DI 27501.005 Reopening and Revising a Determination or Decision
A. Policy principles
Conditions for reopening and revising are guided by the rules of administrative finality. If a claimant does not file an appeal of an administrative determination or decision in a timely manner, they may lose their rights to further review.
If a determination or decision is not timely appealed and good cause for late filing an appeal does not exist, reopening and revision is at the discretion of SSA or the Disability Determination Services (DDS).
B. Operating policies
1. How Reopening Issues May Arise
Consider a reopening when:
A party to the determination or decision requests (or impliedly requests) reopening by:
writing SSA or the DDS;
writing a third party (e.g., a congressman); or
filing a new claim (e.g., a denied claimant files a subsequent claim and alleges an onset of disability in the period adjudicated by the prior denial determination or decision).
SSA or the DDS questions the correctness of a prior determination or decision as a result of:
2. Requirements Before Reopening
The following are required before a determination or decision may be reopened:
An administratively final determination or decision of disability as defined in (DI 27501.001A.3.) (may be an initial claim or a continuing disability review (CDR) determination or decision), and
Reason to consider reopening (e.g., new and material evidence), and
A timely written statement by a party to the determination or decision indicating disagreement with the correctness of a final determination or decision, or
A timely written statement (affirmative action in writing) by an authorized component of SSA or DDS, questioning the correctness of a prior determination or decision.
“Timely” means within the timeframes and conditions described in Conditions for Reopening a Final Determination or Decision (DI 27505.001).
“Authorized” means the component has the authority to reopen the determination or decision in question. For information on who may reopen see in this section (DI 27501.005B.3.).
NOTE 1: Always obtain the prior folder(s) per Procedure – DDS Must Request Prior Folder (DI 20505.010C) before reopening. There are circumstances that permit reopening without the prior folder. See Prior Folder Lost or Destroyed (DI 27510.005H).
NOTE 2: Compute the time limits for reopening from the date of the notice of the initial determination, regardless of whether the final decision in the case was at the initial, reconsideration, Administrative Law Judge (ALJ) hearing, or Appeals Council (AC) level.
3. Who May Reopen
An SSA or DDS component at the same or higher adjudicative level may reopen an administratively final determination or decision, when reopening is appropriate.
a. The Disability Hearing Unit (DHU)
The DHU has jurisdiction to reopen and make an adverse revision based on medical or medical/vocational factors of prior favorable DDS reconsideration determinations. See The Right to a Disability Hearing at Reconsideration Level (DI 29001.001) for additional information.
NOTE: The DDS or Office of Disability Operations (ODO) reconsideration examiner cannot reopen a DHU decision.
b. Administrative Law Judge (ALJ) or the Appeals Council (AC)
An ALJ or the AC may reopen an ALJ decision.
NOTE: An adjudicative level below the ALJ may not reopen a decision made at the ALJ, AC or Court level.
c. Appeals Council (AC)
The AC may reopen an AC decision.
d. Field Office (FO), ODO or Processing Center/Disability Processing Branch (PC/DPB)
These adjudicative levels may reopen Substantial Gainful Activity (SGA), income and resources, or other nonmedical issues at the initial and reconsideration levels.
NOTE: The FO has the authority to reopen the DDS's disability determination and deny the claim when an SGA, income, resources, or other non-medical issue arises after the DDS has made a medical determination on a disability claim. The FO does not have the authority to change onset of disability based on work issues that arise after the DDS has made a favorable determination. Refer to Return to Work (DI 13010.105).
4. Effect of the Medical Improvement Review Standard (MIRS)
The MIRS applies when a favorable disability determination or decision is being reopened and revised to a determination or decision of denial, cessation, or closed period. The favorable disability determination or decision may be reopened and revised to a denial, cessation, or closed period determination or decision only where:
The MIRS does not apply to reopening and revision to a later onset or to revised determinations concerning insured status or other nonmedical issues.
5. When a Revised Determination or Decision Is Required
A revised determination or decision is required to:
Make a less favorable (adverse) revision.
Make a more favorable revision.
Change a basis code only--no change in the determination or decision to deny or allow, or onset or cessation date.
Revise to a statutorily blind diagnosis, or revise from a statutorily blind diagnosis to other diagnosis. See Continuance Cases Where There Is a Change from “Blind” to “Disabled” (DI 28080.065).
Conform conflicting determinations or decisions in common issue claims. Refer to:
Collateral Estoppel – General (DI 27515.001) for adoption of prior determination or decision; and
Conflicting Determinations or Decisions in Disability/Blindness Common Issue Claims (DI 27520.030) for responsibilities.
Reopen certain erroneous notice/payment cases. See Erroneous Notice/Payment Cases (DI 27520.025).
6. Effect of Failure to Make a Determination
The rules for reopening do not apply to:
For a discussion of what is and what is not, an initial determination see Appeals – Actions Which Are Initial Determinations (GN 03101.070) and Appeals – Actions Which Are Not Initial Determinations (GN 03101.080).
