BASIC (12-93)

SI 04030.070 Redetermination After SSI Reversal

A. Policy

In the event that an ALJ, the AC, or a court reverses an unfavorable determination/decision, in most cases, an unscheduled redetermination is necessary to assure that all the relevant elements of eligibility have been completely developed and established. These unscheduled redeterminations must receive priority over any scheduled redeterminations pending in the FO.

NOTE: This is particularly important because of the time which may have elapsed during the pendency of the appeal and the fact that appellant decisions do not necessarily cover all elements of eligibility.

For disability initial claims, see SI 00603.001 ff.

B. Procedure

1. Obtaining Data from the SSR

Obtain an SSI3 query or an online SSID query and conduct the redetermination based upon the data in the query.

NOTE: The timing (pre-or posteffectuation) of these unscheduled redeterminations is dependent upon the scope of the appellate decisions; i.e., whether all elements of eligibility were specifically addressed in the decision.

2. Redetermination Before Effectuation

Conduct an unscheduled redetermination prior to effectuating an appellate reversal of an unfavorable determination/decision, particularly when the appellate decision does not specifically address all elements of eligibility (e.g., appellate decision restricted to disability element, without addressing the nonmedical elements of eligibility) for the period covered by the decision.

NOTE: This is not to change or alter the appellate decision but, rather, to insure that the file is complete and current with respect to all elements of eligibility not specifically addressed in the appellate decision and to assure correct payment action.

3. Redetermination Before Effectuation Is Not Required

If there has been at least one RZ between the date the appeal was filed and the date of the ALJ decision, an unscheduled RZ is not required prior to the effectuation of the ALJ decision.

4. What to Cover

In addition to the current and the prospective period, review the entire period covered by the initial determination which originally gave rise to the appeal.

5. When to Conduct a Redetermination—60 Day Rule

  1. Conduct an unscheduled redetermination on a priority basis so as not to delay the necessary effectuation action unduly.

  2. Complete the redetermination and effectuation within 20 days after receipt of the appellate reversal by the effectuating FO.

    NOTE: Where unusual circumstances prevent effectuation within 20 days, the effectuating action must be completed as soon as possible but no later than 60 days from the date of the appellate decision.

  3. If the preeffectuation redetermination is not completed within 60 days of the date of the appellate decision, effectuate the decision based on the information available, except in cases in which one or more of the circumstances described in SI 04030.070B.6. apply. Complete a posteffectuation redetermination on these cases as soon as possible after effectuation.

Assure, through the necessary control and followup, that the above schedule is followed.

6. Exceptions to 60-Day Rule— Payments Are Not Certified

Do not certify payments if:

  1. Effectuation is impossible without further clarification of the appellate decision; or

  2. The review has produced discrepant information or uncovered a change in circumstances that potentially precludes payment; or

  3. One or more factors of eligibility has never been developed in accordance with normal development and documentation requirements and this development is incomplete at the end of the 60-day period; or

  4. Representative payee development is incomplete (see GN 00502.000 ff. for determining when a payee is needed and GN 00504.000 ff. for direct or interim payment while a payee is being developed); or

  5. Delay or refusal by appellant and/or his/her representative to supply necessary evidence or information; or

  6. Delay or refusal by a third party to supply necessary evidence or information.

REMINDER: Initiate payments as soon as the factor(s) precluding effectuation is (are) resolved, clearly establishing claimant's eligibility.