OR 3 UNDER SSI RECON, IS INTERPRETER
NEEDED (Y/N): X
IF YES, SPECIFY LANGUAGE: XXXXXXXXXXXXXXXXXXXXXX
REPRESENTED (Y/N): X
IF NO, LEGAL REFERRAL LIST TO CL (Y/N): X
ATTORNEY/REP NAME: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
IF YES, ATTY (Y/N): X
ATTORNEY/REP ADDRESS: XXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXX
CITY: XXXXXXXXXXXXXXXXXX
STATE: XX
ZIP: 99999
PHONE: 999 999 9999
COUNTRY: XXXXXXXXXXXXXXX
CONSUL CODE: 999
FILED BY: 9
1. APPELLANT
2. REP
DATE FILED: 999999
DETER DATE BEING APPEALED: 999999
TIMELY REQUEST (Y/N): X
IF NO,: 9
1. CLMT’S EXPLANATION
2. OTHER INFORMATION 3. BOTH 1 AND 2 APPLY
EXPLANATION:XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
DATE SCREEN BEGUN: 999999
**************(LINE 23 RESERVED FOR APPLICATIONS INFORMATION)*****************
**************(LINE 24 RESERVED FOR OPERATING SYSTEMS INFORMATION)***********

The key to the highlight values is:
Yellow Mandatory
Green Conditional
Blue
Optional

8
0
5

Ln
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23

2
4

0
1
2
3
4
5
6
7
7
1 2 3 4 56 7 890 1 2 34 5 678 9 0 12 3 456 7 8 90 1 234 5 6 78 9 012 3 4 56 7 890 1 2 34 5 678 9 0 12 3 456 7 8 90 1 234 5 6 78 9
C MCS
H EAR I N G R EQU E S T 1
HNG 1 SD 3
0
NH SSS S S SS S S
SS S SS S S SS S SSS S S
CL S SS S SSS S S
SSS S S S S SSS S S SS S
L
U
C R OS S RE F E RE N CE
S S N: S S SS S SSS S
BI C : S S
SS N : S S S SS S SSS
BIC : SS
M
A P PE L LAN T (I F OT H E R T HAN C LM T OR R EP ) : X X X XX X XXX X X XX X XXX X X XX X XXX X X XX X
N
A D DR E SS: X XX X XXX X X XX X XXX X X XX X XX X XX X XXX X X XX X XXX X X XX X XX
*
X XX X XXX X X XX X XXX X X XX X XX X XX X XXX X X XX X XXX X X XX X XX
O
C I TY: X XX X XXX X X XX X XXX X X X
S T A TE : XX
Z IP: 9 99 9 9
PH O NE: 9 99 999 9 99 9
N
C O UN T RY: X XX X XXX X X XX X XXX
C ONS U L C O DE: 9 99
E
B I C: XX
S POU S E S S N: 9 9 99 9 999 9
CAS E TY P E: 9 1. INI T I AL ENT
A P PE A L C L A IM TYP E : 9 9
R
1. RSI
RSI
5. S S I B LIN D / TI T LE I I
S SB C
E
2 . D I SAB I L IT Y WO R K ER OR C H IL D D I W C 6. S S I D ISA B I LI T Y/T I T LE II S SD C
S
3 . D I SAB I L IT Y WI D O W( E R)
D I W W 7. H E AL T H I N S E N T
H IE
E
4 . S S I A G E D/ T ITL E II
S S A C 8. O T HE R
R
H E AR I NG R E QU E STE D (Y / N): X
V
R E AS O N H E A RI N G R E Q UE S TED : XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X
E
X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X
D
X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X
X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X
A D DI T ION A L E V IDE N C E ( Y/N / F ): X
* * * ** * *** * * ** * (LI N E 2 3 RE S E RV E D F O R A P PLI C A TI O NS I N FO R MAT I O N) * *** * * ** * *** * * ** *
* * * ** * *** * * ** * (LI N E 2 4 RE S E RV E D F O R O P ERA T I NG SYS T E MS INF O R MA T ION ) * ** * *** * * **

The key to the highlight values is:
Yellow Mandatory
Green Conditional
Blue
Optional

8
0
6

Ln
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0
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*
O
N
E
R
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S
E
R
V
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D

