TN 3 (10-09)

DI 12005.010 Processing a Reconsideration Request for an Initial Non-Medical or Technical Denial

Reconsideration determinations of disability claims that were denied for non-medical reasons, as listed in GN 03102.175B.1.d, are the jurisdiction of the field office (FO). The Processing Center is responsible for processing all other non-medical reconsideration requests (GN 03102.175B.2.). The reconsideration evaluation and determination cannot be made by the person who made the original determination. If you reverse a prior non-medical or technical denial, see DI 12005.010F, in this section before making any MCS and MSSICS inputs.

A. Developing and documenting a determination

Take the following steps:

  1. Review the reconsideration request and any supplemental documentation and evidence collected in support of the appeal.

  2. The claims representative either reverses or affirms the prior determination.

  3. Record the determination on the appropriate form or screen, such as the SSA-821 (Work Activity Report – Employee), in the space provided. Store it in the official folder.

  4. If a form does not provide a place for a determination, or if a specific form is not needed:

    • Use the Report of Contact (RPOC) screen for Modernized Claim System (MCS) cases and the Non-Medical Reconsideration Disposition Rationale (ARAT) screen for Modernized Supplemental Security Income Claims System (MSSICS) cases, as appropriate.

    • For non-MCS Title II cases, document the determination on an SSA-553 (Special Determination).

    • For non-MSSICS Title XVI cases, document the determination on an SSA-8450 (FO Record of SSI Reconsideration).

B. Determining applicability of res judicata

Res judicata is a rule in civil law and an administrative policy. We apply it at all levels of the claims process to avoid deciding an issue that we have previously decided based on the same facts, same issues, same parties, and same adjudicative period. The purpose of administrative res judicata is to protect SSA from having to consider the same claim (on which it has already issued a determination) repeatedly.

Reference:

C. Developing substantial gainful activity (SGA)

If the claimant is appealing the decision to deny his or her claim due to SGA, the FO updates all work activity before making a reconsideration determination.

  • Review the folder to ensure the description of work obtained during the initial process was complete, and that any work since the initial report has been documented.

  • If not, obtain an SSA-821 (Work Activity Report-Employee) or an SSA- 820 (Work Activity Report-Self–Employed) to document any new information about prior or current work activity.

  • Develop all pertinent information, including specific details about current duties, and verify as necessary with employers or others, especially in cases where the claimant alleges special consideration, subsidy, impairment related work expenses (IRWE), or a reduction or end of work activity.

NOTE: Evaluation of SGA does not apply to Title XVI claimants when approved for disability benefits based on blindness. Until a determination of “Statutory blindness” is made, an SGA evaluation is required. For additional information, see DI 26005.005B.

If you reverse the prior denial, follow DI 12005.010F (in this section).

If you affirm the prior denial, follow DI 12005.010G (in this section) with the following clarification:

  1. Complete an SSA-831 (Disability Determination and Transmittal) in EDCS.

  2. Send the SGA Recon Denial Letter (SSA-L800) via the Document Processing System (DPS) . This personalized denial notice (PDN) explains the determination and is required for cases that are denied because the claimant is performing SGA. These notices cannot currently be produced via MCS or MSSICS.

NOTE: If the prior SGA determination is affirmed, but the work activity has ended or has been reduced to below SGA, develop and process the reconsideration request in the same manner as an initial claim. Then transfer the claim to the disability determination services (DDS), because an initial medical determination is now needed (see DI 12005.005E).

D. Developing insured status

If the claimant appeals the decision denying his or her claim due to lack of insured status, the FO examines all available evidence and makes a reconsideration determination.

1. Earnings record review

Review the earnings information to see if there are any gaps in the earnings record and whether any additional quarters of coverage can be credited via:

  • Summary Earnings Query (SEQY),

  • Detailed Earnings Query (DEQY), or

  • Disability Insured Status Calculator Online (DISCO).

Request any proof of lag earnings from the claimant that may provide insured status.

2. Earlier onset possible

If disability insured status is met at an earlier point, question the claimant to see if an earlier onset can be established. Secure an SSA-821 to document any work performed since the earlier onset.

