TN 13 (11-11)

GN 01010.001 Adjudicative Policy and Standards

Citations:

Code of Federal Regulations (CFR) §404.602

A. Introduction to the adjudicative policy

This subchapter explains the adjudicative process for an initial entitlement or eligibility determination, including specific responsibilities of field offices (FO) and processing centers (PC).

  • Title II Retirement, Survivors & Disability Insurance (RSDI) and title XVIII Hospital Insurance/Supplementary Medical Insurance (HI/SMI) procedures regarding reconsiderations are in GN 03102.100.

  • Title XVI Supplemental Security Income (SSI) procedures regarding reconsiderations are in SI 04020.010.

  • Hearing and Appeals Council level for SSI appeals procedures are in SI 04030.010.

B. Definition of terms used in this subchapter

The following definitions apply within this subchapter:

1. Adjudication

Adjudication is the application of the law to the facts and an authoritative declaration of the result (i.e. a signed determination or decision). Consider a claim adjudicated when an employee with adjudicative authority delegated from the Commissioner of the Social Security Administration completes

  • the appropriate electronic adjudicative decision screen,

  • the equivalent direct input screen, or,

  • signs a paper adjudicative form.

Once processed, initial determinations are subject to appeal (e.g., reconsideration, administrative law judge (ALJ), appeals council (AC), or U.S. Court). If the appeal results in a fully or partially favorable determination or decision, the ALJ or AC routes the claim to the FO or PC for development, verification of any remaining entitlement factors, and subsequent adjudication as defined above. Thus, the initial determination and each level of appeal require a separate adjudication.

Adjudication is part of the effectuation process and occurs automatically and simultaneously when processing the claim completely via an electronic claims system (e.g., Modernized Claims System (MCS) or Modernized Supplemental Security Income Claims System (MSSICS). However, in advance filing situations effectuation does not occur until the Treasury Department processes payment certification.

Note: The disability determination or decision made by the Disability Determination Service (DDS), ALJ, AC or U.S. Court constitutes only a part of the adjudicative process for disability claims.

2. Adjudicator

An adjudicator is an employee with delegated authority from the Commissioner of Social Security to approve or disapprove applications for Social Security benefits. Adjudicators are title II and title XVI Claims Representatives (CR), title II Claims Authorizers (CA), and other personnel with specifically delegated authority.

3. Adjudicative signature

An adjudicative signature is the signature of the employee who adjudicates or authorizes the claim. The personal identification number (PIN) serves as the signature for electronic claims and for direct input screens used to adjudicate a claim. See GN 01010.275 for related signature procedures.

4. Adjudication date

The adjudication date is the date the adjudicator signs the adjudicative screen or form authorizing the determination or decision after considering all eligibility and entitlement evidence.

5. Adjudicative screens and forms

Adjudicative screens and forms include:

  • DECI screen ( (MSOM MCS 009.013);

  • DADJ screen ( (MSOM MSSICS 025.003);

  • ADJU screen (Automatic 101 (A101) MSOM MCS 014.009);

  • EFADJU screen (Electronic Form 101 (EF101) MSOM T2PE 009.035);

  • SSA-450-SI (Title XVI Data Input form OS 15040.060);

  • SSA-1719-B (Title XVI Data Input form OS 15040.200); and

  • SSA-521 (Request for Withdrawal of Application form OS 15010.155).

6. Applicant

An applicant is an individual filing for Social Security benefits (or benefits administered by Social Security) on his or her own behalf, or a third party applicant filing on someone else’s behalf. If the applicant is filing on his or her behalf, he or she is also a “claimant.” For more information on third parties, refer to “Third party applicants” GN 01010.001B.8 in this section.

7. Claimant

A claimant is the individual who files an application for benefits for himself or herself or the person for whom an application is filed. A claimant filing on his or her own behalf is also an “applicant.” The rule is, all claimants are applicants, but not all applicants are claimants.

8. Third party applicants

Third party applicants are individuals who file a claim for Social Security benefits (or benefits administered by Social Security) on a claimant’s behalf. Third party applicants are usually non-proper applicants and cannot sign the application on the claimant’s behalf, see GN 00204.013 Third Party Non-proper applicant and Protective Filing. In certain situations third party applicants are proper applicants, see GN 00204.003.

9. Claims file

The term “claims file” includes information in the electronic Disability file (eDIB) also known as the Certified Electronic Folder (CEF), the Non-Disability Repository (NDR), the paper claims folder, and any other information stored or archived in a retrievable electronic medium (e.g., MCS, evidence (EVID) screen).

10. Effectuation of a claim

Effectuation of a claim is processing or triggering an adjudicative determination for allowance, disallowance, denial, abatement, or pre-effectuated withdrawal via a processing system (e.g., MCS, MSSICS,) resulting in an update to the appropriate master data base (e.g., Master Beneficiary Record (MBR) or the Supplemental Security Record (SSR)).

Note: “Adjudication” and “effectuation” can occur automatically and simultaneously when processing the claim completely via an electronic claims system (e.g., MCS or MSSICS). However, in advance filing situations effectuation does not occur until the Treasury Department processes payment certification.

11. Field office (FO)

  1. The term FO includes district offices (DO), branch offices (BO), and Workload Support Unit (WSU). WSUs are scattered throughout the continental U.S., one of their functions is to take applications for specified claims types and process them to completion. WSUs also review and process internet claims (iClaim).

  2. The Office of International Operations (OIO) is PC8, but it also has an FO function known as the International Benefits Office (IBO). The IBO acts as the FO (i.e., E15 on Detailed Office/Organization Resource System (DOORS)) for claimants who do not reside in the 50 United States, the District of Columbia, Puerto Rico, American Samoa, Guam, the Northern Mariana Islands, or the U.S. Virgin Islands.

    Note: Refer to GN 00904.015 for FO jurisdiction of claimants residing in Samoa, the British Virgin Islands, and Canada.

12. Processing center (PC)

The term PC, as used in this subchapter, includes the six program service centers (PSCs), the Office of Disability Operations (ODO) known as PC7 and the Office of International Operations (OIO) known as PC8.

C. References


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0201010001
GN 01010.001 - Adjudicative Policy and Standards - 01/28/2015
Batch run: 01/28/2015
Rev:01/28/2015