Consider a reopening when:

1. a. 

   A party to the determination or decision requests (or impliedly requests) reopening by:

   • •

     Writing SSA or the DDS;

   • •

     Writing a third party (e.g., a congressman); or

   • •

     Filing a new claim (e.g., a denied claimant files a subsequent claim and alleges an onset of disability in the period adjudicated by the prior denial determination or decision).

2. b. 

   SSA or the DDS questions the correctness of a prior determination or decision as a result of:

   • •

     New information or evidence; or

   • •

     Quality or other review.

The following are required before a determination or decision may be reopened:

1. a. 

   An administratively final determination or decision of disability as defined in DI 27501.001A.3 (may be an initial claim or a continuing disability review (CDR) determination or decision), and

2. b. 

   Reason to consider reopening (e.g., new and material evidence), and

3. c. 

   A timely written statement by a party to the determination or decision indicating disagreement with the correctness of a final determination or decision, or

4. d. 

   A timely written statement (affirmative action in writing) by an authorized component of SSA or DDS, questioning the correctness of a prior determination or decision.

   • •

     “Timely” means within the timeframes and conditions described in DI 27505.001 Conditions for Reopening a Final Determination or Decision.

   • •

     “Authorized” means the component has the authority to reopen the determination or decision in question. For information on who may reopen, see DI 27501.005B.3 in this section.

An SSA or DDS component at the same or higher adjudicative level may reopen an administratively final determination or decision when reopening is appropriate.

NOTE: Only the Field Office (FO) has jurisdiction to reopen a FO nonmedical failure to cooperate or whereabouts unknown CDR cessation.

Also, see:

• •

  DI 81020.115 Processing Reopenings

• •

  DI 81020.117 Processing Medical Reactivations

1. a. 

   The MIRS applies when a favorable disability determination or decision is being reopened and revised to a determination or decision of denial, cessation, or closed period. The favorable disability determination or decision may be reopened and revised to a denial, cessation, or closed period determination or decision only where:

   • •

     There is medical improvement related to the ability to work (or a Group I exception is met) and the beneficiary/recipient can currently perform SGA; or

   • •

     A Group II MIRS exception is met.

2. b. 

   The MIRS does not apply to reopening and revision to a later onset or to revised determinations concerning insured status or other nonmedical issues.

For details, see:

• •

  DI 28005.001 Legal Standard for Determining if Disability Continues

• •

  DI 28020.001 General – Groups I & II of Exceptions to Medical Improvement (MI)

• •

  DI 28010.001 Medical Improvement (MI)

• •

  DI 28020.900 Group II Exceptions

A revised determination or decision is required to:

1. a. 

   Make a less favorable (adverse) revision.

2. b. 

   Make a more favorable revision.

3. c. 

   Change a basis code only--no change in the determination or decision to deny or allow, or onset or cessation date.

4. d. 

   Revise to a statutorily blind diagnosis, or revise from a statutorily blind diagnosis to other diagnosis. See DI 28080.065 Continuing Disability Review (CDR) Cases with a Basis Change from Blind to Disabled.

5. e. 

   Correct conflicting determinations or decisions in common issue claims when not policy compliant. See:

   • •

     DI 27515.035 Different Determinations or Decisions for the Same Period in Separate Claims; and

   • •

     DI 27520.030 Conflicting Determinations or Decisions in Disability/Blindness Common Issue Claims.

6. f. 

   Reopen certain erroneous notice/payment cases. See DI 27520.025 Erroneous Notice/Payment Cases.

The rules for reopening do not apply to:

• •

  The withdrawal of an application; or

• •

  The failure to make a determination.

For a discussion of what is and what is not an initial determination, see GN 03101.070 Appeals of Actions Which Are Initial Determinations and GN 03101.080 Appeals of Actions Which Are Not Initial Determinations.

Unless otherwise instructed:

1. a. 

   Base consideration for reopening on the statute, regulations, and rulings, which were applicable at the time of the adjudication of the prior determination or decision being considered for reopening.

2. b. 

   Base a revised determination or decision on the current statute, regulations, and rulings.

3. c. 

   Extend a revised determination or decision through the current date (or through the date last insured, age 22, or prescribed period, if earlier) rather than through the date covered by the determination or decision being revised.

1. a. 

   Adverse reopenings other than those indicated in DI 27501.005B.4.b. must follow the MIRS.

2. b. 

   Reopening of a final determination is warranted in title II claims when a claimant returns to work at the SGA level in the waiting period and the SGA work activity is continuing per DI 13010.105 Beneficiary Returns to Substantial Gainful Activity (SGA) Within One Year of Onset Date - Title II.

