TN 1 (11-00)

DI 32548.020 Reopening of Primary Subclass Claims

A. Policy

1. General

Primary Subclass member claims are reopened and disability evaluated in accordance with current adjudicative standards and DI 32548.001B.4.

NOTE: As background, class claims that are reopened are referred to as “readjudication claims” in theHyatt III court order.

2. Subsequent allowances

For class members allowed based on a subsequent application, it is not necessary to develop the period since the subsequent allowance. However, any earlier period of potential entitlement must be reopened and developed.

3. Multiple denial determinations within the court ordered timeframe

In multiple denial determinations within the court ordered timeframe, only a single determination is needed to replace the prior determinations. The application with the earliest filing date, which results in class membership, is used when readjudicating the claim. Claimant is entitled to Primary Subclass relief if at least one claim qualifies as a Primary Subclass claim. If the earliest claim within the Hyatt III period is not a Hyatt III eligible claim, be sure to include that information in the notice of determination. (See DI 32548.045, DI 32548.050, DI 32548.055, DI 32548.060.)

B. Process

1. SGA development before reopening

The FO will develop and fully document SGA before the DDS reopening only if it appears an SGA denial is probable (i.e., SGA began within 12 months of the earliest possible onset and has continued to the present). Otherwise, the FO will:

  • complete a work activity report form (SSA-820-F4/SSA-821-F4);

  • send the case to the DDS for adjudication; and

  • complete its SGA development when the case is adjudicated and returned to the FO.

2. SGA development after DDS determination

The FO will develop work activity discovered during DDS development after the DDS decision and:

  • prepare a revised SGA denial if SGA resumed within 12 months of onset and continues to the present date, or

  • establish a trial work period and/or SGA cessation if appropriate, and undertake work incentive development (e.g., EPE or Section 1619 development).

C. Procedure - general

1. Reopening process

Reopen the claims of the Primary Subclass according to the following instructions.

  1. Reopen the case from the date of the earliest Hyatt III application to the present.

  2. No Benefits Payable – If the class member received a fully favorable medical determination either because of a subsequent application or a previous Hyatt III reopening that established the earliest alleged onset in the earliest Hyatt III claim,

    • complete the Favorable Determination/Decision Worksheet and Transmittal, DI 32548.095, Exhibit 11

    • Staple the worksheet to the front of the folder and

    • forward the file to the FO for payment verification.

  3. If the class member was allowed based on a subsequent application that was not fully favorable as to the earliest Hyatt III claim, reopen and develop only the period from the onset alleged in the earliest Hyatt III claim to the onset established under the subsequent allowance. Unless a CDR is in process on the subsequent allowance, do not intervene on the current period of disability, i.e., do not develop the period or initiate a CDR.

  4. Develop fully the medical record of each, using treating physicians whenever possible and employing consultative examiners when necessary.

  5. Develop the entire period being reopened even if it involves intervening periods of SGA.

  6. Consider the earliest alleged onset date (AOD) found in the Hyatt III folder(s).

  7. Prepare a new determination covering the entire period being reopened.

2. Fully and partially favorable determinations because of Hyatt III readjudications:

For fully and partially favorable determinations because of the new Hyatt III readjudication:

  1. Prepare an SSA-831-U3 and notice language (see DI 32548.045 and DI 32548.050) for release by OCO/PSC.

  2. Request the FO to develop all work activity and make an SGA determination for all periods of work whether previously identified or developed by the FO or identified by the DDS during development. Prepare an SSA-5002 for the file and list all periods of work activity the FO needs to adjudicate before the final determination.

  3. Prepare an open period allowance (unless medical improvement subsequently occurred).

  4. Consider a closed period of disability if medical improvement is indicated,

    • Apply the guides in DI 28005.001 in determining whether the claimant"s disability had ended.

    • Use the onset date as the comparison point called for in DI 28010.105.

  5. Route folder to the servicing FO (or DQB if selected for PER or QA).

3. Unfavorable determination

For unfavorable determinations:

  1. Prepare an SSA-831-U3 in accordance with DI 26510.001.

  2. Prepare and mail the unfavorable notice as directed in DI 32548.045.

  3. Send the folder to the FO to hold for the appeal period. The next level of appeal is to the ALJ hearing level.

4. New claim filed (or pending)

If a new claim is filed (or pending) consolidate the new claim with the Hyatt III claim as follows.

