TN 21 (12-24)

DI 27516.005 Disability Determination Services Res Judicata Development and Processing

A. Disability Determination Services (DDS) jurisdiction of a subsequent Title II claim

See DI 27516.001A. for the definition of res judicata.

The DDS has jurisdiction of a subsequent claim denied through the date the non-disability requirements were last met and an exception to field office (FO) res judicata processing applies. The FO exceptions are:

1.      Mental Incapacity.

2.      Misinformation.

3.      New fact or issue.

4.      Change in law or policy.

See DI 27516.001B2 for a complete explanation of the exceptions. If any one of the exceptions applies, the DDS cannot apply res judicata.

B. DDS review

1. Mental incapacity and misinformation exceptions

The DDS should accept the FO finding on an issue of mental capacity or misinformation. Process these claims as exceptions to res judicata. Procedures in DI 27516.005C apply.

2. Change in law or policy exception

Refer to DI 27516.010.

3. New fact or issue exception - considering an allegation of new and material evidence

Where a new fact or issue is established by the FO, the DDS follows the procedures in DI 57516.005C.

If, however, the claimant alleged new and material evidence, the DDS must consider the new and prior claims as follows:

  • Develop the NEW evidence if the claimant does not provide it.  Follow standard development procedures;

  • Considering the prior final determination with the new evidence, determine whether the new evidence would have changed the outcome.

IMPORTANT: In all cases where new evidence is considered in the medical evaluation of the claim, we require a signed medical assessment form documenting the medical consultant (MC)/psychological consultant (PC) review. The MC/PC should attest to the DDS determination of a res judicata denial (evidence is not new or material), a denial considering the new and material evidence, or a favorable finding based on new and material evidence and the medical development through the date of adjudication.

Evidence, Application, Procedures

If the evidence is -

Then -

Follow the procedures in -

Not new

Res judicata may apply

DI 27516.005E

New, but not material

Res judicata may apply

DI 27516.005E

New and material

Res judicata does not apply

DI 27516.005C

C. Res judicata does not apply

1. If a substantive denial is appropriate

Annotate the SSA-831 (Disability Determination and Transmittal) as follows:

  • Item 26 (List No.) - “243” (subsequent claim -- prior claim medically denied through date non-disability factors last met); and

  • Item 34 (Remarks) - “Res judicata not applicable.”

NOTE: If you cannot determine the applicability of res judicata because the prior folder was not located, enter “Res judicata not applied -- prior claim not located” in item 34. For cases where the prior folder is not available, enter listing code 243 in item 26.

For prior folder not located cases, the DDS develops the period under consideration and makes a substantive determination.

For all substantive denial determinations, the DDS will obtain MC/PC signatures and issue standard personalized disability explanation (PDEs) and personalized decision notices (PDNs).  See DI 26530.001 for instructions on preparing a PDE.  See DI 26535.005 for PDN instructions.

2. If a favorable determination is appropriate

If new and material evidence or consideration under less restrictive disability criteria or another exception prevents application of res judicata, and a favorable determination prior to the date non-disability requirements were last met is appropriate, the DDS will develop evidence from the date the non-disability requirements were last met through current adjudication. See DI 24501.002B for instructions on developing evidence from date the non-disability requirements were last met through current adjudication.

a. Reopening the prior determination not possible under the rules of administrative finality

Make a new favorable determination setting the onset within the prior adjudicated period.

If the determination or decision on the prior claim cannot be reopened, benefit rights flow only from the new application.

NOTE: An incorrect final determination or decision can be reopened for any reason only within 12 months from the date of the notice of the initial determination. See DI 27505.001 for additional information on reopening under the rules of administrative finality, including exceptions to the general rule that only incorrect determinations and decisions may be reopened and revised.

b. Reopening the prior determination or decision under the rules of administrative finality

The rules of administrative finality are in DI 27505.001.

If the DDS finds a basis for reopening and revising the final DDS determination on the prior claim under the rules of administrative finality, the DDS revises the prior determination.

If an administrative law judge (ALJ) or the Appeals Council (AC) issued the prior final decision, and the decision can be reopened under the rules for reopening, forward the prior and subsequent claims to the Office of Disability Operations (ODO) per DI 27505.010B.2.a.

If a Disability Hearing Officer (DHO) made the determination on the prior claim, and the determination can be reopened under the rules for reopening, forward both the prior and subsequent claims to the Disability Hearing Unit (DHU) per DI 27505.010B.2.b.

D. Res judicata applies

1. Completion of the SSA-831 (Disability Determination and Transmittal) for a res judicata denial

Complete the following:

  1. a. 

    Item 16a (Primary Diagnosis) - Enter a four-digit diagnosis code. If a diagnosis code is not known, enter four zeros "0000".

  2. b. 

    Item 19 (Claimant Not Disabled) - Check block B and insert either date last insured, end of prescribed period, or date attained age 22, as appropriate.

  3. c. 

    Item 22 (Regulation Basis Code) - Enter “S1” (res judicata).

  4. d. 

    Item 25A - Check block A.

  5. e. 

    Item 26 - (List No.) - Enter “243” (subsequent claim or prior claim medically denied through date nondisability factors last met).

  6. f. 

    Items 30 and 31 (Disability Examiner - DDS/Date)

  7. g. 

    Items 32 and 33 (MC or PC signature) – generally not needed for res judicata. See DI 27516.005B for when an MC/PC signature is needed.

  8. h. 

    Item 34 (Remarks) - Enter “Res judicata .”

2. DDS systems input and clearance of a res judicata denial

To process the res judicata determination:

  1. a. 

    Clear the case to the FO and show folder movement clearance.

  2. b. 

    Record the “S1” denial code determination on the State Agency Operating Report.

E. Reconsideration

The notice in a res judicata case informs the claimant that the final determination or decision reached on the prior application applies and that the only appeal available is on the question of whether the same person, facts and issues were present for the same period in both the prior and subsequent claims.

1. Affirmation of res judicata

Follow instructions in DI 27516.005E. (in this section), noting the following exceptions:

  1. a. 

    Check block 25 (Revised Det) and 25 A. B. (Recon); and

  2. b. 

    Enter “Recon Affirmation -- Res judicata applied” in item 34 (Remarks).

2. Reversal of res judicata denial

If the res judicata denial was inappropriate, the DDS will make a substantive initial determination on the evidence.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0427516005
DI 27516.005 - Disability Determination Services Res Judicata Development and Processing - 12/06/2024
Batch run: 12/06/2024
Rev:12/06/2024