DI 40115.005 Definitions and Processing Instructions for Changing Initial Disability Determinations in the Processing Center (PC)
These terms are used throughout this subchapter.
1. Substantive change
A change that alters the conclusion as to:
whether an individual is disabled or not disabled; or
when disability begins or ends; or
the basis for a determination even where there is no change that affects benefits.
2. Non-substantive change
A change other than a substantive change (e.g., change of address).
3. Amended determination
An amended determination is a determination where a substantive change happens prior to effectuation, except as indicated in the second bullet DI 40115.005A.5. in this section.
4. Revised determination
A determination with a substantive change made after effectuation.
5. Corrected determination
A determination with:
a non-substantive change made either before or after effectuation; or
a change to the onset date(s), ending date(s) (i.e., closed period), or both the onset and ending date(s) prior to effectuation.
6. Final determination or decision
A determination or decision (initial or revised) is final as of the date of the notice unless:
it is timely appealed (or a civil suit is filed); or
it is appealed late but good cause for late filing of an appeal or civil suit is found; or
it is reopened and revised; or
the Appeals Council (AC) takes jurisdiction on its own motion within 60 days of an Administrative Law Judge (ALJ) decision; or
the AC denies a request for review (does not issue a decision), in which case the ALJ decision is the final decision as of the date of the notice that the AC denied review.
GN 04001.040, Role of Notice in Reopening
DI 27501.001, Reopening and Revisions: Pertinent Definitions and Related Policy
B. Substantive change by SSA
The law permits SSA to make substantive changes in all Disability Determination Services (DDS) Title II determinations.
In some instances, the disability reviewer may assume jurisdiction and prepare the new determination or return the case to the DDS to prepare a new determination using one of these forms:
A substantive medical change by SSA, regardless of whether it affects the outcome of the case, requires the concurrence of an Office of Disability, Office of Medical Evaluation physician, or a Regional Office Medical Consultant staff physician.
C. Substantive change requiring a revised determination
A revised determination (substantive change is made after effectuation) is required in the following situations:
A different date of onset is established after an effectuated partial award; or
The prior determination is revised during the reconsideration process, or an ALJ, the AC, or court revises the SSA decision, and the processing center (PC) effectuates the decision; or
A withdrawal request is accepted after adjudication of the disability application; or
A cancellation of withdrawal request is accepted after a withdrawal determination has been processed; or
A final determination is reopened and requires a change as to conclusion, onset or ending date under the rules of administrative finality; or
A determination requires a change in conclusion, onset, or ending date after effectuation of the decision. (A claims authorizer may return a determination to a disability examiner/disability processing specialist because the outcome of an earnings or coverage investigation affects the completed determination); or
An effectuated determination requires a basis code change, with no change in the determination to deny or allow, or in the onset or cessation date.
D. Substantive changes not requiring an amended determination
Substantive changes that do not require an amended determination are:
E. Processing non-substantive changes
To make a non-substantive change:
Cross out the incorrect entry on the SSA-831 (Disability Determination and Transmittal);
Enter the correct information; and
Initial any changes made to the SSA-831.
If the correction involves the SSN:
Re-jacket the folder.
Make certain that all material in file has the correct information (i.e., correct name and SSN).
Correct determination forms in the certified electronic folder (CEF), see GN 04440.237.
F. Correcting onset or ending date(s) on uneffectuated Form SSA-831 Disability Determination and Transmittal
Take the following action:
If the correction involves only the onset or ending date(s) in items 15 or 28, line out the incorrect date(s) and enter the correct date(s) and your initials.
Both the examiner and physician must sign the corrected SSA-831 and item 37 (or block 34, Remarks, if more space is needed) unless the change is due to substantial gainful activity.
Correct the determination forms in the certified electronic folder (CEF) see GN 04440.237.
Notify the DDS of the correction (see, Correcting Group II Onset Date Decisional Deficiencies GN 04440.220)
NOTE: If the SSA-831 has been effectuated, a revised determination is necessary, follow GN 04440.250C.3.c.
G. Processing amended determinations in the PC
If an amended determination is necessary and the determination is fully favorable or less than fully favorable, the review technician must:
take jurisdiction of the case,
prepare a new SSA-831, and
provide a rationale in accordance with DI 26515.001.
In situations where the determination is less than fully favorable, the review technician returns the case to the adjudicating component for preparation of the amended award.
DI 81030.021, Routing and Correcting Deficient Certified Electronic Folder (CEF) Cases
GN 04440.232, Correcting Decision Basis Code Deficiencies, for processing fully favorable, unfavorable, and less than fully favorable cases
H. Processing revised determinations in the PC
When revising a DDS or PC determination:
Enter the DDS code number as shown on the processed determination, and
Complete the SSA-831 as described in DI 27530.015.
Include in the rationale, when applicable, a discussion of the Medical Improvement Review Standard (MIRS) requirements per DI 28005.001D.1.
Provide proper notice and appeal rights per DI 27540.000.
Complete the SSA-831 in ALJ, AC, or court reversals per instructions in DI 42010.000.
GN 04440.237, Determination Forms Technical Corrective Action (TCA)
DI 81030.120, Reopenings – Certified Electronic Folders (CEF)