1. a. 

   When new information or evidence is received indicating that improvement in the claimant's condition occurred before the end of the required 12 months duration of disability and it is after a notice of determination or decision has been released, the case is generally considered a continuing disability issue. See DI 25505.025 Duration Requirement for Disability.

2. b. 

   When evidence of improvement is received before the notice of the award is released, prepare a new determination, if warranted. This action is not considered a reopening.

3. c. 

   Onset of disability in a subsequent title II claim may be established within a prior adjudicated period when:

   • •

     The disability criteria has changed and more than 12 months have elapsed since the date of the notice of the initial determination on the previous claim (thereby precluding reopening for any reason); or

   • •

     New and material evidence establishes disability within the period adjudicated and more than 4 years have elapsed since the date of the notice of the initial determination on the previous claim (thereby precluding reopening for good cause); or

   • •

     The prior determination was a FO denial for "insufficient evidence furnished" (M5/M6) when a claimant fails to submit essential evidence. See DI 11018.005 Field Office Responsibilities in a Failure to Cooperate-Insufficient Evidence Decision (FTC).

NOTE 1: Establishing an onset within the prior period adjudicated establishes the disability freeze, which preserves the insured status and may result in an increased monthly benefit amount. When the prior determination is not reopened, the retroactivity of benefits is based on the new application.

NOTE 2: These instructions do not apply if the previously adjudicated period was a CDR cessation.

Also, see:

• •

  DI 27505.020 Change of Ruling or Legal Precedent (Change of Position)

• •

  DI 27510.005 Subsequent Claim Filed

• •

  DI 27505.001 Conditions for Reopening a Final Determination or Decision

• •

  DI 27520.000 Reopenings – Special Issues

1. a. 

   Provide the claimant a due process notice in adverse actions. See DI 27525.001 Due Process Notification for Adverse Reopenings.

   NOTE: Provide a due process decision notice when statutory benefit continuation (SBC) rights are applicable.

2. b. 

   Afford the claimant an opportunity to present any additional information or evidence he or she believes may have a bearing on the determination or decision in adverse actions. See DI 27525.000 Reopenings – Due Process.

Take the following steps when reopening or revising a determination:

1. a. 

   Document the file to assure all opportunities and efforts to comply with due process requirements, when applicable, have been satisfied.

   See DI 27525.000 Reopenings – Due Process.

2. b. 

   Prepare a revised determination.

   See DI 27530.001 Documenting Revised Determinations and GN 04001.080 Documenting the Rationale for Reopening.

3. c. 

   Prepare a rationale.

   See DI 27536.015 Optional Use of a Summary Decision Rationale for Reopening, DI 26515.001 Rationale Preparation, and GN 04001.080 Documenting the Rationale for Reopening.

4. d. 

   Prepare the proper notices and provide appeal rights.

   See DI 27540.001 Due Process Requirements and NL 00708.100 Numbered Paragraphs.

5. e. 

   Route the claim appropriately.

   See DI 32005.095 Disability Determination Services Reopenings and Revisions Case Routing - Initial and Reconsideration - Paper Cases Only.

Provide the appropriate appeal rights to the claimant.

1. a. 

   Give reconsideration appeal rights following a title II revised initial determination that concerns the issue of whether, based on medical factors, the individual is disabled. Reconsideration is also the next level of appeal following a title XVI revised initial determination that involves a suspension, reduction, or termination of SSI benefits. Include the right to a disability hearing at the reconsideration level for adverse revisions based on medical or medical-vocational factors as indicated in DI 29001.001B.3.

   NOTE: Do not give disability hearing rights at the reconsideration level if a revised determination establishes a later onset because of work activity.

2. b. 

   Give ALJ hearing rights when the revised determination was finally decided at the reconsideration level.

3. c. 

   The ALJ hearing level is the next level of appeal following a title II revised initial determination that does not concern the issue of whether, based on medical factors, the individual is disabled. The ALJ hearing level is also the next level of appeal following a title XVI revised initial determination that does not involve a suspension, reduction, or termination of SSI benefits.

When denying a request for reopening:

• •

  Document the file with a SSA-553 (Special Determination), or other electronic writing (RPOC, DW01) or form, describing facts and consideration given to the reopening issue, and reason for not reopening (See GN 04001.080 Documenting the Rationale for Reopening); and

• •

  Provide notification to the claimant of the disposition of any reopening issue the claimant is aware of, but do not include a right to appeal.