TN 11 (05-98)

SI 00603.011 Procedure When a Nondisability Denial Is Reversed

A. Introduction

This section provides instructions on handling a claim that requires a disability determination in order to decide eligibility after a favorable reconsideration determination, hearing decision, or reopening/revision on a nonmedical issue.

B. Procedure

1. Notify Claimant

Notify the claimant orally or in writing that an additional review is necessary. (See NL 00705.145 for language for notice paragraphs.)

2. Deferred Development Claim

If the claim had been processed under deferred development, obtain an SSA-8000-BK (Application for SSI). Exception: If a claim in N18 denial status (Failure to Cooperate) is being reversed solely due to the submission of signed SSA-827’s, deferred development may be continued unless a nondisability issue not previously addressed could preclude eligibility. For a reopening that can be processed on MSSICS, choose DENIED CLAIM REOPENING from the SSI Menu (MSSI) and complete the full path. (See SI 00603.004C. for further instructions for processing the switch from deferred to simultaneous development.)

3. Develop Undecided Issues

Review all nondisability issues not addressed in the appellate determination/ decision or reopening and develop them appropriately. Resolve questionable issues that could preclude eligibility before sending the disability folder to the DDS.

4. Develop Disability

Obtain the disability forms or review and update any disability forms previously obtained and send the disability folder to the DDS with the SSA-831-C3/U3 (Disability Determination and Transmittal) or the Title XVI Disability Transmittal (if being processed on MSSICS) annotated “Manual Notice Necessary - Please Provide Appropriate Disability Paragraphs.”

5. Conduct PERC

If the disability is allowed and if required by SI 00603.031, conduct a preeffectuation review contact (PERC). (See SI 00603.030 for the definition of a PERC.)

6. Issue Notice

When the disability decision/determination is received from either the DDS or the administrative law judge (ALJ), suppress the systems-generated notice and issue a manual notice.

a. DDS Determination

If the disability is approved, use the SSA-L8455 (SSI Notice of Reconsideration) to explain the determination (see NL 00802.050C.3). Use appropriate award notice paragraphs from NL 00802.015 and disability paragraphs provided by the DDS.

If the disability is denied, use the SSA-L8456 (see NL 00802.050C.5.) and the disability paragraphs provided by the DDS.

b. ALJ Decision

Use an SSA-L8165-U2 (SSI Notice of Decision) with the appeals language for an award notice. (See NL 00804.224.)

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SI 00603.011 - Procedure When a Nondisability Denial Is Reversed - 11/29/2005
Batch run: 01/27/2009