TN 13 (06-11)
GN 03101.070 Appeals of Actions Which Are Initial Determinations
Initial determinations are those determinations that are subject to administrative
and judicial review. Initial determinations include, but are not limited to, determinations
about:
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Other initial determination actions (GN 03101.070F in this section)
A. Entitlement and termination
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entitlement, reentitlement, and continuing entitlement to monthly benefits, lump sum
death payments, hospital insurance (HI) benefits, and enrollment for supplementary
medical insurance (SMI) benefits, including initial, amended, subsequent, and supplemental
awards;
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disallowance, including disallowance of request for recomputation and denial of application
for health insurance benefits and for enrollment to supplementary medical insurance
benefits;
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failure of a wife, mother, surviving divorced mother, husband, father, or surviving
divorced father to have a child in care;
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nonpayment of benefits because of deportation, alien living outside U.S., or conviction
for subversive activities;
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nonpayment of benefits because of confinement in a jail, prison, or other correctional
facility for conviction of a crime or in a public institution by court order in connection
with a crime;
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nonpayment of benefits for failure to furnish satisfactory proof of a social security
number (SSN), or, if SSN has not been assigned, for failure to file a proper application
for one;
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reinstatement of benefits and denial of reinstatement (e.g. party made written request
for reinstatement). Although suspension under section 203(h)(3) of the Act is not
in itself an initial determination (For information on appeals of actions which are
not initial determinations, see GN 03101.080), the beneficiary's request for reinstatement may require an initial determination
involving an issue as to earnings, trade or business, or substantial services in self-employment;
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termination of benefits (including automatic conversion of DIB to RIB and DWB to WIB
and including termination of HI and SMI benefits);
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suspension of benefits for failing to meet the U.S. lawful presence payment requirement.
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conversion of benefit amount following amendment;
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recalculation or recomputation of benefit amount;
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reduction in the amount of benefits because of entitlement on another earnings record
or because of the entitlement of additional beneficiaries;
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permanent deductions made after the close of the taxable year;
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determination of deductions under the 7-day foreign work test;
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deductions due to refusal to accept rehabilitation services;
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computation of a reduction factor adjustment at age 62 or full retirement age or computation
of a delayed retirement credit (DRC);
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penalty deductions imposed because claimant failed to report certain events; such
as, failure to file an annual report of earnings prior to 1996;
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reduction of a disability insurance benefit (and auxiliary benefits payable on the
same earnings record) because of entitlement of the disabled worker to a benefit under
a Federal or State workers' compensation law;
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offset of benefits because claimant previously received supplemental security income
payments for the same period;
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determination that a deduction is not to be imposed or that a benefit is not to be
withheld.
C. Overpayment and underpayment
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determination that underpayment or overpayment has been made and will be adjusted
or a refund will be requested;
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waiver of recovery or adjustment of overpayment;
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determination of whether an underpayment is due a deceased person, the amount of the
underpayment, and the party to whom underpayment will be paid on behalf of the deceased
individual.
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determinations to appoint a representative payee (the capability determination) and
the payee selection are both initial determinations with certain exceptions. For information
on representative payee, see GN 03101.080C. For information on representative payee appeal rights, see GN 00503.110;
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representative payee misuse cases regarding the negligence (or good acquittance) determination.
(For information on misuse, see GN 00604.055).
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establishment or termination of a period of disability;
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whether a claimant's drug addiction or alcoholism is a contributing factor material
to the determination of disability;
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whether a claimant's completion of or continuation for a specified period of time
in an appropriate vocational rehabilitation program will significantly increase the
likelihood that the claimant will not have to return to the disability benefit rolls
and whether their benefits may be continued even though the claimant is not disabled;
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whether or not the claimant has a disabling impairment.
F. Other examples of initial determination actions
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revision of earnings record;
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denial of a request for withdrawal of a claim or for cancellation of a request for
withdrawal of a claim;
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determination of support of parent (includes support determinations made regarding
husband and widower when that was a requirement), including timely filing of proof
of support;
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a claim for benefits based on alleged misinformation. (For more information on what
qualifies as misinformation, see GN 00204.008).