DI 42005.005 Processing Instructions
A. Routing of reconsideration claims involving earnings discrepancies
The ultimate responsibility for resolving earnings issues or discrepancies is with the reconsideration reviewer in the Office of Central Records Operations (OCRO). However, the resolution of earnings discrepancies in cases being processed at the reconsideration level is the responsibility of the RECONR of the Reconsideration (Recon) Staff. Therefore, if an earnings issue is the subject of the request for reconsideration, whether or not insured status is affected, resolution of the issue is always the responsibility of the RECONR.
There are exceptions to this general rule, particularly where a favorable decision has been reached and payment of benefits must be expedited. Use the guides below to process cases where a favorable decision has been (will be) made by the Recon Staff which will result in the payment of benefits, and an earnings discrepancy exists. This includes discrepancies in lag and pre-lag periods, as well as cases containing a DO prepared SSA-7000-U5 or SSA-7010-U5 which has not been signed on the right.
If the file contains evidence to resolve the discrepancy, process the SSA-831-U5 and route the case to RECONR in the Recon Staff for resolution of the discrepancy.
If the file does not contain evidence to resolve the discrepancy and/or if doubt exists or it is not possible to determine if resolution of the discrepancy will result in the claimant meeting the earnings test, route the case to RECONR for resolution before processing the SSA-831-U5.
If there is an earnings discrepancy but it is not material to insured status; i.e., the earnings test is met at onset, process the SSA-831-U5 and route the case to the module Claims Specialist (CS), calling attention to the discrepancy.
If insured status is met, based partly on SSA-7011s or SSA-1002s which establish earnings which were lag when the earnings record was certified and no other discrepancy material to insured status exists, process the SSA-831-U5 and route the case to a CS.
The CS will usually resolve these discrepancies and process the claims to payment. When immediate resolution is not feasible, the CA will have the case returned after payment for post-adjudicatve resolution.
B. Disposition of incoming reconsideration material - folder temporarily transferred to other offices
After a case folder has been sent by the Recon Staff to a DO, DDS, an ALJ or the AC, any correspondence, additional evidence, etc., that is received will be forwarded to the appropriate receipts point if the SSN is identified. Before referring this material, the module will have obtained an MBR printout to obtain exact location of the file.
Module personnel will examine the material to determine what requires referral to Reconsideration Staff and what will remain for processing or other transfer. Material received for processing by the module will be handled as described in the following sections.
1. Letters and memos
All memoranda, regardless of source, and all case related inquiries from lawyers, doctors, public welfare, etc., as well as from the wage earner will be referred to the Inquiries Staff who will evaluate it and if possible give an immediate reply. If it is not possible to give an immediate response to the question raised, prepare a reply stating that the claimant’s folder is currently in the DDS or DO and that a reply to the inquiry will be made as soon as possible. If appropriate, request status from the DO or DDS and send a copy of the inquiry together with a copy of any response to that office for folder association.
If the MBR printout shows the folder is in transit, the correspondence is placed on the A freeze, the system updated to show A freeze and the material held until the folder is received.
2. Teletype request for claims file
All teletype requests for claims files received while the folder is in the DO or the DDS will be referred to the appropriate module. If the folder is in the DDS or DO, follow instructions in DI 42010.005D. Return the teletype request with a copy of your notice that a request for hearing has been filed to the DO or the DDS as explained in 1 above.
3. Status request
In replying to status requests, provide as much information as possible and explain that the folder is currently charged out to the DO or DDS (give name) and place copy of all replies on A freeze.
4. HA-501-U5—request for hearing
If a formal request for a hearing is received in the PC, an MBR is obtained to locate folder and the HA-501-U5 is forwarded for association with the folder by the RMC in ODO and the screener in DRS.
