A How to Complete a DDSA Referral
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A How to Complete a DDSA Referral

 

Program

Manual Section

SSI MAO

AHCCCS FTW

MA509

MA504

 

Procedures

Complete a referral to the Disability Determination Services Administration (DDSA) for a disability determination when:

NOTE     A full DDSA packet may not be needed in all cases. Send the Modified DDSA Packet when the customer states or the electronic SSA record shows a disability determination is in progress. For example, the Title XVI status code on the WTPY is H80.

 

1) Contents of the Full DDSA Packet

All Customers

  • A completed DDSA Cover Sheet (DE-123) form;

  • A completed Disability Report (DE-121) form;

  • An Authorization Disclose Information to the Social Security Administration (SSA-827) form for each medical source listed on the DE-12 form, plus two extra SSA-827s;

  • For customers with an authorized representative, the Authorized Representative Form (DE-112); and

  •  A SOLQI dated within 5 days of the referral.

NOTE     Customers with end-stage renal disease (ESRD) or acute leukemia only need to complete pages 1, 4 and 10 of the DE-121.

Deceased Customers
  • A copy of the death certificate.

NOTE     A referral packet may be submitted without the death certificate when the death certificate has been requested.

Customers who are unable to sign the DE-112 or SSA-827 forms

A Physician Statement of Incapacity (DE-217) form.

Customers who:

  • Are not screening for FTW;

  • Do not have ESRD, kidney disease or failure, or acute leukemia; AND

  • Are employed or were employed in any pending application months

Paycheck stubs or a Request for Verification of Employment (DE-206) form.

 

2) Contents of the Modified DDSA Packet

A modified DDSA Referral Packet includes everything in the full DDSA packet EXCEPT for the employment verification.

 

3) Review the Packet for Completeness

Take the following actions when reviewing the DDSA packet for completeness:

Step

Action

1

Review the DE-121. Check that:

  • The customer signed the form; and

  • The date field is blank.

2

Verify that the following information in HEAplus matches the customer information in the packet.

  • Name;

  • Date of birth;

  • Address;

  • Social Security Number; and

  • Application month.

NOTE     The date on the DE–123 must be within the same month as the application month in HEAplus.

3

Check the SOLQI for the following information to make sure everything is accurate.

  • Name;

  • Date of birth;

  • Social Security Number;

  • Title II Benefits;

  • Title XVI Benefits; and

  • Medicare.

4

Write “Modified” in the "Remarks" section on the DE–123 if the SOLQI shows "H-80 Development Pending" status.

5

E-mail the completed packet to ssimao@azahcccs.gov

 

4) Send the Packet to DDSA

Send the packet to the following address:

DDSA MD 3671
Attn: Richard Poepsel or Kim Murphy
4000 N Central Ave #1800
Phoenix, AZ 85012-3512

 

5) Track DDSA Decision

When DDSA makes a disability determination and returns the packet, the designated MA-SP worker tracks the diary date and the date the packet is returned from DDSA in the Excel Log.