  1. Claim pending in DDS:

    • Hyatt III claim last decided in DDS -- consolidate folders and process in DDS.

    • Hyatt III claim last decided in OHA -- consolidate folders and process in DDS. If DDS action is not fully favorable, request FO to forward the files to OHA after taking any effectuation action.

  2. Claim pending in OHA and hearing:

    • has been scheduled but not held -- no DDS action required, claims will be consolidated and processed in OHA.

    • has not been scheduled -- consolidate folders and process in the DDS.

    • has been held -- do not consolidate.

NOTE: If a new claim is pending in OHA, contact the hearing office by telephone to find out if a hearing has been scheduled.

5. Subsequent claim filed but no longer pending

In subsequent claim situations where the subsequent claim is no longer pending:

  1. Reopen the prior Hyatt III claim(s) even if a later determination /decision was made based on a subsequent application. Do not develop periods for which disability has been established based on a subsequent claim.

  2. If last prior Hyatt III decision was ALJ or AC level and no current claim is pending in DDS, send to OHA.

  3. If a subsequent fully favorable determination established the earliest possible AOD but full retroactive benefits were not paid because the earliest application was not reopened:

    • Prepare an SSA-831 reopening the Hyatt III claim,

    • Annotate “H3 reopening fully favorable” in block 34,

    • Annotate the route slip “Fully favorable medical determination made on ___      . Retroactive benefits due based on reopening of Hyatt III application of _______Priority action required,”

    • Send the folder to the FO for payment action.

    NOTE: If there is any question as to whether full retroactive benefits have been paid, request FO assistance by telephone.

  4. If the determination/decision on the subsequent claim is not fully favorable to claimant either because a later onset date was established or because the claimant amended his/her onset date to some date after the onset date alleged in the Hyatt III claim, review the unfavorable portion of the determination/decision as an unadjudicated period under Hyatt III .

    Send notice in DI 32548.060 if Hyatt III review affirms prior denial.

    NOTE: If additional benefits are due claimant under Hyatt III because of the partially favorable determination/decision on the subsequent claim, DO NOT forward the folder for payment. Any retroactive benefits or underpayment due claimant will be released after a determination/decision on the unadjudicated period has been made.

  5. If a CDR diary is due on a subsequent allowance but not initiated:

    • Process Hyatt III claim to conclusion.

    • Take no action on the CDR due diary.

  6. If a CDR alert is pending process the Hyatt III claim and the CDR at the same time.

6. Failure to cooperate

In failure to cooperate situations follow normal procedures in DI 23010.005 - DI 23010.025.

D. Procedure - Hyatt III claim with related CDR in process

1. General

For a claim with a related CDR in process, consolidate the Hyatt III claim with the CDR and develop both claims concurrently. Two separate determinations covering two separate periods may be needed (i.e., the time period involved in the Hyatt III evaluation may be outside that involved in the CDR evaluation). Follow DI 32548.005 for systems input of Hyatt III determinations/decisions and SM 05901.118 for the CDR determinations/decisions. The normal adoption/collateral estoppel rules are applicable (see DI 27515.001).

2. Hyatt III claim and CDR both favorable

If the Hyatt III claim and the CDR are both favorable:

  1. Prepare the SSA-831-U3 per DI 32548.025 covering the entire period from the earliest Hyatt III application date through the current date of adjudication.

  2. Enter in SSA-831-U3 remarks, Hyatt III reopening favorable--one continuous period of disability established. This determination is the CPD for future CDRs.”

  3. Enter in the SSA-831-U3 remarks of the subsequent allowance, “This determination superseded by the favorable Hyatt III determination/decision of (date of Hyatt III decision). The Hyatt III determination is the CPD for future CDRs.”

  4. Follow DI 32548.050 for preparing Hyatt III language pertaining to the retroactive period. Add the following language to the lead-in shown in DI 32548.050B.1.a. and/or DI 32548.050B.2.a., “This determination applies to both the Hyatt III case review and the continuing disability review we conducted on your later application on which you are now getting checks.”

  5. Process the CDR as a no decision.

  6. Make NDDSS input on both claims. Enter:

    • The CDR claim as a no determination.

    • The Hyatt III claim as described in DI 32548.005.

