TN 1 (11-02)

DI 12045.027 New Claim or Appeal Filed While a Prior Claim or Appeal is Pending Before the Appeals Council (AC) — Title II or Title XVI

A. Introduction

This section provides field office (FO) instructions for processing a new claim or appeal when a Request for Review is pending before the Appeals Council (AC). Follow the procedures in this section if the prior claim is:

  • for a different title;

  • for the same title, but for a different benefit type (e.g., claimant wants to file a new title II disabled widow(er)’s benefit application and the claimant has a claim pending for title II disability insurance benefits);

  • a continuing disability review;

  • an expedited reinstatement (EXR) claim;

  • an age 18 redetermination; or

  • in Federal court or was remanded from Federal court to the hearing or AC level.

IMPORTANT: Do not accept or process a new disability application if the claimant has a prior disability claim for the same title and benefit type pending at any level of administrative review. See Procedural Change for Subsequent Disability Applications Effective July 28, 2011 DI 51501.001.

B. Policy

When a claim is pending at the AC level and an individual files a subsequent claim (DI 12045.010A.) under the same title or different title, the subsequent claim will be processed as a new initial claim. The subsequent claim will be processed under current claims processing procedures with normal appeals through the filing of a request for an ALJ hearing. This process also includes new claims filed when an appeal of a continuing disability review (CDR) is pending at the AC level. It does not include claims that are merely duplicates; e.g., a claim for disability insurance benefits in which the date last insured expired before the ALJ's decision on the prior application for the same benefits.

For subsequent nonmedical claims with a new issue, the claim will be processed as a new initial claim. For subsequent nonmedical claims involving issues that have already been decided, the subsequent claim will be sent to the AC for association. See GN 03104.370.

C. Procedure - Before DDS Adjudication of Subsequent Claim

1. Subsequent Claim Filed

Take the following action when a subsequent claim has been filed:

  1. Ask the claimant or representative if he or she has filed a Request for Review (RR) of an ALJ decision on a prior claim. Obtain a CPMS query to verify. The RRD field on the query is the request for review date; this indicates if a claim is pending at the AC level. The ADD field on the query indicates whether the AC has taken action on the RR.

  2. Follow current instructions to process the claim if it is determined that NO RR has been filed or that NO appeal is pending at the AC level.

  3. If it is determined that a RR has been filed and that an appeal is pending at the AC level, take the subsequent application using current procedures.

  4. Secure a SSA-1696-U4 if the claimant is represented.

    NOTE: A new SSA-1696-U4 is necessary even if the representative is the same as on the prior claim. SSA will apply the fee agreement rules as if there was a single application or claim (See GN 03940.038C.2.).

  5. Complete the SSA-3367-F4 as usual and include the following:

    • Item 3 - Show the recommended onset date as the day after the ALJ decision (or the day after the cessation if the prior claim was a CDR).

    • Item 4 - Check “Other” as the reason and show “Appeal pending at AC level on prior claim dated mm/dd/yy.” (See note in DI 12045.027C.1.f. regarding onset restriction.)

  6. Secure appropriate medical Forms SSA-3368-BK, SSA-827's, etc. using current processing procedures.

    NOTE: The DDS will follow normal development of medical history covering the 12 month period beginning with the date of the subsequent application.

  7. Include the following remarks as applicable on the SSA-3367, Disability Report-Field Office, Remarks page in Electronic Disability Collect System (EDCS).

    • “Onset Restriction—Prior claim dated mm/dd/yy pending at the Appeals Council level.”

    • Initial claims and closed period cases – “Onset restriction--Onset date cannot be established earlier than the day after the date of the ALJ decision.”

    • Cessations (CDR)--Onset restriction—“Onset date can be set no earlier than the day after the date of disability cessation.”

      EXCEPTION: In the 6th circuit (Ohio, Michigan, Tennessee, Kentucky), the onset date can be no earlier than the day after the date of the ALJ decision regardless of whether the prior claim is an initial claim, CDR cessation or a closed period.

  8. Explain to the claimant that, until the AC completes its action, we will not be deciding the period on or before the date of the ALJ decision (or before the date of cessation in a CDR case (see DI 12045.027C.1.g.)), because that period is before the AC on the appeal of the ALJ decision on the prior claim. Explain that there will be separate notices for each claim and that each notice will explain the claimant's appeal rights.

    NOTE: The period on or before the date of the ALJ decision rests with the AC; therefore, the DDS will not establish an onset date earlier than the day after the date of the ALJ decision or cessation date in a CDR cessation. A claimant may allege any onset date, even if that date is in the period covered by the ALJ's decision on the prior application. Do not try to persuade the claimant to allege a specific onset date. The date of the ALJ decision can be found in the Hearing held date field of the CPMS query, and the date of cessation can be found in the CSD field of the DDSQ.

