DI 42001.020 Other Reopening Issues
A. Consistency review
All types of disability determinations are subject to a sample review. The consistency review is an assessment of a disability quality review. Occasionally, during consistency review, substantive errors are found which could reopen a decision. If an actual case is deficient and requires corrective action by the review component, the folder is returned to the review component.
Cases selected for the CD preeffectuation review will be reviewed by the quality control examiner before notice of continuance or cessation is released to the claimant. These cases may, therefore, be returned by the examiner to the DO or DDS as appropriate, using Forms SSA-109-U4 for developmental and adjudicative deficiencies, and SSA-1774-U4 for substantive vocational and medical issues.
B. SGA determination already effectuated
If the DO has made a determination that a claimant is engaging in SGA, and the evidence in file clearly indicates that the claimant is not engaging in SGA, the examiner should prepare an SSA-831-U5 (or
SSA-833-U5 in cessations) amending the DO determination. The file, with the amended determination, may be forwarded by SSA-847-U3 directly to the DDS. Send a copy of the determination to the DO for their records. When there is sufficient evidence to reopen and revise an allowance to a denial because of a return to work in the waiting period or before the date of the award, there will be no need to forward the case to the DO. The RECONE in ODO or DE in DRS will prepare the revised determination and issue the due process letter. (See DI 13010.000.) In all other SGA situations, the examiner should route the case to the DO for development, with instructions to forward the case to the DDS if indicated.
C. Reopening of prior SGA decisions
Whenever there is an increase in the SGA earnings and the increase is retroactive, the possibilityof reopening the prior SGA decision must be considered. See DI 10505.035 for further information.
D. Duplicate application1
Review the application information and any evidence submitted therewith to be sure of the correctness of the prior favorable determination. If there is a question about the correctness of the determination, consider reopening the case in accordance with the procedures in DI 27501.000. If a continuing disability issue is raised, process the case in accordance with the continuing disability procedures in DI 40500.000. In a case where a freeze had been established for a statutorily blind individual who has been denied DIB, an SSA-833-U5 determination is required on the issue of whether the individual is able to engage in SGA for cash benefit purposes. (Refer to DI 40120.015B.1. for the instruction for handling this type of case.) If the duplicate application was filed prior to the release of an allowance notice but received after release, no acknowledgment of this duplicate application will be necessary, unless an issue of reopening or continuing disability is raised. If the application was filed after release of the favorable notice and no issue of reopening or continuing disability investigation is raised, in the ODO/DRS type notification case, send a letter to the applicant acknowledging the duplicate application (see DI 40120.015C.1.). Route the folder by SSA-559 to DBS.
In a PC-type notification case, route the file by SSA-559 to a CA or to the appropriate PC depending on the type of case involved, e.g., DIB or CDB claim based on an RSI NH. On this SSA-559, indicate that no change in the disability determination is necessary and request that the duplicate application be acknowledged.
If the duplicate application was filed by a party other than the claimant, institution, etc., who had filed the prior application, follow the same procedure as indicated above for notifying the secondary applicant (see DI 40120.015C.).
Where an auxiliary applicant files a duplicate application on behalf of a NH and also files an auxiliary application on behalf of self and others, and the primary claim has been or is being denied, use the language in DI 40120.015C.3. for preparing the notice.
E. Application filed within 4 years after notice of initial denial or cessation
Occasionally after reconsideration, a claimant, instead of requesting a hearing, will file a new application, will submit additional evidence, or will write to the DO or PC, taking exception to the determination.
In some instances, the claimant may write to a member of Congress, union official, etc., who in turn may write to the SSA. The PC should review the case in the light of the new application, new evidence, and/or the information contained in the correspondence. The new application by itself is not a basis for review of the prior decision. The claimant or other party has to specifically request such a review.
New evidence included with the SSA-16-F6, SSA-4-BK or SSA-5-F6 may provide a basis for reopening or may simply require a determination on the new application. ODO or DRS may prepare a substantive denial for the unadjudicated period if insured status ended before the date of the last determination on the prior application. However, the case must be forwarded to the DDS if it appears the new claim may be allowed. Therefore, onset of disability may be established during or after the previously adjudicated period.
See DI 27501.000 and DI 27505.000.
F. Application filed within 4 years after a technical denial
If the claimant was previously denied for not meeting the QC requirement and still does not meet that requirement, process as an administrative res judicata case per DI 40105.050. If the previous application was withdrawn, process as an initial application.
If the claimant was previously denied for failure to furnish medical evidence (paragraph MK17) and has now submitted evidence, process as an initial case. If no evidence has been submitted with the new application, determine whether development is necessary and whether the claimant needs assistance in presenting his/her claim. If necessary, return the folder to the DO requesting development (per DI 11010.520) of claimant's ability to furnish the needed information.
If the claimant was previously denied for insufficiency of medical evidence (paragraph MK19) and new evidence is submitted, consider reopening. If reopening is not appropriate, process as an initial case.
If the latest determination in file is a reconsideration decision and the new application meets the criteria for reopening, the DE will process the case per the instruction in DI 42001.015E.
G. Application filed more than 4 years after notice of initial denial or cessation
When new and material evidence is received with a subsequent application that is filed more than 4 years after the date of the initial notice of the prior determination, the new application must be adjudicated on the merits of the complete case. Since the earlier claim may not be reopened, under such circumstances, payment and retroactivity must be based on the current application.
However, where the total evidence supports an onset within that prior period of adjudication, onset may be set within it.
1. No new and material evidence submitted
If no new and material evidence is submitted, the application must be adjudicated on the basis that the original determination was correct unless error on the face is apparent. If the current evidence or any other evidence shows that a severe condition existed after the last adjudicated period and while insured status was still met, an allowance will be appropriate. In all other cases, denial would be in order.
2. New and material evidence submitted
If the DDS has correctly established an onset based on new and material evidence within the last adjudicated period, enter in Item 34 of the SSA-831-U5, “Retroactivity of benefit payments restricted to application filed (date of later application),” and check PD in Item 10.
H. Application received after ALJ, AC or court decision
Applications received after an affirming ALJ decision will be referred to the DE together with the related folders. The DE will be responsible for determining the disposition of these cases.
If the unadjudicated application has been considered by the ALJ, take no further action. Return the folder to merged files.
If the unadjudicated application has not been considered by the ALJ, i.e., has not been listed in the “List of Exhibits” appended to the ALJ decision or otherwise discussed in the decision, send the case (if DDS jurisdiction) to the appropriate DDS by SSA-847-U3 for an initial determination. If DO updating of the application is required route the case through the DO by SSA-5526-U3 with the necessary guides.
The ALJ may confine his/her determination to either the non-disability aspects (insured status, etc.) or the disability aspects of the case; however, his/her decision will usually encompass both issues. His/her decision is treated as binding upon ODO/PSC, and the DDS (1) in a denial through the date of his/her decision or the date the insured status expires, whichever is earlier, and (2) in a cessation, through the cessation date found by the ALJ.
If the ALJ has dismissed a request for hearing without deciding the issue of disability, process the case as if the new application had been received after a reconsideration decision.
Applications received after affirming AC or Court Decisions are processed as above except that whenever the reference “ALJ” is shown, read “A.C.” (See DI 27510.000.)
1 This section reflects duplicated material.