TN 1 (07-99)
SI 04010.020 SSI Appeals Considerations
A. Policy - notice of initial determination
SSA will send notice of an initial determination to the claimant at his/her last known address and to each of the following: his/her representative payee, legal guardian, or appointed representative (if any).
Notice is generally not sent when:
termination is due to claimant's death; or
redetermination results in a determination that eligibility for and amount of benefits have not changed; or
eligibility is terminated after 12 continuous months of suspension (SI 02301.270).
1. Essential Elements of the Notice
All initial determination notices must contain the following information:
See NL 00801.000 ff. for notice preparation instructions for SSI notices.
2. Who May Appeal
A party to any initial determination who can show in writing that his/her benefit rights may be adversely affected by the initial determination may appeal it. An appointed representative, representative payee, or someone who would be considered a proper applicant per SI 00601.012 can make the request for appeal on behalf of the claimant. Also, when someone writes on behalf of the claimant requesting appeal but the request clearly originated with the claimant, we treat the request as a writing from the claimant.
3. Due Process Notice Prior to Suspension, Termination, Reduction of Benefits
On actions to suspend, reduce, or terminate benefits, the recipient has a right to advance notice before the determination takes effect. The advance notice provides 60 days for filing the reconsideration and explains that if it is requested within 10 days, SSI payments continue until there is a determination.
B. Policy - defective notice
1. General Policy
The regulations that require a notice for an initial determination contemplate a correct notice will be sent. SSA considers that an initial determination has been made even if we send an incorrect notice (e.g., an allowance instead of a denial).
When a determination or decision is made with respect to eligibility, amount or the actual payment of benefits, the individual to whom that determination or decision applies should be able to rely on its correctness. Once issued, the initial determination is binding unless appealed or revised.
If the claimant files a reconsideration request after the time limit for filing an appeal has expired, we would find good cause for extending the time limit due to misinformation resulting from the defective notice.
2. Mistake In Issuing Closeout Paragraph
If a title XVI claim is filed, and the CR inadvertently fails to explore potential entitlement to title II benefits, and the claimant receives closeout language on the award/denial notice, he/she has received an incorrect determination. The reopening provisions are applicable. In this situation, a mistake was made in issuing closeout language and the title II aspects remain open. See GN 00204.025B.2.c. for more information on the blanket closeout paragraph.
3. Appeal Paragraph Omitted
In those cases where the appeal paragraph has been omitted from an initial determination, although this is a defective notice, SSA has still made an initial determination. These determinations can be reopened if the rules of administrative finality permit.
If the claimant files a reconsideration request beyond the time limit for filing an appeal, we would find good cause for extending the time limit due to misinformation resulting from the defective notice.
If the file is not clear on whether an appeal paragraph was included, we will presume that it was added.
4. Appeal Requested More Than 60 Days After Receipt
If the claimant files an appeal request beyond the time limit for filing an appeal, we would find good cause for extending the time limit due to misinformation resulting from the defective notice.
5. Administrative Finality
Administrative finality applies to defective notices the same as to initial determinations with correct notices, i.e., use the date of the defective notice to count the time for reopening. See GN 01010.480 for procedures on reopening erroneous awards. Similar procedures should be followed for title XVI, i.e., if it is possible to reopen, document the rationale for terminating payments. Follow administrative finality and reopening procedures (e.g., due process, appeal rights, etc.) in SI 04070.000 ff.
C. Policy — cost of living adjustment (cola) notice
A COLA is an initial determination in that the claimant can question our calculation. Direct depositors receive a printed notice. For nondirect depositors who get a check stuffer, use the first check issued in the increased amount as the notice of the COLA for counting the period for appeal purposes.
NOTE: See GN 04030.060 for information on COLA's and administrative finality.
D. Policy - when determination or decision becomes final
1. General Policy
A determination or decision (initial or revised) is final as of the date of the notice unless:
it is timely appealed (or a civil suit is filed); or
it is appealed late but good cause for late filing of an appeal or civil suit is found; or
the AC takes jurisdiction on its own motion within 60 days of the date of the ALJ decision; or
the AC denies a request for review (does not issue a decision), in which case the ALJ decision is the final decision as of the date of the notice that the AC denied review; or
it is reopened and revised (see SI 04070.001 ff.).
2. Significance of Appeals Period
The 65-day period (60 days plus 5 days for receipt of the notice) following the date of the initial determination is significant for determining whether an appeal has been filed timely. The date that the appeal period ends has no significance in determining whether a determination or decision is final.
3. Change Occurs within Appeal Period
If a change occurs within the appeal period, it does not alter the fact that the initial determination is final and can only be revised if it is appealed or reopened (or the AC initiates own motion review). See GN 04001.040 for an example of a change during the appeal period.