C. Reconsideration and hearings forms
OS 15010.000 exhibits the following forms applicable to reconsideration and appeal:
|Exhibit|| 1 SSA-561-U2||Request for Reconsideration|
|Exhibit|| 2 SSA-662||Reconsideration Determination|
|Exhibit|| 5 HA-501-U5||Request for Hearing|
|Exhibit|| 7 HA-4608||Waiver of Rights to Oral Hearing|
|Exhibit|| 7 HA-4608SP||Spanish Version of the Above|
|Exhibit|| 9 HA-520-U5||Request for Review of Hearing Decision/Order|
|Exhibit||21 SSA-3583-U2||(Formerly SSA-636 BDI)|
Transmittal Notice Hearing Case—Disability
|Exhibit||25 SSA-3441-F6||Reconsideration Disability Report|
In addition to the above forms applicable to reconsideration and appeal, the following 3 exhibits refer to forms and notice letters used in the processing of reconsideration and appeal cases.
| || || |
|Exhibit||1 SSA-L844||Social Security Notice of Reconsideration|
|Exhibit||2 SSA-1227||Reconsideration Determination|
|Exhibit||3||Acknowledgement of Informal Request for Reconsideration|
1. Exhibit 1, SSA-L844 Social Security Notice of Reconsideration
This form letter is used in conjunction with SSA-1227 (Reconsideration Determination) to inform the claimant that the original decision was correct and in accordance with the law and regulations.
Exhibit 1, SSA-L844 - Notice of Reconsideration
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2. Exhibit 2 SSA-1227 Reconsideration Determination
This form is used in a non-disability issue case to notify a claimant who filed for reconsideration that the claim was disallowed because the person did not meet a non-medical requirement. It also notifies the claimant that because the non-medical requirement is not satisfied, a determination as to disability has not been rendered. A detailed statement as to claimant earnings, employer, period earned and social security credits may be included in the letter.
Exhibit 2 - SSA-1227 Reconsideration Determination (Use for Non-Medical Disability Cases)
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3. Exhibit 3 - Acknowledgement of Informal Request for Reconsideration
This guide form letter is used to acknowledge receipt of the claimant’s letter (notice, etc.) which is accepted by SSA as an informal request for reconsideration. A formal request for reconsideration would be filed by the claimant on an SSA-561-U2, Request for Reconsideration.
The guide form letter also informs the claimant that the claims file is being sent to a particular Social Security office for further contact with the claimant.
Acknowledgement of Informal Request for Reconsideration
Dear Mr. .
This refers to your letter about your claim for disability insurance benefits.
Since it appears you want reconsideration of your claim, your records are being sent to your Social Security office at (name of office). A representative from the Social Security office will contact you to obtain additional information about your condition. When this is completed, your claim will be re-evaluated by the agency in your State which works with us in making disability determinations. A review of your claim will be made to see whether the decision was correct or should be changed.
You may be assured that every effort will be made to complete this action as quickly as possible. Your cooperation will be helpful.
D. Flagging “disagreement” and partial allowance cases
1. “Disagreement” cases
In review of DDS title II disability determinations before or after payment is made and/or notification to the claimant, SSA disability examiners are authorized to change a denial to an allowance or cessation to a continuance. However, in exercising this authority, SSA disability examiners will follow the guides in DI 40115.005E which provide that the examiner will usually return the case to the DDS before making substantive changes. Flag the case with Form SSA-641 (Flag Notice) and give details as complete as possible regarding the disagreement.
2. Partial allowance cases
If the Reconsideration Staff prepares an allowance on a case which is only partially favorable to the claimant, flag the folder with an SSA-641. If the claimant later files for a hearing, the flag will serve to direct the case to a CS to prepare a folder copy of the award notice. The ALJ needs copies of these notices in order to have a complete record of the hearing.
If the partial allowance is made but subsequent development results in a revised determination which is fully favorable to the claimant (prior to any request for hearing), the SSA-641 should be removed from the folder and destroyed.
3. Onset with future month of entitlement established on initial determination—claimant requests reconsideration prior to first month of entitlement
When an onset with a future month of entitlement has been established at the initial level, the claimant will be sent a conditional award notice which tells when he or she may expect his or her first check and advises that he or she should let us know about any change in his or her condition or work status. This notice also advises the claimant of the 60 days’ appeal period for requesting reconsideration.
Occasionally, a claimant who has received this notice may nonetheless request reconsideration before his or her first month of entitlement. Should this occur, the reconsideration request will be accepted, associated with the file and forwarded to the Reconsideration Staff, RECONE/ODO or DEC/DRS.