  7. Route both claims to the servicing FO for payment of retroactive benefits due on the Hyatt III claim.

3. Hyatt III claim unfavorable - CDR favorable

If Hyatt III claim is unfavorable and CDR favorable:

  1. Prepare an SSA-831-U3 documenting the unfavorable determination for the Hyatt III claim covering the period from the earliest Hyatt III application date to the onset date of the subsequent allowance.

  2. Enter in SSA-831-U3 remarks, “This unfavorable Hyatt III determination covers the period (date of earliest Hyatt III application) to (onset of subsequent allowance).”

  3. Prepare and release the unfavorable Hyatt III notice per DI 32548.045. The personalized section of the notice should pertain to only the period reviewed under Hyatt.

  4. Add the additional language to the optional paragraph shown in DI 32548.045B.1.b. and DI 32548.045B.1.c., if the earliest claim within the Hyatt III period is not a Hyatt III eligible claim, “You will receive a separate notice about the continuing disability review claim that was recently completed.”

  5. Prepare an SSA-832-U3/SSA-833-U3 for the CDR continuance in the normal manner. Add in remarks, “See SSA-831-U3 dated      for unfavorable Hyatt III determination covering (date of the earliest Hyatt III application) to (onset of the subsequent allowance).”

  6. Prepare and release the continuance notice. Add as the last paragraph, “You will receive a separate notice about the decision of your claim being reviewed under the Hyatt III court order.”

  7. Make NDDSS input for both claims.

  8. Route both claims to the FO for retention during the Hyatt III appeal period or forward to OHA, as appropriate.

4. Hyatt III favorable - CDR unfavorable

If Hyatt III claim is favorable and CDR unfavorable:

  1. Prepare an SSA-831-U3 for the favorable Hyatt III determination.

  2. Enter in remarks, “This favorable Hyatt III determination covers (date of earliest Hyatt III application) to (onset of subsequent allowance). Disability determined to have ceased (date of cessation) per (SSA-832-U3/SSA-833-U3) dated      ”.

  3. Follow DI 32548.050 for preparing Hyatt III language pertaining to the retroactive period. Add the following language to the lead-in shown in DI 32548.050B.1.a. and/or DI 32548.050B.2.a., “You will receive a separate notice about the continuing disability review claim that was recently completed.”

  4. Prepare an SSA-832-U3/SSA-833-U3 cessation in the normal manner. Add in remarks “See SSA-831-U3 dated      for favorable Hyatt III determination covering (date of earliest Hyatt III application) to (onset of subsequent allowance).”

  5. Prepare and release cessation notice per DI 28095.040. Add at the end of the personalized explanation, “You will receive a separate notice about the decision of your claim being reviewed under the Hyatt III court order.”

  6. Make NDDSS input for both claims.

  7. Route both claims to FO for processing payment of retroactive benefits due under Hyatt III and for processing appeal and request for benefit continuation on the CDR cessation.

5. Hyatt III claim and CDR both unfavorable

If Hyatt III claim and CDR are both unfavorable:

  1. Process unfavorable Hyatt III determination per DI 32548.020D.3. Do not follow the procedures shown in DI 32548.020D.3.e. - DI 32548.020D.3.h.. for the CDR part of the claim.

  2. Prepare an SSA-832-U3/SSA-833-U3 cessation in the normal manner. Add in remarks “see SSA-831-U3 dated      for unfavorable Hyatt III determination covering (date of earliest Hyatt III application) to (onset of subsequent allowance).”

  3. Prepare and release cessation notice per DI 28095.040. Add at the end of the personalized explanation, “You will receive a separate notice about the decision of your claim being reviewed under the Hyatt III court order.”

  4. Prepare and release the unfavorable Hyatt III notice required in DI 32548.045.

  5. Make NDDSS input for both claims.

  6. Route both claims to the FO to retain for appeal period and to process request for benefit continuation on the CDR cessation.

    NOTE: If both the Hyatt III claim and CDR cessation are appealed, the CDR cessation will be processed by DHU and the Hyatt III claim will proceed to the ALJ hearing level.

  7. Prepare and release the cessation notice. Add as the last paragraph, “You will receive a separate notice about the decision of your claim being reviewed under the Hyatt III Court order.”

  8. Route both claims to the FO for retention during the Hyatt III appeal period or forward to OHA, as appropriate.


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http://policy.ssa.gov/poms.nsf/lnx/0432548020
DI 32548.020 - Reopening of Primary Subclass Claims - 02/20/2013
Batch run: 02/20/2013
Rev:02/20/2013