TN 5 (07-24)

DI 11011.001 Applying Collateral Estoppel in Disability Claims

A. Collateral estoppel policy

We will not again decide the issue of disability if, in our prior final determination or decision (and any subsequent continuance determination or decision), we have already decided the individual is disabled for the time period covered by the new application and all of the following conditions are met:

  1. 1. 

    Both the prior determination or decision and new claim require application of the same statutory definition of disability.

  2. 2. 

    We have not made an intervening medical determination or decision finding that the individual’s disability ceased.

  3. 3. 

    The claimant has not engaged in substantial gainful activity (SGA) since the prior established onset date (EOD).

  4. 4. 

    The EOD in the prior claim is on or before the date when the nonmedical requirements for entitlement are last met in the new claim.

  5. 5. 

    The record with the prior favorable disability determination or decision is not in terminated status.

  6. 6. 

    We do not have reason to believe that the prior disability determination or decision was wrong.

NOTE: The instructions in this section apply only to collateral estoppel cases. The field office (FO) will continue to develop potential res judicata claims under existing policy guidelines.

For FO res judicata development and processing, see DI 27516.001.

For initial title II technical denials and claims not requiring a disability determination, see DI 11010.075.

B. Jurisdiction of disability claims involving collateral estoppel

1. FO jurisdiction

When the criteria in DI 11011.001A in this section are met and adopting the prior disability determination or decision would be fully favorable in a new initial claim or reconsideration, the FO has jurisdiction for applying collateral estoppel.

NOTE: FO collateral estoppel claims will be processed as District Office Final Authorization (DOFA), unless a DOFA exclusion applies. For general information on FO adjudicative responsibilities, see GN 01010.008.

2. Disability Determination Services (DDS) jurisdiction

When the criteria in DI 11011.001A in this section are met for a new Title II claim, but the potential onset date (POD) in the new claim is before the EOD in the prior claim, the DDS has jurisdiction for making a disability determination covering the period between the new claim's POD and the prior claim's EOD. For processing instructions, see DI 11011.001F in this section.

C. When to apply collateral estoppel

When an individual receiving Social Security benefits or Supplemental Security Income (SSI) based on disability files a subsequent disability claim under a different title or for a different benefit under the same title, the FO must adopt the prior favorable disability determination or decision if the criteria in DI 11011.001A in this section are met.

EXCEPTION: The FO may not apply collateral estoppel to establish that disability began on the new claim before the EOD in the prior claim. For more information, see DI 11011.001F in this section.

D. When not to apply collateral estoppel

When collateral estoppel does not apply, continue to process the new disability claim following usual claim development procedures, as with any other case not involving collateral estoppel. For instructions on disability claims processing, see sections in DI 11010.000.

When a disabled beneficiary or SSI recipient files a new disability claim under a different title or for a different benefit under the same title, the FO cannot adopt the prior favorable disability determination or decision if any of the following conditions applies:

1. The prior determination or decision and the new claim require application of different statutory definitions of disability.

The FO cannot apply collateral estoppel when the new claim requires application of the adult definition of disability and the prior favorable disability determination or decision was made using:

IMPORTANT: Collateral estoppel may apply to adopt the adult disability determination or decision from an age-18 medical redetermination. Collateral estoppel may also apply to adopt the disability determination or decision from a welfare conversion case with a subsequent continuing disability review (CDR) continuance under federal criteria (for welfare conversion cases that have been allowed or continued under federal criteria, the SSI Display (SSID) rollback indicator (RB) field is coded “4”).

NOTE: Collateral estoppel may apply to adopt, in a new claim under Title II or XVI, a favorable statutory blindness determination or decision under Title II. However, a statutory blindness determination or decision under Title XVI may not be adopted in a new claim, because statutory blindness under Title XVI is not subject to SGA rules and duration requirements.

2. An intervening determination or decision in a medical CDR found that the individual’s disability ceased.

For medical CDR cessations, including those where we have not yet effectuated the cessation, as described in DI 40505.315, collateral estoppel does not apply to the new claim unless the cessation was reversed on appeal or reopening.

NOTE: If a CDR appeal is pending in the Electronic Disability Collect System (EDCS) and the new initial claim requires a determination by the DDS, the multiple pending cases (MPC) will consist of two different classification folders (initial and CDR). For instructions on EDCS exclusions and limitations, see DI 81010.030.