E. Processing future month of entitlement cases
There will be times when in processing a reconsideration request the prior determination will be affirmed and an onset established with a future month of entitlement. In this event, the claimant will receive both a notice and reconsideration determination which explains the affirmation and a conditional award which advises that he or her has been found disabled, gives the date when he or he may expect his or her first check and advises that he or she should let us know about any changes in his or her condition or work status. See instructions below for processing these cases.
There will also be situations in which a request for reconsideration will be received prior to the first month of entitlement in a case in which the prior determination was a future allowance. Onset with future month of entitlement established on reconsideration will be processed as described below.
If the prior determination is affirmed and at the same time an onset date is established which results in a future month of entitlement, enter in item 28 of the SSA-831-U5 the date the period of disability began. Also prepare a notice of reconsideration determination in the usual way. In that notice, just before the hearing paragraph, include the following: “However, the evidence shows that you have been disabled since (date). You will soon receive an award notice stating that you will become entitled to disability insurance benefits when your disability has existed for five full calendar months. If your condition improves or there is a change in your work status, you must notify us immediately.”
After releasing the notice of reconsideration determination, forward the file by SSA-559 for preparation of the award indicating thereon that the hearing paragraph (140) should be included on the SSA-L30 in place of the reconsideration paragraph. Subsequent processing is essentially the same as in initial cases.
F. Simultaneous processing of requests for reconsideration of DIB-DWB claims
ODO has jurisdiction over all requests for reconsideration of DIB-DWB claims under age 59. All DIB-DWB claims age 59 or older are the jurisdiction of DRS. If either of the claims (or both) require DDS action, the DO will send both to the DDS who will return them, after their action, to ODO or DRS. If the issue on either claim is non-disability, refer it for reconsideration of the non-disability issue and preparation of language for inclusion in the notice to be sent by the disability examiner. (If both claims are concerned only with non-disability issues, special attention will be necessary to process both cases including preparation of the notice.) The RECONE/ODO DEC/DRS should complete action on the case and take action as follows:
Denial of Both Claims - Send a combined denial notice and return both folders to files.
DIB allowed—DWB denied—Prepare DWB denial language on SSA-865 for inclusion with the hearing paragraph (140) on the SSA-L30 award notice. Refer the case to the CS for further processing.
DWB allowed—DIB denied—Prepare DIB denial language on SSA-865 for inclusion with SSA-30 award notice. Send the DWB folder by SSA-559 to the servicing PSC and request inclusion of the DIB denial language and the hearing paragraph. Return the DIB folder to files.
Both DIB-DWB Claims Allowed—Refer both folders to the CS and ask them to process the DIB claim to payment and to send the DWB claim folder to the servicing PSC after enclosing a photocopy of the SSA-101-U3 (Determination of Award) on the DIB claim in the DWB folder.
G. Reconsideration request filed before receipt of notice of initial determination—title II (see GN 03101.050)1
Occasionally a claimant who has not received notice of initial determination will file a request for reconsideration. This may occur if he or she feels strongly that an adverse initial determination will be made, and he or she wishes to appeal the determination immediately. Under the regulations, a claimant does not have a right to request reconsideration in advance of the initial determination. However, any request for reconsideration filed under these conditions will be accepted and forwarded to the appropriate office for processing. The adjudicators in the processing offices will dismiss such requests on the basis that an initial determination has not been made in accordance with GN 03102.200. Also, since the claimant still retains the right to reconsideration, notify him of this right when the dismissal notice is prepared. Include in this notice, language similar to the following.
“We have dismissed your request for reconsideration dated because an initial determination has not been made in your case. The Social Security Regulations provide the right to reconsideration only after an initial determination has been made. Also, there is no authority in the Social Security Act or implementing regulations which permits us to combine the initial and reconsideration determinations.
“You still have the right to reconsideration once we process the initial determination. You will be advised of this right in the initial determination notice.”
“If you have any questions about your claim, get in touch with any Social Security office. Most questions can be handled by mail or telephone. However, if you visit the office, please take this notice with you.”
(See GN 03101.070 for Medicare and SI 04020.030 for SSI).
