TN 1 (10-08)

DI 81030.120 Reopenings – Certified Electronic Folders (CEF)

A. Background for prior CEF determinations

Prior to eView functionality updates, when a prior CEF determination required a reopening and revision, electronic processing was ceased and a paper modular disability folder (MDF) was created. With the implementation of additional eView functionality, reopening and revision of these prior CEF determinations, in most situations, are now processed electronically, using either the Reopen Prior Claim or Reactivation functionality available in eView.

B. Definition of reopening

Reopening is a formal review of a determination or decision which has become administratively final. Some situations in which a reopening may occur are when:

  • New and material evidence is furnished; or

  • The prior determination or decision clearly shows an error on the face of the evidence; or

  • A clerical error occurred in the computation or recomputation of benefits.

For additional information regarding reopenings, see DI 27500.000

C. eView functionality

  1. Reopen prior claim is an eView function that is used to “link” a current pending CEF with the prior closed CEF(s) that contains the determination(s) and documents needed for the reopening. A disability quality branch (DQB) user with the appropriate security profile and jurisdiction of the current pending CEF may use the reopen prior claim feature in eView, to reopen and revise a prior closed CEF determination. The reopen functionality in eView brings the filing date of the oldest determination to be reopened into the current pending CEF as the “revised effective filing date.” In addition, all documents from the selected prior closed CEF(s) are linked and displayed in the Case Documents page of the current pending CEF and are displayed as level “PF” to indicate prior folder.

  2. Reactivate is an eView function that changes a CEF claim from “closed,” “transferred,” or “manually cleared” status to “pending” status. A DQB user with the appropriate security profile may use the reactivate feature. Reactivate may be used for a number of reasons, including reopening and revising a prior CEF determination.

D. Electronic processing overview

  1. Reopenings are processed electronically if the user’s case processing system has the appropriate electronic processing functionality. The following requirements must be met in order to electronically reopen a claim:

    • The user must have jurisdiction of a current pending CEF claim;

    • Current claim is a non-continuing disability review (CDR) pending CEF claim;

    • Prior determination to be reopened is a non-CDR closed CEF of the same claim type; and

    • All intervening determinations for the same claim type are non-CDR closed CEFs and are reopened as well.

    NOTE: If a reopening requirement (annotated in this section) is not met, electronic processing must cease and a paper modular disability folder (MDF) must be created.

  2. Reactivations are performed if the user’s case processing system has the appropriate electronic processing functionality. To reactivate a claim, a claim must be:

    • A CEF;

    • In the most recent electronic folder;

    • At the highest adjudicative level in that folder; and

    • In “closed,” “transferred,” or “manually cleared” status.

    NOTE: If a reactivation requirement (annotated in this section) is not met, electronic processing cannot be used and a paper MDF must be created.

The DQB case processing system has the appropriate electronic processing functionality needed for electronic reopenings and reactivations.

E. Reviewing prior folder(s) in eView

In order to review prior electronic folders to determine if a reopening is applicable:

  • Leave the current pending CEF and access other related folders; and

  • View each CEF, including case data information, case related forms, and documents, one folder at a time; or

  • Remain in the current pending CEF and use the “Locate Documents” feature to select the folder document(s) you wish to view. For instructions on how to use the “Locate Documents” feature, see DI 81005.052.

F. Some situations involving reopenings

DQB reopening situations may arise:

  • At the time of DQB review; or

  • After a Request for Program Consultation (RPC) resolution does not affirm a DQB-established onset date, ending date, or basis code change.

Examples of reopening issues:

  1. Disability determination services (DDS) determinations may be inadvertently effectuated prior to DQB review, and depending on DQB review findings, reopening and revision of the DDS determination may be needed to a more favorable determination.

  2. If DDS fails to reopen a prior determination when applicable, reopening and revision of the prior determination is needed.

  3. If DDS erroneously reopens a prior determination, cancellation of the reopening is needed.

  4. DDS may submit an RPC after the DQB changes an onset date, ending date or basis code, and the case is closed. In this scenario, depending on the RPC resolution, reopening and revision of the determination may be needed.

G. Reopening policy

  1. DQB users with the appropriate security profile are able to electronically reopen and revise a prior CEF determination, or cancel a reopening.

  2. DQB does not electronically reopen and revise prior CEF determinations or cancel a reopening in the following situations, but returns the cases to DDS for appropriate action.

    • A group I deficiency; or

    • A group II deficiency with another necessary DDS corrective action; or

    • Intervening paper folders are involved

    NOTE: If there is an intervening CEF and its decision was made at the field office (FO), eView will not display the intervening CEF or any CEF determinations prior to the intervening CEF. Therefore, DQB can not electronically reopen and revise. Return the case to the DDS for appropriate action.

