TN 48 (11-94)

DI 32594.010 Screening and Readjudication - General

A. Policy

1. Poster

Copies of State of New York poster must be displayed in public contact areas in DDSs, FOs, and OHA offices that service New York State. Posters will be provided by the Office of the Deputy Commissioner for Programs, Litigation Staff.

2. Screening

  1. Within 30 days of screening, the screening component or CO must mail to the individual a notice of the class membership decision at the address indicated on the response form.

  2. An individual (or the individual's attorney) who has been denied class membership (including ones who were denied on the grounds that their requests were untimely and not excused for “good cause”) may appeal this decision to Office of the General Counsel (OGC), either directly or through their personal counselor or class counsel.

3. Level of review

  1. With the exception of b. and c. below, all readjudications will be processed at the reconsideration level on a flow basis. Cessation cases will be readjudicated in the DHU. Appeals of readjudication determinations will be processed by an ALJ.

  2. Cases in which a current claim is pending at the initial level are consolidated with the State of New York case and processed at the initial level. Appeals of these cases are processed by the DDS at the reconsideration level.

  3. The following types of cases will be readjudicated by an ALJ, who will conduct a hearing:

    • membership in the State of New York class is based on a claim that was appealed to the ALJ level or higher; or

    • a current claim is pending at the ALJ level.

4. Method of readjudication

  1. Original determination was a denial - After fully developing medical and vocational evidence for the period of time covered by the application subject to readjudication, the adjudicator, using the standard set forth in DI 32594.015, DI 32594.020, and DI 32594.030, will readjudicate the same period covered by the original determination.

    • If the denial is affirmed, the DDS will send a notice to the claimant and any representative. No further readjudication is necessary.

    • If the review indicates that a reversal to an allowance is indicated for the period originally adjudicated, the DDS will develop the period from the date of the original determination through the present and will readjudicate this period also. If there has been a subsequent favorable determination see b., below.

  2. Original determination was a cessation - After fully developing medical and vocational evidence for the period from the date of the original determination through the present, the adjudicator, using the standard set forth in DI 32594.015, DI 32594.020, and DI 32594.030, will reopen the entire period from the date of the cessation determination through the present except for any period for which the class member is entitled to benefits pursuant to another SSA decision.

    In cases where the claimant has received an allowance on a subsequent claim after a prior claim was either denied or ceased, in the absence of evidence to the contrary, SSA adjudicators will assume that the favorable decision on the subsequent claim was correct and will limit development and readjudication to the period up to the date of onset established in the subsequent claim. However, if new evidence submitted or developed in connection with the State of New York readjudication raises a question of continuing disability, SSA adjudicators will not be barred from considering and deciding the issue under the normal continuing disability review procedures and standard. In this situation, return the folder to the FO with a request to conduct a face-to-face CDR interview.

5. Appeals From readjudication determinations

Class members retain appeal rights with respect to readjudication determinations, as indicated in DI 32594.010 A.3.

B. Procedure

1. Case receipt

  1. For cases received directly from PC, OHA, or Wilkes-Barre, enter as receipts (DREC) on NDDSS with the following information:

    • PIN, LUN, LEX - Enter usual information.

    • AN, BIC, AH, XAH, DB, XAN, XBC - Obtain from original 831, 832, or 833 in folder.

      NOTE: Code BIC “AR” if subsequent claim is currently pending.

    • TYP - Enter level code “RC” followed by claim type (DIB, DI, etc.) from original SSA-831-U3/C3.

    • RCD - Enter current date (MMDDYY).

    • SRD - Enter current date (MMDDYY).

    • SO - Enter “N.”

    • DO - Enter office code for office that sent folder to DDS. This information can be found on court case flag attached to case folder. Folder example: PC7.

    • SLC - Use “I.”

    Input address as indicated on claimant's request for review, if address is different from that in file.

  2. For cases received from FO, enter following normal procedures using an SLC code of “I.”

  3. New claim received in DDS after State of New York case - Use update facility (DUPD) to establish State of New York case as assistance request by making following entries before receipting new claim:

    • PIN, T2/T16, AN, BIC, AH - Enter identifying information.

    • SO - Enter “Y.”

    • MBC - Enter “AR.”

2. DDS receives case that should be OHA jurisdiction

Route to the following address cases that should be OHA jurisdiction as indicated in A.3.c. above;

State of New York Coordinator
Office of Hearings and Appeals
Office of Appellate Operations
Box 3200
Arlington, VA 22033

3. Screening - general

  1. Complete screening sheet in duplicate (see DI 32594.095, Exhibit 2).

  2. Each week, send copies of screening sheets to address in DI 32594.040 A.2.b.

  3. Notify individual (and representative, if individual is represented) of screening results immediately, using most recent address available.