H. Hearing filed before receipt of reconsideration - title II (see GN 03101.060)1
ODO or DRS will send the hearing file copy of the SSA-3583-U2 to ODAR without the claims folder but with the certification below if (1) no reconsideration has been requested, or (2) a reconsideration is in process but a determination has not been made (see exception below), or (3) a reconsideration request was not timely filed and was dismissed.
If a reconsideration determination can be made within 3 days of the time the HA-501-U5 is received in the Reconsideration Branch and such determination will be unfavorable, process the determination but substitute the following for the regular hearing paragraph;
“Since you have requested a hearing, we are referring your request to the administrative law judge for his or her action on your request.”
The claims file will then be prepared as indicated in GN 03103.120 and forwarded to the DO for transmittal to the ALJ. If a favorable reconsideration determination will be made, or an unfavorable decision will not be made in 3 days, do not delay processing the SSA-3583-U2 but forward immediately without the claims file to the ALJ. This will permit the claimant to decide whether he or she again wishes to request a hearing after the ALJ’s dismissal of the premature hearing request, and the favorable reconsideration determination has been received.
In those cases in which the SSA-3583-U2 is forwarded without the claims file to the ALJ, enter the following certification under “Remarks.”
“The undersigned, an employee of the Social Security Administration, Department of Health and Human Services, certifies that on (date) , notice was mailed to (name of appellant) that it was determined (issue) and he or she was advised of his or her right to request a reconsideration if he or she disagreed with the findings. On (date) , (Ms.) (Mr.) (name of appellant) requested a hearing with respect to the above determination. The undersigned further certifies that the appellant (has a request for reconsideration pending on which no determination has been made) (has not requested reconsideration of the initial determination) (did not timely request a reconsideration of the determination).”
The SSA-3583-U2 will be completed in all other respects as indicated in GN 03103.110. The control copy of the completed form should be forwarded to the DO so that they may cancel any controls they have established for securing the claims folder.
If the request for hearing is not accompanied by the required RC explaining why the claimant insisted upon filing for a hearing before having a reconsideration, the RECONR, RECONE (ODO) or DEC (DRS) will, when it forwards the certification to the ALJ, request the DO to contact the claimant to explain the necessity for reconsideration and a reconsidered determination before a right to hearing arises. The DO will assist the claimant in requesting a reconsideration if he or she so desires and he or she has not previously done so. The DO will submit the RC called for above to document the file. (See GN 03103.1205 for development where a letter requesting a hearing or an HA-501-U5 is received in the PC.)
If the ALJ dismisses the hearing request, he or she will advise the claimant that he or she has no jurisdiction to hold a hearing since the initial determination has not been reconsidered by SSA.
The PC would not take any final related action pending the ALJ action on the hearing request. Upon receipt of notice of the ALJ action, the PC may proceed to complete any pending action and/or consider any additional evidence or information submitted. In a dual determination situation, where SSA makes a revised initial determination and an initial determination on the same case, the ALJ will not dismiss the case merely because the initial determination has not been reconsidered; i.e., he or she will not dismiss the case since a hearing is proper with respect to the revised initial determination. See GN 04040.001. Therefore, if the PC cannot reconsider the initial determination within the time limit specified above, the entire claims file should be forwarded to the ALJ. An example of this situation usually occurs when an initial determination of entitlement is revised and thereby creates an overpayment. The claimant receives a notice telling him or her that his initial entitlement determination is now revised and he or she is at the same time given an initial determination as to the overpayment.
I. Handling cases where good cause for late filing is not established (see GN 03101.020)
Where good cause for late filing is not established, the RECONE(ODO) or DEC (DRS) should still examine the case to verify the correctness of the prior action. Bear in mind that although the period for requesting reconsideration has expired, we may be able to revise the initial determination under the rules of administrative finality. See GN 04040.001 for notice of revision. If there is no basis for reopening and revising the initial determination, the PC should notify the claimant of his or her request for reconsideration, giving the reason for the dismissal and an explanation of the initial determination. Do not include a hearing paragraph.
Where reconsideration was not specifically requested, the letter should merely explain the basis for the initial determination. Where additional repetitious or cumulative evidence had been submitted, acknowledge the receipt of the evidence, indicate that it was considered and include an explanation. In all instances, the letter should avoid any inference that the claim was re-examined or reconsidered.
