TN 1 (02-06)

DI 28057.025 Appeals Process Under Expedited Reinstatement

A. Background

Generally, there are two types of determinations that can be made in connection with an individual's request for EXR: provisional benefit determinations and EXR determinations. If an individual disagrees with a determination, then the procedure for handling the disagreement is directed by the type of determination that is involved.

B. Policy – FO Provisional Benefit Determinations

NOTE: This section is background only for DDSs. Provisional benefit appeals do not affect the DDS.

Determinations made in connection with provisional benefits are not subject to the administrative and judicial review (appeals) process (see GN 03101.080 and SI 04010.010C.).

If an individual indicates an interest in protesting a determination concerning payment of provisional benefits, the FO explains that determinations regarding provisional benefits (including determinations to stop payment and/or amount of provisional benefits) are not subject to our formal administrative review procedure. If the individual still protests the provisional benefit determination, the FO accepts any statements and/or evidence the individual presents and reviews the determination to make sure it is correct.

C. Policy – Expedited Reinstatement Determinations

1. Appeals

Determinations concerning an individual's EXR requests, which include decisions that a claimant's impairment is not the same as or related to the impairment on which the previous entitlement was based, are initial determinations subject to the administrative and judicial review (appeals) process (see GN 03101.070 and SI 04010.010B.).

NOTE: There is no continuation of provisional benefits during the appeals process or if a case is being reviewed as a result of a protest as referenced in DI 28057.025B.

2. Time Limit For Filing Appeal

The time period for filing an appeal is 60 days from the date the individual received notice of the initial EXR determination. See GN 03101.010 and SI 04005.012 for further discussion of the appeals period and consideration of good cause for late filing of an appeal.

3. Who May File An Appeal

A party to any initial determination who provides a written statement showing that his/her benefit rights may be adversely affected by the initial determination may appeal that determination (see GN 03101.050A.2.).

D. Procedure – Reconsideration Request

The procedural steps to follow depend upon whether the issue in the initial determination, with which the individual disagrees, is a medical or a non-medical issue. Refer to DI 13050.085 for complete FO appeals procedures.

1. Reconsideration of Non-Medical Issue(s)

If the individual files an appeal on a non-medical issue, such as an SGA denial in a title II case, or an excess income denial in a title XVI case, the FO will handle the reconsideration request per instructions in GN 03102.000 and SI 04020.000.

If the FO reverses the technical denial it will forward the EXR request for a medical determination. Use the procedures in this section to process the EXR request as an initial request for expedited reinstatement.

2. Reconsideration of Medical Issue(s)

If the individual appeals a medical determination, such as reinstatement denial based on the finding that the individual is not disabled under MIRS, the FO will obtain a request for reconsideration and complete a SSA-561-U2 and development forms normally used for reconsideration of a medical cessation (SSA-782, etc). The FO will forward the appeal, EXR folder and supporting documents following the procedures in DI 12005.000. EXR reconsideration requests are not processed under CDR DHU procedures.

NOTE: EXR cases are not processed under prototype procedures. In addition, EXR cases are not afforded any payment continuation provisions that are normally applicable to a medical cessation.

E. Policy- Special Processing Considerations

1. EXR Denied and New Initial Claim Possible

An individual can file for reconsideration of the denied EXR request and also file a new initial claim, if applicable. Use procedures in this section to handle the EXR request. Use normal initial claim procedures to handle an initial claim.

Refer to DI 13050.090 for special considerations regarding joint EXR and initial claim actions. When an EXR request and simultaneous initial claim both require medical decisions, escalate the initial claim to the reconsideration level (see DI 12045.030). The FO will note on the EXR Flag that both the EXR and initial claim are included and both require a medical decision.

Per the statute, the original EXR request is a protective writing for the new initial claim. See DI 13050.090 for instructions.

The FO will forward the EXR reconsideration and new initial claim in the same folder.

2. Initial Claim Denied And EXR Possible

An individual can file for reconsideration of the initial claim denial under current reconsideration procedures and file an EXR request, including the start of provisional payments and provisional Medicare. Process the EXR request in the appropriate manner under instructions in this section. If both the initial claim and the EXR request require medical decisions escalate the EXR request to the reconsideration level (see DI 12045.030). The denied initial claim is not a protective writing for EXR. See DI 13050.090 for instructions and special consideration regarding joint EXR and initial claim actions.

The FO will forward the reconsideration and new request for EXR in the same folder.

3. EXR Requested And Medical Issue Pending With ALJ

An individual may inquire about EXR while a hearing request is pending at the ALJ level on a prior termination decision or an initial claim denial. If the requirements for EXR are met, process the EXR request according to this section.

Do not escalate the EXR decision to the hearing level. Contact the hearing office to request the medical records (the comparison point decision, or CPD, file) if the FO has not already done so. This should be done in accordance with locally established procedures.

If the EXR request is approved, DDS will contact ODAR immediately so that the Administrative Law Judge (ALJ) can dismiss the pending hearing request. If the EXR request is denied and the individual files a request for reconsideration, the reconsideration request can be escalated to the hearing level if it is determined there is a common issue (if both cases present medical issues the case could be escalated). The FO will coordinate this with the hearing office prior to forwarding the file for a reconsideration determination. See DI 12010.001 and DI 12045.015.

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DI 28057.025 - Appeals Process Under Expedited Reinstatement - 01/27/2012
Batch run: 04/14/2014