BASIC (03-86)

DI 42010.040 Processing Unfavorable Decisions and Dismissals Requiring Supplemental Actions

Cross refer to DI 42010.230.

A. General

Cases received from OHO that require supplemental actions will be referred for special attention to the Recon Staff in ODO and to the PSC/DRS. Ordinarily, such cases will require processing of unadjudicated applications in file for consideration of a claimant's worsening condition after the period covered by the ALJ's decision.

Claims files containing dismissal action also will be reviewed for consideration of any new evidence or information received since the last determination was rendered. When the hearing decision contains a remark about possible rehabilitation services, forward copies of pertinent evidence from the file to the DDS for an evaluation of rehabilitation potential. Prepare copies of the materials shown in DI 26520.025, including the disability determination, reports of disability interviews, the medical development summary, and current medical and vocational evaluation reports, as well as the hearing decision and list of exhibits. Forward these copies by an SSA-408 route slip to the appropriate DDS annotated “ALJ suggested possible rehabilitation services. Please screen for possible VR referral.”

B. Unfavorable decisions and dismissals—claimant already allowed

These cases contain the ALJ's decision affirming a previous allowance at a lower level of administrative review (e.g., a partially favorable reconsideration determination which was never processed to payment). In these situations, prepare a determination by following DI 42010.020 and release the case for payment action.

C. ALJ or AC affirms cessation/closed period—new period of disability established—PC action

The ALJ (or AC) decision may affirm a cessation of disability, while finding that the claimant became disabled again subsequent to the cessation date.

D. Unadjudicated DIB or DWB application in file

All ALJ and AC decision folders containing unadjudicated applications will be referred for processing per current unit operating instructions.

E. Significant worsening of claimant's condition after period ruled on by ALJ

Where there is evidence in file indicating a significant worsening of the claimant's condition to the point of “disability” after the period ruled on by the ALJ, but while the person still meets the earnings requirement (or the prescribed period), forward the case to the DO by SSA-5526-U3. Request the DO to secure a new application and explain that it appears the claimant's condition has worsened and the filing of a new application is advisable to protect any rights of the claimant. Show file symbol in the upper right portion of the SSA-5526-U3, and use status and interim action code “P-19” in the Evidence Code Space.

F. Review of dvidence received after last ODO or DDS determination in dismissal action cCase

If there is a proper basis for reopening the prior determination, handle as you would a reopening that does not include a request for hearing.