For SSI procedures, see SI 04020.030.
J. New claim, evidence or correspondence involving identical issue received after reconsideration (see GN 03102.475)1
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 RECONE (ODO) or DEC (DRS) should review the case in the light of the new application, new evidence, and/or the information contained in the correspondence. The required action is as follows:
1. New application filed—no new and material evidence and no change in law or regulations—reconsideration determination final
Where the claimant files a new application calling for a determination of the same issue which was involved in the prior claim, no new and material evidence is submitted, and there has been no change in the law, regulations, or judicial precedent applicable to the issue in the claim, treat the prior reconsideration determination, after it has become final, as binding on that issue. The PC will disallow the new application and advise the claimant that the question had been previously decided upon reconsideration and that since the present claim involves the same issue and is based on the same facts and law, favorable action may not be taken on the new application.
Furthermore, the claimant will be advised of the right to reconsideration, and that any subsequent reconsideration will be limited to whether the issue is the same as that previously determined (see GN 03101.120). If on reconsideration, it is clear that the issue is the one previously determined, repeat the above notice and advise the claimant of the right to request an ALJ of the Office of Disability Adjudication and Review to hold a hearing.
2. New evidence or correspondence received after reconsideration
a. Reconsideration determination affirmed but period for requesting a hearing has not elapsed
If the reconsideration determination is affirmed and the inquiry or additional evidence was submitted within the period for requesting a hearing, provide a full explanation by letter to the claimant or correspondent where disclosure is permitted. (See GN 03305.000.)
If at the time the final reply is being released, the period for requesting a hearing has not expired, include in the letter of explanation a reference to the person’s right to request a hearing and a reminder that the request must be filed on or before 60 days from receipt of reconsideration notice.
If, when the final reply is being released, the period for requesting a hearing has expired, include in your letter a statement that while the period for requesting a hearing has expired, for good cause shown the ALJ may extend the period. Where the claimant later requests a hearing, the PC should call the ALJ’s attention to the fact that the claimant had expressly or implied requested further consideration within the period for requesting a hearing, and that the ALJ should explain the action taken.
b. Reconsideration determination affirmed but period for requesting a hearing has elapsed
If the reconsideration determination is affirmed and the period for requesting a hearing had elapsed before the inquiry or the submission of the evidence, make no reference to a right to request a hearing or an extension of time unless the question was specifically raised. If the question is raised, the reply should include a statement that the time for requesting a hearing has expired but if good cause is shown an ALJ may, upon petition, extend the time for requesting a hearing. Further inform the party that if the claimant wishes to request an extension of the time to request a hearing because good cause for late filing exists, the DO will assist in the preparation of the request. (See GN 03101.020.)
c. Reconsideration determination should be reopened and revised under the rules of administrative finality
If it is concluded that the reconsidered determination should be reopened and revised under the rules of administrative finality, take the appropriate action and include the regular hearing paragraph. See GN 04040.001 for the definition of what constitutes a revision of an initial or reconsidered determination.
3. Change In law, regulations, or judicial precedent
Where the applicable law, regulation, or judicial precedent has been changed, but the change does not permit the reopening of the prior decision, the disability examiner/ODO or disability specialist/DRS) will adjudicate the new application and notify the claimant accordingly, including a notice of the right to reconsideration.
Where the prior reconsideration determination may be reopened, the instructions announcing the change in law, regulation, or judicial precedent will state the procedures for processing claims affected by such change.
For SSI procedures, see SI 04020.030.
K. Processing end stage renal disease (ESRD) cases (DI 45000.000)
Requests for Reconsideration will be handled by the ODO Reconsideration Staff.
1. Acknowledgment of receipt
When a request for reconsideration is received, send an acknowledgement of receipt to the requestor. If the requestor is a third party, send a copy of the acknowledgement to the patient.
2. Referral of cases to CMS
Refer all medical denials or cessations to CMS, Office of ESRD, 1C2 Dogwood West Bldg., by SSA-559 and enter in remarks section “Recon Case” . They will review the folder and develop any new material considered necessary. The folder will be returned after CMS has completed their action with a reevaluation to sustain or reverse the initial determination.
