TN 13 (11-11)

GN 01010.035 Scope of Review of the Prior Claim

A. Policy on reviewing prior claims

1. Processing center (PC) Reviews

The role of the PC is generally limited to payment effectuation activities. However, other PC technicians conduct limited reviews. Any PC review, either pre- or post-adjudicative, is limited to the issue or evidence in question. If there is an error on the face of the evidence, see GN 04010.020.

Refer to GN 01010.285 for cases where the Benefit Authorizer (BA) refers a claim to a claim authorizer (CA). The CA review is limited to the resolution of the issue identified. However, the CA can take corrective action within the rules of reopening; see GN 04001.010 for more information.

NOTE: Remember that a full PC review is required if the claim is a non-DOFA case.

2. Field office (FO) reviews

The FO review is limited to the last adjudicative action, including any subsequent action taken or the related evidence. Therefore, you must retrieve the prior claims file if electronic documentation does not exist or the claimant fails to supply the needed information and telephone contacts are unsuccessful. After the review, correct any errors detected within the rules of Administrative Finality.

B. Procedures for reviewing prior claims

1. Reviewing the last adjudicative screen or form

When reviewing the last adjudicative action for completion and consistency with the current claim, follow the guidelines in GN 01010.007 and GN 01010.285.

2. Subsequent actions

Limit the review to actions taken since the date of the last adjudicative action to identify factors that might affect the current claim.

3. Prior evidence

Review evidence in the prior claims file only if any of the following issues apply:

  • The prior determination was an abatement, disallowance or withdrawal;

  • The previously submitted evidence is needed to adjudicate the subsequent claim;

  • The current claim contains material that raises a question about the accuracy of the prior determination;

  • The material filed on the prior claims file raises a question about the current claimant's right to benefits;

  • In the adjudicator's judgment, a review is necessary to ensure the accuracy of the current decision;

  • Material is submitted with the current claim for the purpose of questioning the prior award (see GN 01010.320 if an adverse claim is involved);

  • Wage credits, possibly creditable to a World War II (WWII) or post-WWII veteran under Section 217 of the Act are identified;

  • The Number Holder (NH) worked in the railroad (RR) industry after 1936 and there is no determination as to whether SSA can use the RR compensation as wages;

  • The prior determination did not establish a factor of entitlement for the current award. The complete file requires review to resolve the particular factor(s).

    Example: While converting a young spouse to widow(er) benefits, the adjudicator discovers that the prior determination did not establish the young spouse's date of birth (DOB). The adjudicator will review the file to establish the DOB, but will not review the file with respect to unrelated factors.

C. New claimant filing on a previously established record

If the Master Beneficiary Record (MBR) shows any claimant currently receiving benefits, the FO must:

  • Review the full account (FACT) MBR to see if the new claimant’s entitlement will affect those already receiving benefits;

  • Provide payment information and instructions regarding adjusted monthly benefit amounts (MBA)s, worker’s compensation (WC)/ public disability benefit (PDB) offset involvement, representative fee data, Supplemental Security Income (SSI) offset, representative payee, and other pertinent data on the automated 101 (A101) benefits continuity remarks/notice (BCRN) screen and cover sheet;

  • Alert the PC of any special remarks, instructions, and notice language using the report of contact (RPOC) or the A101 or electronic form 101 (EF101) BCRN;

  • Consider possible protective filing when a subsequent claimant was eligible for benefits at the time the NH filed;

  • Determine whether an open application or protective filing exists that would affect the subsequent claimant's month of election (MOEL), see GN 00204.025;

  • Consider prior claimants on the same record when assigning benefit identification codes (BICs).

Note: Erroneous BIC assignments trigger subsequent Daily Update Master Accounting System (DUMAS) exceptions in the PC and cause additional processing delays.

Example: If a claimant BIC “B6” (divorced wife - first claimant) is already on the MBR and an aged spouse later files, the adjudicator must assign the aged spouse BIC “B3” (aged spouse - second claimant). The fact that the first “B” claimant is a divorced spouse and the second “B” claimant is currently married to the NH is not apparent to the system for BIC assignment purposes. Refer to SM 00550.010 for BIC codes.

D. References

To Link to this section - Use this URL:
GN 01010.035 - Scope of Review of the Prior Claim - 11/10/2011
Batch run: 02/05/2014