TN 13 (06-11)

GN 03101.050 Appeals of the Initial Determination Notice

A. Policy regarding the notice of initial determination

1. General information on sending initial determination notices

We will send a notice of an initial determination to the claimant’s last known address. Do not send a notice when the beneficiary's entitlement has ended due to death. All initial determination notices must contain the following information:

  • what the initial determination is; and

  • the reasons for the determination; and

  • the right to appeal.

On actions to suspend, reduce, or terminate benefits, the beneficiary has a right to advance notice before the determination takes effect.

2. Who May Appeal an initial determination

A party to any initial determination may appeal if they can show in writing the determination may adversely affect their benefits. An appointed representative, representative payee, a third party, or someone considered a proper applicant can make the request for appeal on behalf of the claimant. For more information on a proper applicant, see GN 00204.003

In addition, when someone writes on behalf of the claimant requesting an appeal and the request clearly originated with the claimant, we treat the request as an appeal from the claimant.

B. Policy regarding an incorrect or defective notice

1. General information regarding notices

The regulations that require a notice for an initial determination contemplate sending a correct notice. We consider that an initial determination is correct even if we send an incorrect notice (for example. an allowance instead of a denial).

When making a determination or decision with respect to eligibility, amount, or the actual payment of benefits, the claimant to whom that determination or decision applies should be able to rely on its correctness. Once issued, the initial determination is binding unless appealed or revised.

If the claimant files a reconsideration request after the time limit for filing an appeal has expired, we would find good cause for extending the time limit due to misinformation resulting from the defective notice.

2. Closeout paragraph omitted

A blanket closeout paragraph appears on all award, disallowance, and denial notices to dispose of all classes of benefits not specifically requested. If the notice of initial determination does not contain a closeout paragraph, there is no initial determination of disallowance of all other classes of benefits. For more information on the blanket closeout paragraph, see GN 00204.025B.2.a.

3. Appeal paragraph omitted

In those cases where there is no appeal paragraph in an initial determination (although this is a defective notice), we still made an initial determination. We can reopen these determinations if the rules of administrative finality permit.

If the claimant files a reconsideration request after the time limit for filing an appeal has expired, we would find good cause for extending the time limit due to misinformation resulting from the defective notice.

If the file is not clear on whether an appeal paragraph was included, presume it added.

4. Appeal requested more than 60 days after receipt

If the claimant files an appeal request beyond the time limit for filing an appeal, we would find good cause for extending the time limit due to misinformation resulting from the defective notice.

5. Administrative finality

Administrative finality applies to defective notices the same as to initial determinations with correct notices. Use the date of the defective notice to count the time for reopening. For procedures on reopening erroneous awards, see GN 01010.480. Follow administrative finality and reopening procedures. (See due process and appeal rights in GN 04001.040B.)

C. Policy for cost of living adjustment (COLA) notice

A COLA is an initial determination subject to administrative and judicial review. Therefore, the claimant can question our calculation. Direct depositors receive a printed notice. For non-direct depositors who get a check stuffer, use the first check issued in the increased amount as the notice of the COLA for counting the period for appeal purposes.

NOTE: For information on COLA's and administrative finality, see GN 04030.060.