3. Review of cases not referred to CMS
Cases which do not require a medical review, i.e., not insured, relationship questions, etc., will be reviewed by the RECONR, who will be responsible for final review of all non-medical issues.
In all cases, affirmations or reversals, an SSA-831-U5 or SSA-833-U5, as appropriate, must be prepared.
Follow guidelines in DI 45001.020 and the guidelines below.
a. Prior denials
If it is determined that the case is now an allowance, complete the SSA-831-U5 (see DI 45010.020).
If the denial is affirmed, send notice as described in DI 45001.076. Appropriate language should be entered in the blank space to explain the reason for denial.
b. Prior cessations
If it is determined that the cessation should have been a continuance, prepare an SSA-833-U5, except check Item 10(B), 18(B) and delete “Period of”. Route the folder to reinstate the Medicare annotation on the MBR. If the cessation action is affirmed, annotate the previous SSA-833-U5 of the fact, send a notice as described in DI 45010.035 and enter appropriate language in the blank space.
L. Cessation affirmed on reconsideration—new period of disability established
The Reconsideration Staff or module may affirm a cessation of disability, while finding that the claimant became disabled again subsequent to the cessation date. If the claimant will lose benefits because his or her new application (or protective writing) is not retroactive to the first month of potential entitlement under the new period of disability, see DI 42010.040.
M. ODO/PSC-DRS responsibilities - disability hearing process
If ODO or a PSC receives a request or implied request for reconsideration on a case meeting the criteria for the disability hearing process, it will associate the request with the claims folder and forward it to the servicing DO for its necessary action. The primary ODO/PSC-DRS responsibilities for cases in the disability hearing process are at the end of the process. (See DI 43525.050 for INTPSC instructions.)
1. DDS favorable determinations
ODO/PSC-DRS conducts a pre-effectuation review (PER) for title II favorable DDS determinations in accordance with existing PER procedures. If no deficiencies are detected, ODO/PSC-DRS will effectuate the determination, release the notice of the fully favorable determination and process the payment adjustment actions. If the review results in a fully favorable determination no longer being made, use current procedures to notify the DDS. The DDS will prepare the Summary of Evidence, realign the claims folder, notify the DHU, and dispatch the claim to the disability hearing unit.
NOTE: In rare cases, ODO/PSC-DRS will receive additional evidence which indicates that the DDS reversal was erroneous and the time period for reopening (see GN 04001.000) has not expired. ODO/PSC-DRS will forward the folder to the DDS citing the reason(s) it feels the DDS determination should be reopened. If the DDS disagrees with ODO/PSC-DRS, the DDS will forward the case to DHU citing the reason(s) it disagrees with ODO/PSC-DRS. In this situation, it will not be necessary for the DDS to prepare a Summary of Evidence or to realign the folder. If, however, the DDS agrees with ODO/PSC-DRS, the DDS must prepare a Summary of Evidence, realign the folder and forward the case to the DHU. In both instances, the disability hearings officer, DHO will review the case and decide whether or not the DDS determination should be reopened. If the DHO decides, based on the additional evidence, that the DDS determination should be reopened, the DHU will afford the claimant due process offering a disability hearing. If, however, the DHO determines the DDS determination to be correct, the DHO will annotate the additional evidence, documenting the fact that he or she did not reverse the DDS determination and return the claims folder to ODO/PSC-DRS for maintenance.
2. Processing cases received from DHU
Following the disability hearing, cases will be routed as described in DI 42010.050. Such cases are excluded from any pre-effectuation review or reversal by ODO/PSC-DRS; the DHO’s decision is subject only to a review by the Disability Quality Branch and a subsequent review by the Disability Hearing Quality Review Branch (DHQB) of the Office of Disability. However, if in processing a post-adjudicative action, an error is detected or if additional evidence is received that may affect the decision, prepare a memorandum citing the problem and forward the case to DHQB, OD for resolution. Refer to GN 04010.000 regarding the expiration of the specific time limits provided in the act and/or regulations for reopening or revising a determination.
3. Request for reconsideration on non-disability issue as well as medical issue pending
There may be instances where ODO/PSC-DRS has a Request for Reconsideration (SSA-561-U2) pending on a non-disability issue which is not critical to eligibility (e.g., worker’s compensati