    • Use DI 32594.095, Exhibit 3 if individual is found to be class member.

    • Use DI 32594.095, Exhibit 4 if individual is foundnot to be class member. Fill in reason for non-membership. Forward the claims folder(s) to the NEPSC to be held 90 days for a possible appeal of the class membership decision.

4. Screening - lost folder cases

  1. Case is listed under code 170 - screen case following above procedures. (FO will have reconstructed folder already).

  2. Case is not listed under code 170 - obtain information needed to make class membership decision if FO has not already done so.

    • Individual is not class member - follow procedures in 3. above.

    • Individual is class member - initiate full reconstruction of claims folder. Request FO assistance, if necessary.

5. Appeal of screening decision

If appeal request or inquiry is misdirected to DDS, ascertain whether individual chooses to appeal directly to OGC or through State of New York class counsel. Prepare SSA-5002 to summarize contact if it is oral.

  1. If individual chooses to appeal through State of New York class counsel, forward SSA-5002 and other documentation to:

    • Cardiac Case Membership Unit
      Legal Services for the Elderly,
      130 W. 42nd St. 17th Floor
      New York, NY 10036.

  2. If appeal is directly to OGC, forward SSA-5002 and any other documentation to:

    • Office of the General Counsel
      Social Security Division
      Altmeyer Building
      6401 Security Boulevard
      Baltimore, MD 21235.

6. Development before review

Fully develop these cases prior to review, as stated below. (This includes contacting claimants to see if they have any additional evidence related to the relevant time period (see A.4. above)).

  1. If original determination was a denial, fully develop for the period covered by the application subject to readjudication.

  2. If original determination was cessation, fully develop period from cessation date through present.

NOTE: In some cases, the claimant may have received an allowance on a subsequent claim after a prior claim for initial entitlement was denied or after a prior award of benefits was ceased. In these cases in the absence of evidence to the contrary, SSA adjudicators will assume that the favorable decision on the subsequent claim was correct and will limit development and readjudication to the period up to the date of onset established in connection with the subsequent claim. However, if new evidence submitted or developed in connection with the State of New York readjudication raises a question of continuing disability, SSA adjudicators will not be barred from considering and deciding the issue under the normal continuing disability review procedures and standard. Route the folder to the FO for a face-to-face CDR interview.

7. Review

  1. Follow review standard elucidated in DI 32594.015, DI 32594.020, and DI 32594.030. Do not readjudicate periods for which disability has been established already.

  2. Cessations - review and readjudicate cessation determination and period from that date to present.

  3. Denials - review and readjudicate period covered by original determination.

    • If readjudication of this period results in affirmation of denial, see 11. below. No further adjudication is necessary.

    • If readjudication of this period results in reversal to allowance, proceed to 9. below. Do not prepare determination or notice until entire period through present has been readjudicated.

8. Multiple denial determinations on or after June 1, 1980

  1. For multiple denial determinations on or after June 1, 1980, prepare only one determination (for each title) to replace prior determinations.

    NOTE: The new determination must take into account all claims that are subject to readjudication and all time periods covered by those claims.

  2. Use earliest filing date that results in class membership.

  3. If earliest determination was denial but later determination was allowance, use filing date of earliest application.

  4. If DDS becomes aware of earlier determination made on or after June 1, 1980, that has not been associated with alert, ask FO to help locate and forward missing folder to DDS for review.

9. Actions after review - original determination was denial - readjudication resulted in allowance

After the review, if the original determination was a denial and the readjudication resulted in an allowance:

  1. Update medical sources and develop medical and vocational factors for period from date of original determination through present.

  2. Complete readjudication of period from alleged date of onset through present.

NOTE: In cases where the claimant has received an allowance on a subsequent claim after a prior claim was either denied or ceased, in the absence of evidence to the contrary, SSA adjudicators will assume that the favorable decision on the subsequent claim was correct and will limit development and readjudication to the period up to the date of onset established in the subsequent claim. However, if new evidence submitted or developed in connection with the State of New York readjudication raises a question of continuing disability, SSA adjudicators will not be barred from considering and deciding the issue under the normal continuing disability review procedures and standard. In this situation, return the folder to the FO with a request to conduct a face-to-face CDR interview.

10. Wholly favorable or partly favorable final readjudication

For a wholly favorable or partly favorable final readjudication: