TN 11 (05-98)

SI 00603.015 Processing Nondisability Aspects of a Disability Appeal

A. Procedure - reconsideration

When a claimant files a reconsideration request on a disability denial, follow the instructions below regarding the nondisability aspects of the claim.

1. Consider simultaneous development

If the claim is deferred development, consider whether the claimant's medical condition has changed so that the claim now meets the criteria for simultaneous development per SI 00603.002C. If so, see SI 00603.004C. for documentation and systems input instructions.

2. Check address

Check that our record has the claimant's current mailing and residence addresses and telephone number. Change the record if any of these has changed.

3. Develop and input changes

If the claimant reports any changes that do not make eligibility questionable:

  • in a deferred development claim, do not develop the alleged changes but input them on the system if possible;

  • in a simultaneous development claim, develop alleged changes and input them on the system.

4. Eligibility questionable

If, on either a simultaneous or deferred development claim, there remains a nondisability eligibility issue which could affect eligibility in all months in the life of the application, resolve the issue, if possible, before sending the disability folder to the DDS per SI 00603.010.

a. Claimant Is Eligible

If you determine that the claimant is eligible for any month in the life of the application, make any appropriate systems changes.

b. Claimant Is Ineligible

If you determine the claimant is ineligible for all months in the life of the application:

  • deny the reconsideration on the basis of that factor,

  • immediately notify DDS of the denial if the disability folder has already been sent—even in concurrent claims,

  • make systems input to effectuate the denial, and

  • issue a manual reconsideration notice, SSA-L8456. (See NL 00802.050C.5. and the paragraphs for a denial notice in NL 00802.025.)

5. Simultaneous development incomplete

If the claim was simultaneous development and development was incomplete (i.e., the claim was in payment status H80 or should have been when the disability was denied), continue to develop the nondisability issues.

If there is a possibility a reconsideration determination could be rendered before the 90-day time limit in SI 00603.031, include in remarks of the SSA-408 (Route Slip), “Nondisability Development Incomplete - Do Not Input a Reconsideration Reversal.”

NOTE: The DDS routinely inputs reconsideration reversals and could send an incomplete claim to pay if the disability determination is recorded on the system within the time limit. The fact that the claim had been in payment status H80 prior to the initial denial will not prevent payment because the medical denial code overlaid the H80 payment status.

B. Procedure - hearing

When a claimant files a hearing request on the issue of disability, follow the instructions below regarding the nondisability factors.

1. Consider simultaneous development

If the claim is deferred development, consider whether the claimant's medical condition has changed so that the claim now meets criteria for simultaneous development per SI 00603.002C. If so, see SI 00603.004C. for documentation and systems input instructions.

2. Check address

Check that our record has the claimant's current mailing and residence addresses and telephone number. Change the record if any of these has changed.

3. Changes reported - eligibility not effected

Follow the procedures below if the claimant reports any changes that do not affect eligibility for all months.

a. Deferred Development Claim

Do not develop the alleged changes but record them on the system if possible.

b. Simultaneous Development Claim

Develop alleged changes and record them on the system.

4. Eligibility questionable

If eligibility is questionable for all months in the life of the application, pursue development to resolve the issues. However, do not delay sending the file to the hearing office (HO).

a. Claimant Is Eligible

If you determine that the claimant is eligible for any month in the life of the application, make any appropriate systems changes.