2. Subsequent Claim and RR filed simultaneously

Take the following action if a subsequent claim and request for review are filed simultaneously:

  1. Determine if the claimant has filed an earlier subsequent claim via MCS/MSSICS.

  2. If a subsequent claim had been filed earlier, see DI 12045.027C.3.

  3. If a subsequent claim had not been filed earlier take the following action:

    • Secure the subsequent application and medical development as indicated in DI 12045.027C.1.

    • Process the RR using current procedures. Include with the RR a Report of Contact with the following information, “On mm/dd/yy, a subsequent claim was filed by claimant. Notification will be sent to AC if the DDS allows the subsequent claim.”

3. Subsequent Claim Previously Filed

Take the following action in lieu of securing a new (or third) application:

  • Obtain an MBR, SSID or DDSQ to determine the date of the previous subsequent application and whether it has been processed.

  • Reestablish the previous application from MCS/MSSICS.

  • Enter “ZZZ” in the first three positions of the unit field when establishing/reestablishing the systems record.

  • Secure SSA-3367-F4, SSA-3368-BK, and SSA-827's to update medical development for the period beginning with the date of the previous subsequent claim.

  • Send a Report of Contact via FAX to Office of Disability Adjudication and Review, Office of Appellate Operations (ODAR/OAO) at 703-605-7101 to the attention of Subsequent Application Coordinator; include the claimant's name, Social Security number, a statement that the second application was previously forwarded to AC for association, the date it was forwarded, and the fact that you are now forwarding the second application to the DDS for adjudication.

4. Systems Input - Title XVI

Take the following systems actions for Title XVI cases:

a. For Initial Claims

  • Re-establish MSSICS to control subsequent claim, this automatically terminates prior claim.

  • Control the prior claim (the claim pending at AC) with an MDW record and completion of DWO1 development worksheet as shown below.

  • On the subsequent claim, include the following supplemental security record (SSR) remark: PRIOR CLAIM AWAITING AC DECISION

  • On the MDW record include:

    • An ISSUE “AC APPEAL.”

    • In the REMARKS for that ISSUE: Prior claim dated mm/dd/yy pending at the AC.

    • The date of appeal and date sent to AC.

  • On the development worksheet (DW01) include:

    • An ISSUE “AC APPEAL.”

    • In the REMARKS for that ISSUE: Prior claim dated mm/dd/yy pending at the AC.

    • The date of appeal and date sent to AC.

    • Set an appropriate tickle date for the AC's decision.

b. For CDR Cessation Claims

  • Follow T-33 procedure to terminate the prior claim.

  • Enter the new record on MSSICS or via 450SI to control subsequent claim.

  • Follow DI 12045.027C.4.a., beginning with bullet 2, to control the prior claim.

5. System Input For Title II claims

Take the following systems actions for Title II claims:

  • Process the subsequent claim through MCS.

  • Control the prior claim (the claim pending at the AC) with an MDW record and completion of DWO1 development worksheet as shown below.

  • On the MDW record include:

    • An ISSUE “AC APPEAL.”

    • In the REMARKS for that ISSUE: Prior claim dated mm/dd/yy pending at the AC.

    • The date of appeal and date sent to AC.

  • On the development worksheet (DW01) include:

    • An ISSUE “AC APPEAL.”

    • In the REMARKS for that ISSUE: Prior claim dated mm/dd/yy pending at the AC.

    • The date of appeal and date sent to AC.

    • Set an appropriate tickle date for the AC's decision.

6. Routing of Medical Material

Take the following actions to route disability material to the DDS:

  • Route the disability claims folder containing: SSA-3368-BK, SSA-827, any other medical evidence, and CPMS query to the DDS.

  • Attach a flag (see DI 12045.027G., Exhibit 1) to the outside of material. Information needed for completion of the flag is on the CPMS query.

NOTE: A flag is also required when a claimant who has not appealed an ALJ's decision on a prior application files a subsequent claim within the 60-day period for appeal following the ALJ's decision. This will ensure that there is a flag on the claim if the claimant later decides to appeal the decision. If a RR is not subsequently filed, the flag should be removed.

7. Subsequent Claim — Substantial Gainful (SGA) Denial

Take the following action if the subsequent claim results in an SGA denial:

a. Title XVI

  • Process the claim through MSSICS.

  • Send appropriate disallowance notice.