  3. DQB can not electronically reopen and revise a prior paper determination. Return the case to the DDS for appropriate action.

  4. DQB will not reopen and revise an inadvertently effectuated CEF determination that has a group I deficiency. Return the case to the DDS for appropriate action. For reviewing cases that are inadvertently effectuated, see GN 04440.250.

Examples of inadvertently effectuated determinations:

  • The FO inadvertently effectuates a DDS denial determination; however, DQB reviews the sample case post-effectuation and decides there is a group I decisional deficiency because the case should be allowed. DQB prepares an SSA-1774-U5 (Request for Corrective Action) and returns the case to the DDS to reopen the prior determination and revise it to an allowance.

  • The FO inadvertently effectuates a DDS allowance determination; however, DQB reviews the sample claim post-effectuation and decides that the determination should be a denial. DQB prepares an SSA-1774-U5 and returns the case to DDS for appropriate action, including application of the medical improvement review standard.

NOTE: Return the case to the DDS regardless if the DDS case processing system has the electronic processing functionality to keep the folder electronic. DDS is responsible for converting a current pending CEF to paper, if applicable.

H. Procedure for reopening issues

1. DDS failed to reopen prior CEF determination

Reopen and revise a prior CEF determination electronically, if the DDS failed to reopen and revise a determination that should be reopened and revised (e.g., DDS failed to reopen a determination to set the onset date in a prior adjudicated period). However, if any of the situations in DI 81030.120G.2. are met, return the case to DDS for all appropriate actions, including reopening and revision.

2. DDS erroneously reopened prior CEF determination

Cancel the erroneous CEF reopening electronically. However, if any of the situations in DI 81030.120G.2. are met, return the case to DDS for all appropriate actions, including cancellation of the reopening.

3. DDS selected the incorrect prior CEF determination to reopen

Cancel the erroneous CEF reopening and reopen and revise the correct prior CEF determination electronically. However, if any of the situations in DI 81030.120G.2. are met, return the case to DDS for all appropriate actions, including cancellation and reopening and revision.

4. DDS reopened the correct prior CEF determination but there are intervening paper folders that should also be reopened

Return the case to DDS for all appropriate actions because electronic processing does not apply. DDS is responsible for converting the current pending CEF to paper.

5. Split routing

If DQB finds that not all sampled claims need to be returned to the DDS for reopening and revision, use split routing to route the deficient claim to the DDS and the non-deficient claim(s) to the FO, provided the rules for split routing are met. Split routing is applied even if the necessary actions to the deficient claim require that the case is removed from electronic processing and converted to paper. For instructions for split routing, see Disability Case Adjudication and Review System (DICARS) 5.7 Release Notes and the DQB Examiner Guide.

NOTE: If the DDS reopening action results in the case being converted to paper, include the following instruction in the SSA-1774-U5:

When a paper MDF is created as a result of a reopening, the SSA-831 (Disability Determination and Transmittal) for all claims must be placed in the folder.

Avoid stating that the non-deficient claim must be converted to paper, because this terminology may cause confusion in the DDS. The conversion process for DDS includes sending a No Determination (ND) transaction for each claim, and we do not want the DDS to think that they must also prepare a ND for a claim not pending in DDS.

6. Request for Program Consultation (RPC)

Reactivate the prior closed CEF electronically and then reopen and revise the determination to correct the onset date, ending date, or basis code in the following instances:

  • The RPC resolution upholds DDS’s onset date, ending date or basis code; or

  • The RPC resolution determines that the correct onset date, ending date or basis code is different from the one determined by either the DDS or DQB.

NOTE: If the onset date or ending date is adverse, reactivate the case, and return it to DDS for all appropriate actions.

7. Reopen prior claim and reactivate instructions

Once it is determined that a reopening or cancellation of a reopening is needed, DQB users with the appropriate security profile should follow the instructions outlined in DI 81020.115, EM-08053 SEN dated 04/25/2008, and the DICARS DQB Admin Guide 5.7. If a reactivation is needed, DQB users with the appropriate security profile should follow the instructions outlined in DI 81020.117 and the DICARS DQB Admin Guide 5.5.

I. Reopen and revise a determination

To reopen and revise a determination:

  • Make applicable changes, (i.e., correcting an onset date, ending date, or basis code if necessary).

  • Manually add this remark in item 34 of the SSA-831 eForm: This revises the previous determination of (date). For correcting determination forms – certified electronic folders (CEF), see GN 04440.237.

  • Prepare any necessary rationales and/or notices, and move any incorrect notices to Section C – Current Development/Temporary (Green) under the Case Documents tab in eView. For moving incorrect disability determination services (DDS) notices – certified electronic folders (CEF), see GN 04440.236.

  • Verify that the correct filing date is displayed in the DQB column entry for “Application Date” in DICARS. If it is not correctly disp