TN 1 (12-11)
DI 27525.001 Due Process Notification for Adverse Reopenings
NOTE: Sections NL 00705.201 through NL 00705.266 provides model language and related instructions for the Disability Determination Services (DDS) when reopening and revising prior determinations. For specific examples see, Disability Sample Guide Letters – Table of Contents NL 00705.000.
A. What is due process?
The Fifth Amendment to the Constitution provides that no person shall be deprived of property interest without due process of law. Due process is giving the beneficiary an opportunity to offer rebuttal evidence and respond to the proposed adverse action before we render a final decision.
Specifically, due process requires that we inform the beneficiary that we may stop or reduce his or her benefits (or an overpayment may result) if:
He or she is no longer disabled (cessation).
He or she is no longer entitled to disability benefits or payments on the current application (adverse reopening).
He or she received erroneous payments after a decision of denial.
We change the onset date to a later date.
We change the cessation date to an earlier date.
However, merely advising the beneficiary that his or her benefits may stop or be reduced because of the disability review does not satisfy due process requirements; we must also inform the beneficiary of his or her right to respond and provide rebuttal evidence and allow the beneficiary to provide that response before we make a final adverse decision.
Extend due process to the beneficiary in writing, and store a copy of the notice in the official claims folder. Resolve any doubts regarding the need to provide due process in favor of providing it.
B. Types of due process notification
We provide due process notification in the disability program by sending either a due process pre-determination notice or a due process decision notice. We send the pre-determination notice when we do not consider the determination a medical cessation and benefit continuation language is not required. We send the decision notice in medical cessation cases when benefit continuation language is required.
1. Due process pre-determination notice
Prepare a pre-determination notice when the determination is not considered to be a medical cessation and benefit continuation language is not required; e.g., whereabouts unknown, failure to cooperate, change to a later onset, failure to follow prescribed treatment.
NOTE: Prepare and release a pre-determination notice prior to processing the SSA-831 Disability Determination and Transmittal or SSA-833 Cessation or Continuance Title II.
2. Due process decision notice
The processing component prepares a decision notice in medical cessation cases when benefit continuation language is required. Release the determination notice following processing of the SSA-831, SSA-832 Cessation or Continuation Title XVI, or SSA-833.
Do not hold the case awaiting a claimant response.
Send a due process decision notice in the following medical adverse reopenings:
Revision from allowance to denial,
Revision from allowance to a closed period of disability,
Revision from continuance to cessation, or
Revision from cessation to an earlier or later cessation date that requires benefit continuation language in the decision notice.
NOTE: For specific instructions on due process decision notices see DI 27540.000.
C. Component responsibilities
The DDS provides due process notification for adverse reopenings when a medical determination is required.
The field office (FO) provides due process notification for adverse reopenings involving work issues that do not require a medical determination. Notify the beneficiary and all auxiliary beneficiaries not living in the same household of any proposed action to stop benefits.
The Central Office (CO) and the Office of Quality Performance (OQP) reviewers ensure the DDS and the FO follow appropriate guidelines for affording due process and file documentation. If the reviewer ceases or reverses the case to denial, afford appropriate due process before stopping benefits.
The Office of International Operations (OIO) functions as the DDS for beneficiaries who reside outside of the 50 US states, D.C., American Samoa, Virgin Islands, Puerto Rico and Guam. Like the DDS, OIO affords due process and documents the official claims folder.
DI 12027.015 Cases Excluded From Statutory Benefit Continuation (SBC)
DI 27525.010 Providing Due Process in Adverse Reopenings Involving Title XVI and Concurrent Title II / Title XVI Cases
DI 27540.025 Title II-Only Predetermination Notice Previously Mailed – Final Decision Notice Instructions
DI 27540.030 Title XVI-Only – Goldberg/Kelly Payment Continuation Applies
DI 27540.035 Concurrent Title II/Title XVI – Statutory Benefit Continuation Does Not Apply