TN 13 (06-11)

GN 03101.070 Appeals of Actions Which Are Initial Determinations

Initial determinations are those determinations that are subject to administrative and judicial review. Initial determinations include, but are not limited to, determinations about:

A. Entitlement and termination

  • entitlement, reentitlement, and continuing entitlement to monthly benefits, lump sum death payments, hospital insurance (HI) benefits, and enrollment for supplementary medical insurance (SMI) benefits, including initial, amended, subsequent, and supplemental awards;

  • disallowance, including disallowance of request for recomputation and denial of application for health insurance benefits and for enrollment to supplementary medical insurance benefits;

  • failure of a wife, mother, surviving divorced mother, husband, father, or surviving divorced father to have a child in care;

  • nonpayment of benefits because of deportation, alien living outside U.S., or conviction for subversive activities;

  • nonpayment of benefits because of confinement in a jail, prison, or other correctional facility for conviction of a crime or in a public institution by court order in connection with a crime;

  • nonpayment of benefits for failure to furnish satisfactory proof of a social security number (SSN), or, if SSN has not been assigned, for failure to file a proper application for one;

  • reinstatement of benefits and denial of reinstatement (e.g. party made written request for reinstatement). Although suspension under section 203(h)(3) of the Act is not in itself an initial determination (For information on appeals of actions which are not initial determinations, see GN 03101.080), the beneficiary's request for reinstatement may require an initial determination involving an issue as to earnings, trade or business, or substantial services in self-employment;

  • termination of benefits (including automatic conversion of DIB to RIB and DWB to WIB and including termination of HI and SMI benefits);

  • suspension of benefits for failing to meet the U.S. lawful presence payment requirement.

B. Amount of benefit

  • benefit amount;

  • conversion of benefit amount following amendment;

  • recalculation or recomputation of benefit amount;

  • reduction in the amount of benefits because of entitlement on another earnings record or because of the entitlement of additional beneficiaries;

  • permanent deductions made after the close of the taxable year;

  • determination of deductions under the 7-day foreign work test;

  • deductions due to refusal to accept rehabilitation services;

  • computation of a reduction factor adjustment at age 62 or full retirement age or computation of a delayed retirement credit (DRC);

  • penalty deductions imposed because claimant failed to report certain events; such as, failure to file an annual report of earnings prior to 1996;

  • reduction of a disability insurance benefit (and auxiliary benefits payable on the same earnings record) because of entitlement of the disabled worker to a benefit under a Federal or State workers' compensation law;

  • offset of benefits because claimant previously received supplemental security income payments for the same period;

  • determination that a deduction is not to be imposed or that a benefit is not to be withheld.

C. Overpayment and underpayment

  • determination that underpayment or overpayment has been made and will be adjusted or a refund will be requested;

  • waiver of recovery or adjustment of overpayment;

  • determination of whether an underpayment is due a deceased person, the amount of the underpayment, and the party to whom underpayment will be paid on behalf of the deceased individual.

D. Representative payee

  • determinations to appoint a representative payee (the capability determination) and the payee selection are both initial determinations with certain exceptions. For information on representative payee, see GN 03101.080C. For information on representative payee appeal rights, see GN 00503.110;

  • representative payee misuse cases regarding the negligence (or good acquittance) determination. (For information on misuse, see GN 00604.055).

E. Disability provisions

  • establishment or termination of a period of disability;

  • whether a claimant's drug addiction or alcoholism is a contributing factor material to the determination of disability;

  • whether a claimant's completion of or continuation for a specified period of time in an appropriate vocational rehabilitation program will significantly increase the likelihood that the claimant will not have to return to the disability benefit rolls and whether their benefits may be continued even though the claimant is not disabled;

  • whether or not the claimant has a disabling impairment.

F. Other examples of initial determination actions

  • revision of earnings record;

  • denial of a request for withdrawal of a claim or for cancellation of a request for withdrawal of a claim;

  • determination of support of parent (includes support determinations made regarding husband and widower when that was a requirement), including timely filing of proof of support;

  • a claim for benefits based on alleged misinformation. (For more information on what qualifies as misinformation, see GN 00204.008).

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GN 03101.070 - Appeals of Actions Which Are Initial Determinations - 06/17/2011
Batch run: 08/19/2019