7. Scope of a Determination or Decision
Unless otherwise instructed:
Base consideration for reopening on the statute, regulations, and rulings, which were applicable at the time of the adjudication of the prior determination or decision being considered for reopening.
Base a revised determination or decision on the current statute, regulations, and rulings.
Extend a revised determination or decision through the current date (or through the date last insured, age 22, or prescribed period, if earlier) rather than through the date covered by the determination or decision being revised.
C. Additional policy reminders for processing cases when reopening does or does not apply
1. When Reopening Does Apply
Adverse reopenings other than those indicated in (DI 27501.005B.4.b.) must follow the MIRS.
Reopening of a final determination is warranted in title II claims when a claimant returns to work at the SGA level in the waiting period and the SGA work activity is continuing, per Policy – Return to Work in the Waiting Period (Title II) (DI 13010.105).
2. When Reopening Does Not Apply
When new information or evidence is received indicating that improvement in the claimant's condition occurred before the end of the required 12 months duration of disability and it is after a notice of determination or decision has been released, the case is generally considered a continuing disability issue. See DI 25505.025, Duration Requirement for Disability.
When evidence of improvement is received before the notice of the award is released, prepare a new determination, if warranted. (This action is not considered a reopening.)
Onset of disability in a subsequent title II claim may be established within a prior adjudicated period when:
The disability criteria have changed and more than 12 months have elapsed since the date of the notice of the initial determination on the previous claim (thereby precluding reopening for any reason); or
New and material evidence establishes disability within the period adjudicated and more than 4 years have elapsed since the date of the notice of the initial determination on the previous claim (thereby precluding reopening for “good cause”; or
The prior determination was a FO denial for "insufficient evidence furnished" (M5/M6), when a claimant fails to submit essential evidence. See Claimant Fails to Cooperate (FTC) - Claimant's Whereabouts Unknown (WU) (DI 11018.005).
Establishing an onset within the prior period adjudicated usually results in an increased monthly benefit amount. When the prior determination is not reopened, the retroactivity of benefits is based on the new application.
D. Operating procedures
1. Claimant's Rights
Provide the claimant a due process notice in adverse actions. See Policy - Due Process for Adverse Reopenings (DI 27525.001).
NOTE: Provide a due process decision notice when statutory benefit continuation (SBC) rights are applicable.
Afford the claimant an opportunity to present any additional information or evidence he or she believes may have a bearing on the determination or decision in adverse actions. See Reopenings – Due Process (DI 27525.000).
2. Necessary Steps When Reopening and Revising a Determination
Take the following steps when reopening or revising a determination:
Document the file to assure all opportunities and efforts to comply with due process requirements, when applicable, have been satisfied.
Refer to Reopenings – Due Process, Table of Contents (DI 27525.000).
Prepare a revised determination.
Refer to Reopenings - Completion of Form SSA-831-U5 – General (DI 27530.001) and Documenting the Rationale for Reopening (GN 04001.080).
Prepare a rationale.
Refer to Reopening of Prior Determination (DI 27536.015) and Rationale Preparation – Policy (DI 26515.001) and Documenting the Rationale for Reopening (GN 04001.080).
Prepare the proper notices and provide appeal rights.
Refer to Reopening Notice Instructions – Introduction (DI 27540.001), and for standard “stock paragraphs,” see Paragraphs Used in Notices (NL 00708.100).
Route the claim appropriately.
Refer to Reopenings and Revisions - Initial and Reconsideration (DI 32005.095).
3. Appeal Level after Revision
Provide the appropriate appeal rights to the claimant.
Give reconsideration appeal rights following a title II revised initial determination that concerns the issue of whether, based on medical factors, the individual is disabled. Reconsideration is also the next level of appeal following a title XVI revised initial determination that involves a suspension, reduction or termination of SSI benefits. Include the right to a disability hearing at the reconsideration level for adverse revisions based on medical or medical/vocational factors as indicated in Adverse Reopenings (DI 29001.001B.3.).
NOTE: Do not give disability hearing rights at the reconsideration level if a revised determination establishes a later onset because of work activity.
Give ALJ hearing rights when the revised determination was finally decided at the reconsideration level.
The ALJ hearing level is the next level of appeal following a title II revised initial determination that does not concern the issue of whether, based on medical factors, the individual is disabled. The ALJ hearing level is also the next level of appeal following a title XVI revised initial determination that does not involve a suspension, reduction or termination of SSI benefits.
4. Reopening Request Denied
When denying a request for reopening:
Document the file with a Special Determination (Form SSA-553), or other electronic writing (RPOC, DW01) or form, describing facts and consideration given to the reopening issue, and reason for not reopening (See Documenting the Rationale for Reopening (GN 04001.080)); and
Provide notification to the claimant of the disposition of any reopening issue the claimant is aware of, but do not include a right to appeal.