TN 13 (11-11)
GN 01010.310 Adverse Actions for Initial Claims
A. Definitions of adverse actions applicable to initial claims
1. Adverse action
An adverse action is a determination resulting either in, non-entitlement, the termination of entitlement or in a benefit reduction to an earlier (i.e., a currently entitled or previously entitled) beneficiary because of a subsequent award to a late-filing claimant on the same social security number (SSN).
2. Adverse claim
An adverse claim is an award of benefits (as initial claim) to a subsequent claimant or the reinstatement or resumption of benefits to a prior beneficiary that results in the non-entitlement or termination of an earlier beneficiary.
3. Adverse adjustment
We consider a claim as an adverse adjustment when it meets the following criteria.
The family maximum provision results in a reduction in the past or present benefit payment rates of an earlier entitled beneficiary due to:
The “late filer” is not part of the same household as the adversely affected beneficiary. Refer to RS 00615.760 for definition of “late filers”.
IMPORTANT: Do not confuse the late filer(s) with a “delayed” claimant. If the original application does not protect the claimant or files after the closeout period had ended, the claimant is a “late filer”.
EXAMPLE: Gina Huntley is the number holder (NH)'s daughter by a prior marriage and lives in a separate household. She filed for student benefits on April 30 on her father's SSN however, she turned age 18 on January 12 and graduated from high school the following June. Claimants with Benefit Identification codes (BICs) “A”, “B2”, and “C1” had been receiving benefits on this SSN since February. Gina receives her first and only payment as BIC “C2” in July, representing monthly benefits due for April, May and June. Her student benefit entitlement terminated in July per RS 00205.350D.
We consider Gina’s claim an adverse adjustment because her entitlement caused a reduction in the benefits of “B2” and “C1” for April, May and June. Therefore, we must send an advance due process notice of the adverse adjustment to “B2” and “C1” see GN 01010.330.
NOTE: Certified benefit rates for the retroactive period up to, but not including the late filer's month of filing are protected under Section 202(j)(1) of the Act for unreduced beneficiaries already entitled on the same SSN (see RS 00615.760 through RS 00615.761). Only the part of the family maximum (FMAX) that the system does not certified for payment within the retroactive period is due, see RS 00601.020 for rounding of benefits.
B. Definitions that apply to auxiliary and survivor claims
The following definitions apply to auxiliary and survivor claims for the purposes of applying the rules of adverse actions.
1. New claim
A new claim is a subsequent award for an auxiliary not previously entitled on the SSN (i.e., a Master Beneficiary Record (MBR) already exists) in which other claimants are already receiving benefits.
2. Re-entitlement to benefits
A re-entitlement is a subsequent award for an auxiliary or survivor previously entitled on an SSN whose prior benefits were correctly terminated (e.g., interruption of full-time student attendance or a break between an age 18 termination event and the establishment of a subsequent date of onset for childhood disability benefits). This break in entitlement must be for at least one month. A new application is required for a re-entitlement.
3. Resumption of benefits
Resumption of benefits is a continuation of benefits to an auxiliary or survivor erroneously terminated when evidence received subsequently establishes ongoing entitlement (e.g., continuous student or childhood disability entitlement is established after an age 18 termination event has processed). No new application is required for resumption of benefits.