1
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3
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5
6
7
7
2 3 4 56 7 890 1 2 34 5 678 9 0 12 3 456 7 8 90 1 234 5 6 78 9 012 3 4 56 7 890 1 2 34 5 678 9 0 12 3 456 7 8 90 1 234 5 6 78 9
MCS
H E A RI N G R E Q UE S T 2
HNG 2 SD 3
NH SSS S S SS S S
S SSS S S SS S SSS S S SS
C L S SSS S S SS S
S SS S SSS S S SS S SSS S
R E Q UE S T O R A L H EAR I N G ( Y/N ) : X
R E AS O N H E A RI N G W A I VE D : X X X XX X XXX X X XX X XXX X X X
X X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X
X X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X
X X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X
R E P RE S ENT E D ( Y /N) : X
I F NO , LE G A L R EFE R R AL LIS T TO CLM T (Y / N): X
A T T OR N EY/ R E P N AME : XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX
I F YE S , A T TY ( Y /N ) :
A T T OR N EY/ R E P A DDR E S S: XXX X X XX X XXX X X XX X XXX X X X
X X XX X XXX X X XX X XXX X X XX X X
XXX X X XX X XXX X X XX X XXX X X X
X X XX X XXX X X XX X XXX X X XX X X
C I T Y: XXX X X XX X XXX X X XX X XX
S T ATE : XX
Z I P: 999 9 9
PH O N E: 999 9 99 999 9
C O U NT R Y: X X XX X XXX X X XX X XX
C O NSU L CO D E: 9 9 9
F I L ED BY: 9 1 . A P P EL L ANT
2 . RE P
D ATE F IL E D: 9 9 99 9 9
D E T ER DAT E BE I NG A P PE A LED : 99 9 999
T IME L Y R E QUE S T ( Y /N) : X
I F NO , : 9
1 . CL M T ’S EXP L A NA T ION
2. OTH E R I N FOR M A TI O N 3 . B O TH 1 AN D 2 A P PL Y
E X P LA N ATI O N : X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X
X X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X
X X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X
X X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X
I N T ER P RET E R ( Y /N) : X
I F YE S , S P E CI F Y L A N GU A GE: X XX X XXX X X XX X XXX X X XX X XX
* * * ** * *** * * ** * (LI N E 2 3 RE S E RV E D F O R A P PLI C A TI O NS I N FO R MAT I O N) * *** * * ** * *** * * ** *
* * * ** * *** * * ** * (LI N E 2 4 RE S E RV E D F O R O P ERA T I NG SYS T E MS INF O R MA T ION ) * ** * *** * * **

The key to the highlight values is:
Yellow Mandatory
Green Conditional
Blue
Optional

8
0
7

MCS
NH: SSSSSSSSS
DISPOSITION: 9

APPEAL DISPOSITION
SSSSS SSSSSSSSSS
CL: SSSSSSSSS
1. UNFAVORABLE DENIAL
2. PARTIALLY FAVORABLE ALLOW
3. FULLY FAVORABLE ALLOW

DISPOSITION DATE: 999999

DISP SD38
SSSSS SSSSSSSSSS

4. DISMISSAL
5. WITHDRAWAL
6. REMAND

7. ABANDON

EFFECTUATION DATE: 999999

ALJ: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

ALJ HO: XXXX

********************************************************************************
********************************************************************************
The key
Yellow
Green
Blue

to the highlight values is:
Mandatory
Conditional
Optional

MCS
APPEAL ESTABLISHMENT
NH NAME: SSSSSSSSSS S SSSSSSSSSSSSSSSSSSS
NH SSN: SSSSSSSSS
APPEAL
LEV: I
R
H
O
F

NAPP SM20

FILE LEVEL: 9
1. RECON 2. HEARING
3. FEDRO REVIEW
INITIAL
DECISION STATUS:
RECON
1 RSHI ALLOW
5 DIB MED DENY
9 RSHI PARTIAL
HEARING
2 RSHI DISAL
6 NON-MED COMP
10 DIB PARTIAL
REOPEN
3 DIB TECH DIS
7 WITH/ABATE
11 DISMISSAL
FEDRO
4 DIB ALLOW
8 DELAY
FILE
ADJ
CL NAME
CL SSN
DATE
DEC DATE LEV SELECT
01. SSSSSSSSSS S SSSSSSSSSSSSSSSSSSS SSSSSSSSS SSSSSS SS SSSSSS S
X
02. SSSSSSSSSS S SSSSSSSSSSSSSSSSSSS SSSSSSSSS SSSSSS SS SSSSSS S
X
03. SSSSSSSSSS S SSSSSSSSSSSSSSSSSSS SSSSSSSSS SSSSSS SS SSSSSS S
X
04. SSSSSSSSSS S SSSSSSSSSSSSSSSSSSS SSSSSSSSS SSSSSS SS SSSSSS S
X
05. SSSSSSSSSS S SSSSSSSSSSSSSSSSSSS SSSSSSSSS SSSSSS SS SSSSSS S
X
06. SSSSSSSSSS S SSSSSSSSSSSSSSSSSSS SSSSSSSSS SSSSSS SS SSSSSS S
X
07. SSSSSSSSSS S SSSSSSSSSSSSSSSSSSS SSSSSSSSS SSSSSS SS SSSSSS S
X
08. SSSSSSSSSS S SSSSSSSSSSSSSSSSSSS SSSSSSSSS SSSSSS SS SSSSSS S
X
09. SSSSSSSSSS S SSSSSSSSSSSSSSSSSSS SSSSSSSSS SSSSSS SS SSSSSS S
X
10. SSSSSSSSSS S SSSSSSSSSSSSSSSSSSS SSSSSSSSS SSSSSS SS SSSSSS S
X
11. SSSSSSSSSS S SSSSSSSSSSSSSSSSSSS SSSSSSSSS SSSSSS SS SSSSSS S
X
********************************************************************************
********************************************************************************

The key
Yellow
Green
Blue
Note:

to the highlight values is:
Mandatory
Conditional
Optional
APPEAL FILE LEVEL is prefilled in update mode
SELECT is not an MCS Data element on the MCS pending file