Consider reopening when:

1. a. 

   A party to the determination or decision requests (or makes an implied request for) reopening by:

   • •

     Writing to SSA or the DDS;

   • •

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

   • •

     Filing a new claim (e.g., when a denied claimant files a subsequent claim and alleges an onset of disability in the period adjudicated in 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 generally required before a determination or decision may be reopened:

1. a. 

   An administratively final determination or decision as defined in DI 27501.001A.3 (the determination or decision may adjudicate an initial claim or may be the result of a continuing disability review (CDR)), 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 from an authorized component of SSA or the DDS, questioning the correctness of the prior determination or decision.

   • •

     “Timely” means within the time frames 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.

1. a. 

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

   • •

     There is medical improvement related to the ability to work (or a Group I exception is met) and the beneficiary/recipient can currently adjust to other work; 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 non-medical issues.

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 change in onset or cessation date.

4. d. 

   Revise to a statutorily blind diagnosis, or revise from a statutorily blind diagnosis and diagnosis code to non-blind diagnosis and diagnosis code. See DI 28005.090 Evaluating Continuing Disability Review (CDR) Cases involving Blindness.

5. e. 

   Correct conflicting determinations or decisions in common issue claims when not policy compliant. See: DI 27520.030 Conflicting Determinations or Decisions in Disability/Blindness Common Issue Claims.

6. f. 

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

Unless otherwise instructed:

1. a. 

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

2. b. 

   If the applicable statute, regulations and rules have not changed since the adjudication of the prior determination or decision being considered for reopening, 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. See DI 27510.001.

1. a. 

   AMRs 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 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.

2. b. 

   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 return to work 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.

1. a. 

   Establish onset of disability in a prior adjudicated period in a subsequent title II claim 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 an 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: Do not set an onset in a prior adjudicated period for a CDR cessation.

1. a. 

   Provide the individual 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 individual an opportunity to present any additional information or evidence they believe 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 ensure all applicable opportunities and efforts to comply with due process requirements have been satisfied. . See DI 27525.000 Reopenings-Due Process

2. b. 

   Prepare a revised determination. See DI 27530.001 Documenting Revised Determination 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 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 AMR 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 AMR that involves a suspension, reduction, or termination of SSI benefits.

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

2. b. 

   DHU has jurisdiction for appeal rights for AMRs that concern the issue of whether, based on medical factors the individual is disabled. Give ALJ hearing rights when DHU did not favorably decide a RAMR.

3. c. 

   The ALJ hearing level is the next level of appeal following an unfavorable RAMR for a less favorable onset. 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 an 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 individual of the disposition of any reopening issue they are aware of, but do not include a right to appeal.