3. The claimant engaged in SGA after the prior determination or decision EOD.

Determine whether the claimant may have engaged in SGA after the prior EOD.

If work activity after the prior EOD meets the “clearly not SGA” criteria, annotate the alleged monthly earnings and the remarks “clearly not SGA” on a Report of Contact in the applicable claims processing system. For defining “clearly not SGA,” see DI 10501.025A.

REMINDER: If the work after the prior EOD is not SGA, and the other criteria in DI 11011.001A in this section are met, collateral estoppel applies.

If the work after the prior EOD is SGA:

  • Document the work activity using the SSA-821-BK (Work Activity Report—Employee) or SSA-820-BK (Work Activity Report—Self Employment).

  • Document the SGA and potential onset date (POD) determination on the SSA-823 (Report of SGA Determination). In making the SGA determination, consider whether work which lasted 6 months or less meets unsuccessful work attempt (UWA) criteria. For evaluating duration and conditions of work that may constitute a UWA, see DI 11010.145E.

  • If a period of SGA precludes collateral estoppel but does not preclude a POD in the new claim, enter the POD on the SSA-3367 (Disability Report–Field Office) before sending the claim to the DDS.

NOTE: If SGA or other nonmedical factors in the new claim prevent the FO from establishing the POD, the FO must technically deny the new claim.

IMPORTANT: A UWA is not a measure of SGA and will not preclude collateral estoppel. When collateral estoppel applies, the FO is responsible for making applicable UWA determinations in the new claim.

4. The prior EOD is after the date when the nonmedical requirements for entitlement are last met in the new claim.

The FO cannot apply collateral estoppel when the EOD in the prior claim is after the following applicable date in a new claim for benefits under Title II:

  • The date last insured (DLI) for disability insurance benefits (DIB), see DI 25501.320.

  • The prescribed period end date for disabled widow(er)s benefits (DWB), see DI 11005.050.

  • Attainment of age 22 in childhood disability benefits (CDB) initial entitlement cases, see DI 11020.015.

5. The record with the prior favorable disability determination or decision is terminated.

Do not adopt a prior favorable disability determination or decision from a record in terminated status.

6. We have reason to believe the prior disability determination or decision was wrong.

Determine that there is reason to believe that the prior disability determination or decision was wrong, such that collateral estoppel does not apply, only when presented with evidence that clearly indicates that the individual was not disabled. Do not complete unnecessary development or reviews, and do not review the prior record with the intent of finding an error.

NOTE: Collateral estoppel does not apply when we have identified the presence of fraud or similar fault (FSF) in connection with the prior favorable disability determination or decision.

E. Processing of FO jurisdiction collateral estoppel cases

1. Impairment and diary codes

When applying collateral estoppel to adopt a prior disability determination or decision, the FO must review transmittal forms (e.g., SSA-831 (Disability Determination and Transmittal) or Case Processing and Management System (CPMS) disposition page) or systems queries (e.g., DDS Query (DDSQ), Master Beneficiary Record (MBR), or SSID) with information on the prior favorable disability determination or decision and enter the prior diagnosis code(s) and medical diary period when completing the adjudicative screens for the new claim allowance.

2. EOD

If the claimant meets the same statutory definition of disability (based on the collateral estoppel criteria in DI 11011.001A in this section) and the applicable nonmedical requirements during the period covered by the application, determine the EOD for the new claim. Generally, the EOD is the earliest date that the claimant meets both the definition of disability and the nonmedical requirements for entitlement to benefits under Title II or eligibility for payments under Title XVI during the period covered by the new application.

Use the following table to determine the EOD for collateral estoppel cases

Subsequent claim type

EOD for the new claim is generally

DIB

The later of:

• prior claim EOD, or

• the date first insured (DFI).

DWB

The later of:

• prior claim EOD, or

• the controlling date.

CDB

The later of:

• prior claim EOD, or

• the last day of the month before the month of age 18 attainment.

SSI Disabled Adult

The protective filing date in the new claim.

NOTE: If the applicable EOD from the above table does not establish entitlement, e.g., the EOD would be after attainment of age 22 in a CDB initial entitlement case, collateral estoppel does not apply. 

