TN 1 (11-00)

DI 12548.025 Procedures after Disability Determination Services/Office of Hearings and Appeals (DDS/OHA) Action

A. Process

REMEMBER, THE HYATT III DETERMINATION/DECISION CANNOT RESULT IN A LESS FAVORABLE DISABILITY ONSET DATE THAN THE SUBSEQUENT CLAIM. ALSO, COPIES OF ALL DETERMINATIONS/DECISION ISSUED BECAUSE OF THE HYATT III REVIEW MUST BE SENT TO CLASS COUNSEL

1. Earliest Claim Within the Hyatt III Period is Not a Hyatt III Eligible Claim

If the earliest application claimant filed within the Hyatt III period (07/07/1981 through 11/13/1991) is not a Hyatt III eligible claim, be sure to include the following optional language in all determination notices. “We did not review your claim(s) filed on (fill-in date of claim(s) ineligible for Hyatt III review) because (fill in reason claim(s) was not eligible for Hyatt III review). We reviewed your claim(s) filed after that date.”

2. No Benefits Payable

If a fully favorable medical determination/decision was issued either because of a subsequent application or a previous Hyatt II reopening, the DDS/OHA adjudicator will:

  • Complete the Favorable Determination/Decision Worksheet (see DI 12548.095, Exhibit 13).

  • Staple the worksheet to the front of the folder(s)

  • Forward the folder(s) to the FO for payment verification.

  • The FO will release the notice “No Benefits Payable” (see DI 12548.030B.1.e.). If the earliest claim within the Hyatt III period was not reopened and readjudicated under Hyatt III, be sure to include the optional paragraph (see DI 12548.025A.1. after the first sentence on DI 12548.095, Exhibit 12).

3. Reversals

In fully favorable reversals, the DDS will prepare an open period allowance/ continuation.

4. Affirmations

Fully unfavorable determinations are sent to the FO for retention during the appeals period.

5. Partially Favorable Determinations

Partially favorable determinations include closed periods of disability and the establishment of onset dates later than the alleged onset date.

B. Procedure - Fully/Partially Favorable Determinations

To update fully favorable and partially favorable determinations proceed as follows:

1. Title II

  1. Develop any outstanding non-medical factors of entitlement (e.g., substantial gainful activity). Complete SGA development following DI 13010.001 ff.

    If SGA:

    • Requires a change in onset, return the folder to the DDS.

    • Resumed within 12 months of established onset and continues uninterrupted to the present, reopen and revise the DDS determination to an SGA denial determination. In the “Remarks” section, annotate the SSA-831-U3, “This determination revises the DDS determination of  (date) .” Send copy of SSA-831-U3 to Hyatt Coordinator, OPB LS.

    • Does not preclude entitlement (e.g., SGA begins more than 12 months after established onset), establish TWP/EPE/SGA cessation as appropriate.

  2. Develop for suspension, deduction, and termination events.

  3. Enter code UN ZZZ to exclude from processing time.

  4. Prepare and release a SGA denial notice. Be sure to include the optional language from DI 12548.025A.1. If the earliest claim filed within the Hyatt III period is not a Hyatt III eligible claim. Release copies to claimant, claimant's representative, if any, class counsel, and OPB, Litigation Staff.

  5. Follow routine routing procedures.

  6. Retain the file during the appeal period.

NOTE: The determinations of the DDS may be appealed to an ALJ. DI 12548.015 sets out special requirements for Settlement Subclass members whose claims are not reopened.

Individuals whose pending claims in OHA were consolidated at the DDS level are automatically entitled to a hearing before an ALJ, i.e., the individual does not have to request a hearing. Send these cases directly to the servicing OHA hearing office. For partially favorable determinations, effectuate payment before sending to OHA.