TN 32 (04-26)

NL 00705.206 Reopening Notice 2 – Allowance to Denial – Title XVI

Disability Allowance to Denial -- Title XVI

We are writing to you about (1) Supplemental Security Income (SSI) payments. We recently looked at (2) SSI claim again to make sure our decision was correct. After reviewing all of the information carefully, we are changing our decision. Based on our rules, we now find that (3) not disabled. Therefore, (4) claim is denied. You will get another letter soon about when (5) payments will stop.

Fill-ins:

(1) your/claimant’s name (possessive)

(2) your/his/her

(3) you are/ he is/ she is

(4) your/his/her

(5) your/ his/ her

 

The Decision

See the enclosed Explanation.

Attach the Personalized Disability Explanation (PDE) language per DI 26530.020 and DI 26530.055, including a list of the evidence, an explanation of what the evidence shows, and the detailed, personalized reasons for the determination. For additional guidance, see Reopening of Prior Determination DI 27536.015.

If concurrent claims are involved, include the following paragraph :

This decision refers only to (1) Supplemental Security Income payments. You will get a separate letter about (2) Social Security Disability Insurance benefits.

Fill-ins:

(1) your/claimant name (possessive)

(2) your/his/her

 

(Universal text identifier (UTI) 4054)

Who Decided (1) Case

Fill-in:

(1) Your/ his/ her

If DDS disability determination:

Doctors and other trained staff looked at this case and made this decision. They work for the State but used our rules.

If Federal disability determination:

Our doctors and other trained staff looked at this case and made this decision.

 

(UTI ALSC12)

If You Disagree With The Decision

(UTI ALS023 – modified to show the SSA-789 instead of the SSA-561. NOTE: If the revision is due to a non-medical reason, such as work, show “SSA-561, called “Request for Reconsideration” instead of the SSA-789. Do not include the language for the DHO hearing or statutory benefit continuation.)

If you do not agree with this decision, you have the right to appeal. A person who did not make the first decision will decide the case. We will review the case and look at any new facts you have. We will review the parts of the decision that you think are wrong and correct any mistakes. We may also review the parts of our decision that you think are right. We will make a decision that may or may not be in your favor.

• •

  You have 60 days to ask for an appeal.

• •

  The 60 days start the day after you receive this letter. We assume you got this letter 5 days after the date on it unless you show us that you did not get it within the 5-day period.

• •

  You must have a good reason if you wait more than 60 days to ask for an appeal.

• •

  You must ask for an appeal in writing. Please use our "Request for Reconsideration - Disability Cessation" form, SSA-789. You can go to our website at https://www.ssa.gov/forms to locate this form. You can also contact us to request the form or if you need help filling out the form.

Do not send the following caption and paragraph 4061 if there is a determination of fraud or similar fault, since FSF precludes the payment of statutory benefit continuation.

Do not send the following caption and paragraph if the revision is due to a non-medical reason, such as work or other reason that precludes payment of statutory benefit continuation (SBC). Instead, include Goldberg/Kelly payment continuation language in the decision notice as explained in DI 27540.030.

 

 

(UTI 4059)

Appeal In 10 Days To Keep Getting Your Benefits

You have only 10 days to ask us in writing to continue your benefits during your appeal. The 10 days start the day after you get this letter.

• •

  To continue benefits, complete our SSA-792 Statutory Benefit Continuation Election Statement form. Submit this form to your local Social Security office within 10 days. You can go to our website at https://www.sssa.gov/forms to locate this form. You can also contact us to request the form or if you need help filling out the form.

• •

  With this form, you can choose to continue or not continue getting benefits during your appeal. If applicable, you can also choose to continue only Medicare and for your family to keep getting their benefits if they are also receiving benefits on your record.

• •

  If you lose the appeal, you might have to pay back some or all of this money. If you are receiving Medicare, you will not have to pay back Medicare.

