A “reopening” is a formal review of a determination or decision that has become administratively final. Reopening may occur to admit new and material evidence or to correct an error. The DDS can reevaluate the evidence used in a prior determination or decision when an error is involved.

NOTE: The term “determination” refers to adjudications at the initial and reconsideration levels or by a disability hearing officer (DHO). The term “decision” refers to adjudications at the administrative law judge (ALJ) or the Appeals Council (AC) levels. For more information about these terms and definitions, see §§ 404.901, 404,917, 416.1401, and 416.1417.

A “determination” or “decision” (initial or revised) is “final” as of the date of the notice unless:

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  It is timely appealed (or a civil suit is filed);

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  It is appealed late but good cause for late filing of an appeal or civil suit is found;

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  The AC takes jurisdiction on its own motion within 60 days of the date of the ALJ decision;

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  The AC denies a request for review (does not issue a decision), in which case the ALJ decision is the final decision as of the date of the notice that the AC denied review; or

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  It is reopened and revised.

A “revision” is any change in the end result or basis of a “final determination or decision” made in the administrative review process.

Due process requires the DDS to provide the essential information to the beneficiary (and any representative payee) on the right to appeal and submit rebuttal evidence before taking any action that will unfavorably affect benefits.

The predetermination notice applies to reopenings that do not require benefit continuation language. In adverse reopening determinations of concurrent Title II or Title XVI claims, the Title XVI due process requirements also apply to the Title II claim.

Send a predetermination notice if the prior determination involves one of the following:

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  Change from blind to disabled;

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  Failure to follow prescribed treatment (FTFPT);

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  Fraud or similar fault (FSF);

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  Failure to cooperate (FTC) when FTC arose at the field office (FO). In FTC cases identified by the DDS, statutory benefit continuation will be offered because these FTC cessations are considered medical determinations; or

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  Whereabouts unknown (WU); the FO provides all notices. See DI 27540.030 and DI 28075.005G.

The due process determination notice applies to adverse medical CDR reopenings.

When reopening a prior cessation determination due to an earlier or later cessation date, send a due process determination notice if the revised determination requires benefit continuation language.