If the individual wishes to appeal a non-medical issue, such as a substantial gainful activity (SGA) denial, a denial based on excess resources, or a denial because the prior claim was not terminated due to SGA, complete a Request for Reconsideration, SSA-561-U2. Follow established SSA jurisdiction procedures outlined in DI 12005.010.

If the individual wishes to appeal an unfavorable medical determination, take the following actions;

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  Make the necessary systems inputs per DI 13050.085E;

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  Establish the EXR reconsideration request in EDCS;

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  Complete forms SSA-561, SSA-3441, and SSA-827. Store any non-electronic forms in eView;

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  Transfer the EDCS case to DDS and;

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  Create an EXRRECON 90-day tickle on the Disability Control File (DCF) development worksheet (CDRW).

When DDS makes a determination, process reversals per, DI 13050.060 and DI 13050.061 and; process affirmations per DI 13050.065.

If the individual disagrees with the reconsideration determination, the individual can request a hearing with an administrative law judge (ALJ). Take the following actions:

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  Make the necessary systems inputs per DI 13050.085E;

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  Establish the EXR hearing request in EDCS;

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  Complete forms HA-501-U5, SSA-3441 and SSA-827. Store any non-electronic documents in eView;

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  Transfer the EDCS case to the Office Of Hearing Operations (OHO) and;

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  Create and EXRHRN 90-day tickle on the DCF development worksheet (CDRW) for control.

If the individual disagrees with the ALJ's decision, the individual can request an Appeals Council (AC) review of the hearing decision. Take the following actions:

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  Make the necessary systems inputs per DI 13050.085E;

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  Establish the EXR request for AC review in EDCS;

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  Complete form HA-520-U5 (if applicable). Store any non-electronic forms in eView;

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  Transfer the EDCS case to the AC, and;

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  Create an EXR-AC 90-day tickle on the DCF development worksheet (CDRW) for control.

  The AC will notify the individual of the final action and provide an explanation of any appeal rights.

Use the Post-Entitlement Online System (POS) to record an appeal of an EXR medical denial. Refer to MS 06303.024 through MS 06303.026 for detailed input instructions. Take the following actions:

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  From the POS main menu select 6, disability cessation;

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  On the PEC1 screen, select 1 for medical cessation;

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  On the PEC2 screen, input the date of the appeal request and select 3 for reconsideration request without payment continuation; and

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  On the PECN screen, select 1, Decision Notice Released-Additional Systems Notices Possible.

  Add a special message to the MBR to indicate the status of an appeal of a non-medical issue in an EXR case. Indicate the appeal level, date the appeal was filed, SSA employee identifier (such as unit code or last name) and field office code. Indicate in subsequent special messages the outcome of the appeal and any further appeals activity. Also document the reconsideration determination on the IRMK screen of the DCF.

  NOTE: If the case is an EDCS exclusion, select Y to record folder movement and indicate destination of folder on the next screen.

Use the Direct SSR update to record an appeal of an EXR medical denial. Refer to MS 04420.002 through MS 04420.026 for detailed input instructions.

An individual can appeal request the denied EXR request and also file anew initial claim at the same time. For special considerations in processing joint EXR and initial claim actions, refer to DI 13050.090. When an EXR appeal request and simultaneous initial claim both require medical decisions, escalate the initial claim to the reconsideration level, see DI 12045.030 and DI 28057.025. The original EXR request serves as a protective writing for the new initial claim.

An individual can appeal the initial claim denial under current reconsideration procedures while also filing an EXR request, including the start of provisional benefits and Medicare. Escalate the EXR request to the reconsideration level, see DI 12045.030 and DI 28057.025. The denied initial claim does not serve as a protective writing for EXR. See DI 13050.090 for processing instructions and special consideration in processing joint EXR and initial claim actions.

An individual may inquire about EXR while a hearing request is pending at the ALJ- level on a prior termination decision or an initial claim denial. If the requirements for EXR are met, per DI 13050.001B, do not escalate the initial EXR request to the hearing level. Instead, forward the EXR request to DDS for a medical decision. If DDS denies the EXR request and the beneficiary appeals the decision:

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  Determine if both cases are “common issue” cases, see DI 12045.010; if yes,

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  Escalate the EXR appeal to the hearing and coordinate both cases with the appropriate hearing officer per DI 12045.015.

An individual may inquire about EXR while a request for review (RR) of an ALJ decision is pending with the Appeals Council. If the requirements outlined in DI 13050.001B for EXR are met, follow the instructions in DI 12045.027 to process the EXR request. Send the EXR request to DDS to for normal processing and an initial determination independently of the case at the AC level regardless of the title(s) or common issue, see DI 12045.021. If the claimant opts to file a new claim instead of an EXR request, Social Security Ruling 11-1p may apply if the new claim is under the same title of the Social Security Act and for the same benefit type. Follow the appropriate instructions in DI 51501.001 or DI 12045.027 to process the subsequent claim.