(UTI ALSC23)

You May Not Have to Pay Back the Money You Get During Your Appeal

 

(UTI ALS099)

If you ask us to continue your benefits during your appeal, and your appeal is not approved, we will start collecting the money you and your family received during your appeal. You can request to not pay the money back by asking for a waiver. We may approve your waiver if the overpayment was not your fault AND paying us back would mean that you cannot afford to meet your daily living expenses, or it would be unfair for some other reason. We may find you are not at fault for the overpayment of the benefits you received during your appeal if all the following are true:

• •

  You asked for an appeal because you believe you still have a disability.

• •

  You provided the requested evidence.

• •

  You attended all requested examinations.

 

NOTE: Do not send the following caption and paragraph if the revision is due to a non-medical reason, such as work.

(UTI 4066)

How An Appeal Works

A Disability Hearing Officer (DHO) will decide (1) appeal. We will call this person a DHO in the rest of our letter. The DHO will meet with you before making the decision on (2) appeal. The meeting works like this:

• •

  The DHO will mail you a letter at least 20 days before the meeting to tell you its date, time, and place.

• •

  You can look at (3) file before the meeting.

• •

  You can tell the DHO the reasons you think (4) still disabled. You can give the DHO more facts and you can bring people to say why (5) disabled.

• •

  You can have the DHO ask people to come to the meeting to speak about (6) disability and bring important papers. You can question these people at the meeting.

• •

  You do not have to go to the meeting in person. If you do not want to go, you can give the DHO more facts you may have. The DHO will decide your case using these facts and what is now in the file. But, if you go to the meeting, it may help the DHO decide your case.

Fill-ins:

(1) your/his/her

(2) your/his/her

(3) your/his/her

(4) you are/he is/she is

(5) you are/he is /she is

(6) your/his/her

 

 

(UTI REPC01)

If You Want Help With Your Appeal

(UTI REP002)

You may choose to have a representative help you with your case. We will work with this person just as we would work with you. If you decide to have a representative, you should find one quickly so that person can start preparing your case.

Many representatives charge a fee only if you win your case. Others may represent you for free. Generally, your representative cannot charge a fee unless we approve it. Your local Social Security office can give you a list of groups that can help you find a representative.

If you get a representative, you or that person must notify us in writing. You can go to https://secure.ssa.gov/ssa1696/front-end/ to complete the form with your representative online, download the form SSA-1696 "Claimant's Appointment of Representative" at www.ssa.gov/forms, or contact us to request a form.

You can also log into your my Social Security account for information and online service options regarding your representation.

 

 

(UTI 4070)

If (1) Health Gets Worse

Fill-ins:

(1) your/his/her

If (1) health gets worse and you feel that (2) disabled again, please get in touch with us. (3) may be able to get benefits again.

Fill-ins:

(1) your/claimant’s name (possessive)

(2) you are/he is/she is

(3) You/claimant’s name

 

(UTI REF196)

Suspect Social Security Fraud?

Please visit https://oig.ssa.gov/report or call the Inspector General's Fraud Hotline at (800) 269-0271. If you are deaf or hard of hearing, call TTY (866) 501-2101.

Need More Help?

1. 1. 

   Visit www.ssa.gov for fast, simple, and secure online service.

2. 2. 

   Call us at 1-800-772-1213, weekdays from 8:00 am to 7:00 pm. If you are deaf or hard of hearing, call TTY 1-800-325-0778. Please mention this letter when you call.

3. 3. 

   You may also call your local office at (1).

 

                   (2) [Field Office Address

                     City, State, ZIP] per DOORS

 

Fill-ins (per DOORS)

(1) Local field office public line phone number

(2) Local field office address

 

How Are We Doing? Go to www.ssa.gov/feedback to tell us.

 

 

Enclosure:

Explanation

If Limited English Proficiency (LEP) flag exists OR Preferred Language is not English or not Unknown:

Multi-lanuage insert