TN 13 (10-09)
DI 27516.005 Disability Determination Services (DDS) Res Judicata Development and Processing
A. DDS jurisdiction of a subsequent Title II claim
The DDS has jurisdiction of a subsequent claim filed after a prior claim has been denied through the date the nondisability requirements were last met and any one of the other conditions required for applying res judicata in DI 27516.001B. is not met.
NOTE: Due to revised evaluation criteria, the DDS has jurisdiction when the determination or decision denying the prior claim was made before January 6, 1986, and denied the claim through the date the nondisability requirements were last met. For information about revised evaluation criteria, see DI 27516.010.
B. DDS procedure for applying res judicata to a subsequent claim
Review the prior and subsequent claims following the guides in DI 27516.010 – Disability Determination Services (DDS) Medical Evaluation Criteria to Determine Applicability of Res Judicata, to determine if the disability criteria applied to decide the prior claim have become less restrictive. Determine if new facts, which were not present in making the prior determination, are present.
NOTE: For complete DDS electronic processing instructions see DI 81020.000 – DDS Procedures - Electronic Processing.
1. Application of res judicata
Apply res judicata to deny the subsequent claim if:
the disability criteria have not become less restrictive since the prior determination, Administrative Law Judge (ALJ), Appeals Council (AC), or court decision; and
the subsequent claim presents no new facts.
2. Completion of the SSA-831 (Disability Determination and Transmittal) for a res judicata denial
Complete the following:
Item 16a (Primary Diagnosis) - Enter a four digit diagnosis code. If diagnosis code is not known, enter four zeros "0000".
NOTE: The diagnosis code is required for allowances and denials.
Item 19 (Claimant Not Disabled) - Check block B and insert either date last insured, end of prescribed period, or date attained age 22, as appropriate.
Item 22 (Regulation Basis Code) - Enter “S1” (res judicata).
Item 25A - Check block A.
Item 26 - (List No.) - Enter “243” (subsequent claim--prior claim medically denied through date nondisability factors last met).
Items 30 and 31 (Disability Examiner - DDS/Date) - Self explanatory.
Item 34 (Remarks) - Show “The issue of disability is res judicata”.
DI 26510.000 – Completion of Form SSA-831-C3/U3 -- Title II, Title XVI and Concurrent Claims
DI 81020.130 – Electronic Case Closure
3. Routing of a res judicata denial
Annotate the certified electronic folder (CEF) with the statement: “Res judicata applicable to claim filed on (date of subsequent application). Please input S1 denial,” and return the case to the FO. For paper claims, annotate the route slip as such and return the folder to the FO for processing.
4. DDS systems input and clearance of a res judicata denial
To process the res judicata determination:
Clear the case to the FO and show folder movement clearance.
Record the “S1” denial code determination on the State Agency Operating Report.
Enter D831 clearance input with a systems override code of C. For instructions on case closure, see SM 06001.410 – How to Complete the Closure (D831) Data Input Screen.
NOTE: The DDS does not prepare the notice because the S1 denial entry by the FO generates it for the claimant.
C. Reconsideration affirmation of res judicata denial
Follow instructions in DI 27516.005B. (in this section), noting the following exceptions:
Check block 25 (Revised Det) and 25 A. B. (Recon); and
Enter “Recon Affirmation -- Res judicata applies” in item 34 (Remarks).
D. DDS procedure when res judicata does not apply
Prepare a substantive medical/vocational determination per usual procedures if:
the disability criteria have become less restrictive since the prior denial determination (For changes to the listings of impairments that affect the applicability of res judicata, see DI 27516.010); or
the subsequent claim presents new facts which were not present in the prior claim.
Then, annotate the SSA-831 as follows:
Item 26 (List No.) - “243” (subsequent claim -- prior claim medically denied through date nondisability factors last met); and
Item 34 (Remarks) - “Res judicata not applicable.”
NOTE: If you cannot determine the applicability of res judicata because the prior folder was not located, enter “Res judicata not applied -- prior claim not located” in item 34. Also, enter listing code 243 in item 26 for cases where the prior folder is not available.
E. When criteria for reopening a prior determination or decision are met
If a basis for reopening and revising the final determination on the prior claim exists (new and material evidence, error on the face, etc.), see DI 27505.001 – Conditions for Reopening a Final Determination or Decision.
NOTE: Only if it is within 12 months from the date of notice of the initial determination on a claim can a final determination or decision be reopened and revised for any reason (including a change in the criteria).
After reopening the prior determination or decision, forward the case to the appropriate component:
If the ALJ, AC, or court issued a prior decision and the rules for reopening apply, forward the prior and subsequent claims to the Office of Disability Operations (ODO) per DI 27505.010B.2.
If a Disability Hearing Officer made the determination on the prior claim and the determination can be reopened under the rules for reopening, forward both the prior and subsequent claims to the Disability Hearing Unit (DHU).
When a change in disability criteria warrants establishment of disability on the current application, i.e., claimant now meets disability criteria before nondisability requirement last met, prepare a substantive determination on the new claim before referring to ODO or the DHU.
NOTE: This means going into the period previously adjudicated even though the time periods for reopening have not expired. This action is permissible because the determination on the new claim is based on a change in the disability criteria, and does not reopen the decision on the prior claim.
F. When the prior determination or decision cannot be reopened
Make a new initial determination if:
the rules for reopening the final prior determination, ALJ, AC, or court decision do not apply; and
a favorable determination within the prior adjudicated period is warranted because the disability criteria have changed or new and material evidence is submitted since the prior determination or decision. For information on subsequent applications, see DI 27510.005.
NOTE: Since the determination or decision on the prior claim cannot be reopened, benefit rights flow only from the new application.