TN 3 (10-09)

DI 12005.005 Processing a Reconsideration Request for a Medically Denied Initial Disability Claim

Handle assembly and routing of reconsideration cases in the same manner as initial claims. Update disability report information for all levels of appeal up to the Appeals Council review. Maintain this information in the official disability folder.

A. Prepare the folder

Folder preparation depends on whether the case is in a Certified Electronic Folder (CEF) or a paper Modular Disability Folder (MDF).

  • For electronic processing, follow Processing Claims Appeals of Medical Decisions in Electronic Disability Collect System (EDCS) DI 81010.150.

  • EDCS exclusion cases require preparation of an MDF (see General Overview of the MDF DI 70005.005). The MDF houses information and forms that are not completed and captured electronically through another system (e.g., Modernized Claims System (MCS) or Modernized Supplemental Security Income Claims System (MSSICS)).

  • For exclusions to electronic processing, see Certified Electronic Folder (CEF) Exclusions and Limitations DI 81010.030.

NOTE: For official paper filings contained in a two-part folder, keep an appeal taken on such a claim in the two-part folder (DI 70010.001A).

For non-EDCS cases, annotate the route slip (Form SSA-408) with “Recon” and attach it to the front of the folder.

B. Review and update the medical information

  • Review forms submitted by the claimant for completeness and resolve any questionable and or conflicting responses.

  • Obtain a new Form SSA-827 (Authorization to Disclose Information to the Social Security Administration (SSA)) and fax it into the CEF. For non-CEF cases, place the SSA-827 in the MDF.

  • Request any new medical evidence in the claimant’s possession.

NOTE: Do not request that the claimant contact medical sources to get additional records. Handle claimant-submitted medical evidence per Receiving Medical Evidence in the Field Office (FO) DI 81010.125.

See Details:

  • For electronic completion of the SSA-3441 Disability Report-Appeal, see Processing Claims Appeals of Medical Decisions in Electronic Disability Collect System (EDCS) DI 81010.150.

  • For completion of the SSA-827, see Completing the Authorization Form SSA-827 DI 11005.055.

C. Review and update the non-medical issues

  • Resolve any questionable issues involving a non-medical factor that is critical to basic eligibility, e.g., work activity that may constitute substantial gainful activity (SGA), etc. See Processing a Reconsideration Request for an Initial Non-Medical (Technical) Denial DI 12005.010.

  • Deny the claim upon reconsideration and issue the appropriate notice if new evidence obtained while documenting the appeal provides a basis for a non-medical denial (e.g., SGA, failure to cooperate, etc.). See DI 12005.010E.

  • To defer non-medical development not critical to the basic eligibility, follow Guidelines for Deferral of Non-Medical Development DI 11010.025 and Explanation of Deferred and Simultaneous Development SI 00603.002.

  • Handle non-medical evidence according to Storing Non-Medical Evidence in the Electronic Folder (EF) DI 81010.135.

D. Incomplete appeal requests

Occasionally, a claimant requests reconsideration but refuses or fails to complete the necessary forms or to provide additional evidence to support the request. When this occurs, take the following actions:

  • Develop and document the claim folder(s) per GN 03102.300B.1.

  • Send a letter per “Additional Evidence Not Received” GN 03102.300B.2.

  • If the claimant does not submit the SSA-3441 or other forms, such as the SSA-827, etc., and the case can be processed in EDCS, follow Processing Claims Appeals of Medical Decisions in Electronic Disability Collect System (EDCS) DI 81010.150.

E. Obtain the medical determination

Transfer the case to the disability determination services (DDS) if a medical determination is required.

  • Remember to transfer all MCS, MSSICS, and EDCS records.

  • For incomplete appeals, the DDS makes a determination based on available evidence.

  • Recall the folder from the DDS if the FO becomes aware that the claimant is ineligible for any non