TN 16 (01-14)
GN 01010.400 Claim Denials
A. Policy on denying a claim
A disallowance or denial is a formal determination of the beneficiary’s application because they did not meet at least one of the requirements for entitlement or eligibility.
The Social Security Administration (SSA) must formally adjudicate every application filed to an award, a disallowance, a denial, or abatement.
The exceptions to this rule are:
the claimant withdraws an application prior to adjudication;
the claimant files a duplicate application; or
an application for survivor's benefits is transferred to the Railroad Retirement Board (RRB).
B. Considerations before denying a claim
Before denying a claim, consider the possibility of entitlement to other types of benefits (e.g., the possibility that a child claimant may be entitled to benefits on more than one Number Holder's (NH) record as a stepchild or adopted child). In addition, be aware that a title XVI application is also an application for title II benefits that we must adjudicate (see Closeout – Failure to Cooperate Initial Claims in SI 00601.110).
1. Options for denying a claim
Consider the options for denying a claim only when:
all of the required evidence is in the claim file and you establish that the claimant is not entitled or eligible at the time of adjudication;
required evidence is missing, but entitlement or eligibility would not exist even if the claimant provides the required evidence; or
the evidence required is missing (e.g., identity, relationship, insured status, age) and the claimant fails to submit such evidence (see Failure to Submit Essential Evidence in GN 01010.410 and Closeout – Failure to Cooperate Initial Claims in SI 00601.110).
IMPORTANT: Consider correcting the numident (NUMI) record, if you are denying the claim for a factor of entitlement (i.e., relationship, insured status, age) and the claimant has the required evidence to process the SSNAP application at the time of filing.
2. Claim denial for lack of identity evidence
The claim technician is responsible for verifying the applicant’s identity during the initial interview. However, when the applicant alleges different identity information from the NUMI record (e.g., first name, last name, DOB) it is his or her responsibility to provide proper evidence to correct or update our records, see Identity of Claimants in and Reviewing Age, Identity, Citizenship and Lawful Alien Status Evidence for an SSN Card in RM 10210.210.
If the applicant is unable to provide the evidence required to resolve discrepant data, the technician must:
follow instructions to document the claim in GN 01010.410;
enter the denial code “065” on the benefit continuity factor (BECF) screen to deny the claim (see MSOM MCS 009.003); MCS automatically generates and releases the denial letter.
3. Auxiliary claim’s denial due to NH withdrawal
The NH's withdrawal nullifies the auxiliary claim; therefore, we must deny the auxiliary’s claim. If we approved the NH's request to withdraw, send a denial notice to the auxiliary claimant. This is required even if the auxiliary is living in the same household with the NH (see Jurisdiction of Approvals and Denials of Withdrawal (WD) Requests in GN 00206.075B.1).
4. Manual denial
Use the Manual Adjustment Credit and Award Data Entry (MACADE) System to process Modernized Claims System (MCS) exclusions or limitation, which preclude using the earning computation (EC) process to deny or disallow the claim.
GN 00203.020 Identity of Claimants
GN 00206.075 Jurisdiction of Approvals and Denials of Withdrawal (WD) Requests
GN 01010.410 Failure to Submit Essential Evidence
MSOM ORS 002.002 Introduction to Title II Claims Notices
SI 00601.100 Information/Evidence – General
SI 00601.110 Closeout – Failure to Cooperate (N18) - Initial Claims)
SM 00380.500 Overview of MACADE Disallowance Function