E. Developing whereabouts unknown (WU) and failure to cooperate (FTC)

If an initial claim was denied for FTC as a result of insufficient evidence furnished, and the claimant or the claimant’s appointed representative later submits the requested information (e.g., signed SSA-827) within the appeal period, treat the submission of the information as an implied request for reconsideration. Any writing or timely submission of additional evidence by the claimant or the claimant’s appointed representative that clearly implies disagreement with the initial determination constitutes a request for reconsideration. A request for reconsideration can be expressed or implied, but it must be in writing. The FO must receive a written request for appeal. A writing is the receipt of any documentation, e.g., a letter, facsimile, or submission of additional evidence which clearly implies the recipient’s disagreement with the initial determination.

If an initial claim was denied as a result of WU or FTC, and the claimant submits the requested information after the appeal period has expired, treat the submission of the information as an implied request for reconsideration that has been filed late. Follow instructions in Late Filing of a Request for Reconsideration DI 12005.015.

References:

  • DI 11010.045Claimant Cannot Be Contacted or Whereabouts Unknown or Claimant Does Not Wish to Pursue Title II Claim

  • DI 11018.005Field Office Responsibilities When a Claimant Fails to Cooperate (FTC)

    DI 81010.145 - Processing Reconsideration Requests of Field Office (FO) Determinations

  • GN 03102.100 – The Reconsideration Process

F. Reversing the prior denial

If you reverse a prior non-medical or technical denial, resume processing the initial application. There are special instructions below for MCS and MSSICS inputs.

1. Send the notice

Send the notice titled “Reversal of Nonmedical Denial,” located in the DPS Initial Claims folder. This notice informs the claimant we are resuming processing the initial application.

NOTE: There is no appeal language in this notice. The DDS sends the claimant a notice with appeal rights, after making the disability determination. If the claimant disagrees with the DDS determination, the claimant may file a new reconsideration request.

2. Make appropriate MCS and MSSICS inputs

For complete MCS and MSSICS instructions on resuming processing the initial application, see Processing Reconsideration Requests of Field Office (FO) Determinations DI 81010.145.

3. Complete a technical reactivation of the initial determination

The Electronic Disability Collect System (EDCS) provides the ability for FOs to reuse most records for a case that was closed as an FO Determination or a No Determination. To differentiate from reactivations on medical denials, we refer to EDCS reactivations on FO Determinations (technical denials) as “Technical Reactivations.”

See Details:

  • For information about technical reactivations and FO Determinations or No Determinations, refer to Processing Field Office (FO) Technical Reactivations DI 81010.110.

  • For details on FO Determinations or No Determinations, see Processing Field Office (FO) Determinations DI 81010.140.

Once you have established a technical reactivation in EDCS, take the following actions:

  • Obtain/update medical information on the appropriate report forms (e.g., SSA-3368, SSA-3820) for an initial-level medical decision.

  • Resolve any questionable issues that could preclude eligibility.

  • Annotate the Remarks section of the MCS or MSSICS transmittal sheet(s) that the prior technical denial is being reversed.

  • Identify cases that were denied for failure to cooperate or whereabouts unknown with a message in EDCS as either “Prior Denial – Failure to Cooperate” or “Prior Denial - Whereabouts Unknown,” as appropriate. For non-CEF cases, annotate the routing slip (SSA-408) in similar fashion.

  • Send the case to the appropriate decision-making component per Sending Initial Disability Insurance Benefits (DIB), Freeze Claims to the Disability Determination Services (DDS) DI 11010.255.

G. Affirming the initial denial

Affirm the denial and document the new determination on the appropriate form, as discussed in DI 12005.010A.

1. Send the notice

Use MCS/MSSICS, whenever possible, to release the appropriate notice. In situations where the system cannot generate the appropriate notice (e.g., a personalized SGA denial notice), use DPS .

For examples of manual Title II reconsideration notices for non-MCS Title II cases, see:

  • NL 00701.390 – Form SSA-L917 - Reconsideration - DIB Earnings Requirement Not Met, or

  • NL 00705.110 – Model Letter “G” - Request For Reconsideration Filed On Denied Application Involving Issues Identical To Previously Denied Application - Same Law Applies.

For non-MSSICS Title XVI cases, use DPS to prepare an SSA-L8455-U2 (SSI Notice of Reconsideration). After explaining the basis for the reconsideration denial, include a brief statement that, because of the non-medical denial, no further action will be taken on the medical aspects of the claim.

H. Retaining the folder

For non-CEF cases, retain the folder in the FO for 180 days, pending any hearing request (see Field Offices (FO) Retaining and Shipping Paper Modular Disability Folders (MDF) – DI 11010.370).

I. References