  • Follow DI 11010.205 for preparation of SSA-831-U3.

  • Retain subsequent claims folder in field office (FO) until a decision is received on the prior claim.

b. Title II

  • Process the claim through MCS.

  • Follow procedure in DI 12045.027C.7.a., beginning with bullet 2.

8. Expiration of Date Last Insured (DLI)

  1. Determine DLI for subsequent claim. If the DLI has expired and the ALJ decision on the prior claim is still pending, the subsequent claim is a duplicate claim.

    Take the following action:

    • Do not forward to the DDS.

    • Do not deny as res judicata because a final decision has not been made on the prior claim.

    • Forward the claim to the OAO branch of jurisdiction (see the CPMS query).

    • Document the MDW to show that the subsequent claim was forwarded as a duplicate claim.

    • Do not prepare a folder or SSA-831-U3 for the duplicate claim.

  2. If the DLI of the subsequent claim expires after the date of the ALJ decision on the prior claim, forward the subsequent claim to DDS for consideration of disability from the day after the ALJ decision through the DLI.

D. Procedure - After DDS Adjudication of Subsequent Claim

Transmit case control receipt for initial claims. Then take the following actions to process the DDS determinations for Title XVI and Title II claims either initial or reconsideration:

1. Favorable - Title XVI

  1. Verify date of onset established by the DDS.

    • If the date of onset established is on or before the date of the ALJ decision for initial claims or closed period cases, return the folder to the DDS for correction.

    • If the date of onset established is earlier than the day after the date of disability cessation for CDR cessation cases, return the folder to the DDS for correction. Refer to exception in DI 12045.027C.1.g. for processing cases in the 6th circuit (Ohio, Michigan, Tennessee and Kentucky).

    • If the date of onset established is the day after the ALJ decision or later, follow current processing instructions as outlined in SI 00603.030 SI 00603.036.

  2. If the subsequent favorable claim is paper, FAX a copy of the SSA-831-U3 to the number below. This is necessary to provide the AC with advance notice that a subsequent favorable determination is on the way.

    Subsequent Application Coordinator

    Office of Appellate Operations (OAO)

    FAX number (703) 605-7101

    If the subsequent favorable claim is electronic, the FO will send an email to OAO regarding the favorable determination. Send the email to:

    |||ODAR OAO

    The subject line should read:

    FAVORABLE SUBSEQUENT APPLICATION - Name of Claimant, SSN of claimant - Electronic Folder

    The FO should include any relevant information in the text of the message.

    Upon receipt of the email, OAO support staff will obtain an 'ACAPS' and/or 'LOTS' query and forward the email to the Branch Chief with jurisdiction of the pending request for review or court case. The Branch Chief will associate the email with the pending case and take further appropriate action per HALLEX I-5-3-17 III.B.1 (except the Branch Chief will not need to wait for the claims file for the subsequent favorable allowance since OAO will have immediate access to the EF via eView).

  3. Complete development necessary to adjudicate the claim into pay.

  4. Effectuate payment.

  5. Verify payment effectuation and release notice.

  6. After the paper claim is processed, forward the folder to the OAO branch with jurisdiction of the prior claim via an SSA-408 route slip. The OAO branch can be identified through the CPMS query.

2. Favorable - Title II

a. Verify the date of onset.

  • If the date of onset established is on or before the date of the ALJ decision, return the folder to the DDS for correction.

  • If the date of onset established is the day after the date of the ALJ decision or later, or after the cessation date in a CDR cessation case, process the claim through MCS.

b. Notify OAO per DI 12045.027D.1.b. above

  • Verify payment effectuation.

  • Generate standard notice.

  • Route subsequent claim file to OAO (see DI 12045.027D.1.f.) for association with prior claim.

  • Annotate the DW01 screens for subsequent claims on MCS that the subsequent claim was sent to OAO. If the subsequent claim is not on the MCS, use the MDW to track the case.

3. Partially Favorable Determination – Title II and Title XVI

  1. Verify onset established by the DDS as indicated in DI 12045.027D.1.a.

  2. Follow procedures in DI 12045.027D.1.a. - DI 12045.027D.1.e. for Title XVI and DI 12045.027D.2.a. - DI 12045.027D.2.b. for Title II to effectuate payment.

  3. FAX a copy of the SSA-831-U3 to OAO attention Subsequent Application Coordinator.

  4. Whether or not an appeal has been filed on the subsequent claim, route the folder to OAO after effectuation.

  5. Hold any subsequent claim appeal requests until the AC completes its action on the prior claim.

  6. If AC grants review of the prior claim and remands to the HO, forward subsequent claim appeal request to HO for association.