IMPORTANT: The FO may not establish an EOD in the new claim earlier than the EOD in the prior claim. If there is a possibility of additional Title II entitlement before the prior EOD, follow the instructions in DI 11011.001F in this section.

3. Additional claims system inputs

  1. a. 

    Title II claims

    On the Modernized Claims System (MCS) decision input (DECI) screen, enter the listing code of “589”.

    For MCS exclusions, complete an electronic form 101 (EF101) for the new or amended award, as applicable. Enter “collateral estoppel, PC action necessary to manually establish listing code 589” on the EF101 Benefit Continuity Remarks/Notice (BCRN) screen.

  2. b. 

    Title XVI claims

    On the Disability page, select “adopt Title II disability determination” as the reason for not referring the case for a medical decision. This input will generate the medical diary reason (MDR) code of "V".

NOTE: The FO is not required to create a new EDCS segment or SSA-831 for the collateral estoppel determination in claims under either title. The adjudicative decision screens completed in the appropriate claims processing system will serve as the signed determination, and the mainframe record will serve as documentation of the claims activity. For more information on adjudicative policy and standards, as well as examples of adjudicative screens, see GN 01010.001.

4. Suspense issues

If the prior claim is in temporary suspense status for non-disability reasons when the new claim is filed, attempt to resolve the payment suspense issue prior to completing processing of the new claim (e.g., if the prior claim is in “S8” suspense status for payee development, develop for a new payee or establish direct payment when necessary).

  • If the suspense issue on the prior claim is not resolvable when processing the new claim but will not result in a denial on the new claim, apply collateral estoppel to adopt the prior favorable disability determination or decision (if the criteria in DI 11011.001A in this section are met), and

  • If the suspense issue results in any period(s) of nonpayment status in the new claim, place the new claim payment status into the corresponding payment suspense for the applicable months, via the Title II suspension event (SUSP) screen or the Title XVI payment status page, prior to adjudication.

For Title II benefit suspensions, see GN 02602.005.

For Title XVI payment suspensions, see SI 02301.200.

5. Pending CDR considerations

Adopt the favorable disability determination or decision from a prior claim even when an initial medical CDR is pending for that claim. After processing the subsequent claim allowance, initiate a medical CDR on the new record and transfer the new CDR to the DDS to associate with the pending CDR.

NOTE: Do not initiate a CDR based solely on an expired diary on the existing claim. A new claim does not in itself raise a CDR issue on the existing entitlement, even when there is an expired diary. For more information on FO procedures in medical CDR cases, see DI 13005.001.

F. Processing of Title II collateral estoppel claims with DDS jurisdiction for possible earlier EOD determination

When collateral estoppel will apply based on the conditions in DI 11011.001A in this section, and an alleged onset earlier than the prior EOD could provide for additional entitlement, determine the POD to assign to the new claim per instructions in DI 25501.220.

If the assigned POD for the new claim is earlier than the prior EOD:

  1. 1. 

    Obtain the necessary forms, e.g., SSA-3368 (Disability Report–Adult) and SSA-827 (Authorization to Disclose Information to the Social Security Administration). For electronic cases, establish the claim in EDCS to complete the forms, following procedures in subchapter DI 81010.000.

  2. 2. 

    Enter the remarks “The FO finds that collateral estoppel would apply from the prior EOD of [mm/dd/yyyy] - a determination is needed on a possible earlier onset date before the benefits may be issued on the new claim.” with the applicable POD on the SSA-3367. For further instructions on completing the SSA-3367, see DI 11005.045.

  3. 3. 

    Add the “Potential Collateral Estoppel Issues Apply” EDCS flag by selecting the collateral estoppel checkbox at case transfer.

  4. 4. 

    Send the claim to the DDS for a determination on whether the evidence supports the earlier onset applying the sequential evaluation or the prior EOD must be adopted.

IMPORTANT: The steps 1 through 4 in this subsection will not apply if nonmedical factors preclude a POD that is earlier than the prior EOD. The FO applies collateral estoppel when adopting the prior disability determination or decision will be fully favorable based on the POD in the new claim.

NOTE: For EDCS exclusions, use the paper flag:


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DI 11011.001 - Applying Collateral Estoppel in Disability Claims - 07/12/2024
Batch run: 12/03/2024
Rev:07/12/2024