  7. If AC denies review of the prior claim, send subsequent claim appeal request to DDS.

4. Unfavorable determination on Subsequent Claim — Title II and Title XVI

  1. Process through current systems procedures.

  2. Retain file in the FO for appeals period.

  3. Follow normal appeals procedures for taking reconsideration or hearing requests.

  4. Route claim to the DDS or hearing office (HO) as appropriate. Keep the subsequent claim flag on the folder when routing to the DDS and ODAR for appeal.

    NOTE: If the subsequent claim is denied for nonmedical reasons (e.g., SGA), but new medical evidence has been submitted, send it to the OAO branch with jurisdiction of the prior claim via an SSA-408 route slip. The OAO branch can be identified through a CPMS query.

E. Procedure — Prior Claim (Favorable Decision by AC)

Take the following actions to effectuate payment on prior claims for Title II and Title XVI:

1. Title XVI

a. Subsequent claim on MSSICS in current pay status (C01)

Correct the Protective Filing Date and Effective Filing Date to match the filing date of the prior claim. Complete the living arrangement, income, and resource screens to cover the time period from the EFFECTIVE FILING DATE of the prior claim through the date of the PERC.

EXCEPTION: If the PERC is conducted less than 120 days after the date the subsequent application was completed and the subsequent application was simultaneously developed, the PERC may be limited to the time period from the filing date of the prior claim to the filing date of the subsequent claim.

Follow instructions in MSOM MSSICS 008.003 and SM 01005.030 for EFFECTIVE FILING DATE. Update Disability Clearance Data (CDIB) with the established date of onset and other disability information contained in the AC decision. Build the SSR. Issue the FO-prepared-notice for the AC.

b. Subsequent Claim on MSSICS Denial

Terminate the subsequent claim. Establish the prior claim on the system and process that claim using existing procedures for processing an AC award. Issue the FO-prepared notice for the AC decision effectuation. The subsequent claim is considered a duplicate claim.

c. Subsequent Claim Allowed - Not on MSSICS

Follow One-Time-Payment (OTP) procedures in SM 01901.000 ff. for the benefit payments due for the period prior to the new record. Issue the FO-prepared notice for the AC decision effectuation.

2. Title II

Follow current processing instruction and route claim to Office of Central Operations/Processing Service Center (OCO/PSC) as appropriate to effectuate payment on prior claim and generate notices.

F. Procedure – AC Completes Action and Subsequent Claim Pending at the DDS

1. AC Grants Review and Remands the Prior Claim

If AC grants review and remands the prior claim to the ALJ, the subsequent claim becomes a duplicate if it was filed under the same title. The AC will notify the FO of such action, and the FO will take the following action:

  1. Notify the DDS processing the subsequent claim to stop development.

  2. Advise the DDS to forward the claim to the appropriate HO.

    NOTE: There are situations in which a subsequent claim may not be a duplicate (i.e., if the prior claim was a CDR cessation,) or a subsequent claim filed under a different title will not become duplicate, but the ALJ may consolidate.

2. AC Notifies FO of Favorable Decision

If the AC issues a favorable decision on the prior claim, they will notify the FO. The subsequent claim will then become a duplicate claim.

  1. Notify the DDS processing the subsequent claim to stop development.

  2. Advise the DDS to return the claim to the FO.

3. AC Dismisses or Denies Request for Review (RR)

If the AC dismisses or denies the RR for cases in the 4th, 6th and 9th circuits in accordance with the applicable Acquiescence Rulings (AR), the AC will fax the ODAR subsequent claim flag (see DI 12045.027G., Exhibit 2) a copy of the denial notice, and a copy of the ALJ's decision to the appropriate FO. In all other circuits, the AC will not notify the FO.

  1. Notify the DDS that the AC dismissed or denied the RR.

  2. Advise the DDS that, for the purposes of the ARs, the prior ALJ decision has become final.

    NOTE: There are situations in which a subsequent claim may not be a duplicate (i.e., if the prior claim was a CDR cessation,) or a subsequent claim filed under a different title will not become duplicate, but the ALJ may consolidate.

G. Exhibits

Exhibit 1 -- Subsequent Claim Flag

G-DI_12045.027G-1

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Exhibit 2 — ODAR Subsequent Claim Flag

G-DI_12045.027G-2

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G-DI_12045.027G-3

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To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0412045027
DI 12045.027 - New Claim or Appeal Filed While a Prior Claim or Appeal is Pending Before the Appeals Council (AC) -- Title II or Title XVI - 02/20/2013
Batch run: 02/20/2013
Rev:02/20/2013