TN 6 (12-93)

NL 00601.020 Disallowance Notices

A. Policy

Send a disallowance notice to the claimant whenever an initial determination is made to disallow a claim for:

  • nondisability monthly benefits;

  • death underpayment (see GN 02301.010);

  • the lump sum death payment; or

  • health insurance.

B. Description of content

The required content of disallowance notices is shown preferably in the following order:

  1. The date of the notice, and the name and address of the claimant;

  2. The claim number (i.e., the NH's SSN plus the claims symbol); display at the top right of the notice;

  3. The specific reason for disallowance. Specify the type of benefit disallowed and the name of the NH (if auxiliary or survivor claim) at the beginning of the explanation. (See GN 01010.440 for disallowances due to lack of insured status.);

  4. An explanation of what requirements were not met to allow the claimant to decide if he/she agrees with the decision;

  5. A general closeout or a modified closeout if another benefit determination is pending.

    NOTE: See GN 01010.245 for instructions on dual-entitlement claims when we disallow the RIB or B claim.

  6. An appropriate reconsideration or appeal paragraph;

  7. A paragraph explaining that filing a new application is not the same as filing an appeal and that if the claimant thinks we are wrong, he/she should appeal within 60 days.

  8. A paragraph advising people of their right to representation if they wish to appeal. This is sometimes called the “attorney options” paragraph. Do not include this paragraph if the claimant is already represented or has a foreign address.

  9. A referral paragraph (see NL 00601.010B.8.e.),

C. Kinds of disallowance notices

There are several types and sources of disallowance notices. The FO is responsible for requesting the notice with appropriate paragraphs.

1. MADCAP

  • There are no MADCAP computer-generated disallowance notices. However, see SM 00380.001 for establishing MBR disallowance records through MADCAP.

  • The claims representative will indicate the disallowance form or exhibit letter on the SSA-3428-U2. (See NL 00703.900 through NL 00703.917 for disallowance exhibit letters which should be requested in place of the form letters in NL 00701.036, wherever possible.)

2. Dictated letters

Dictated letters are used when there is no standard notice to explain a disallowance. However, the disallowance must still be processed through MADCAP with requested language shown on an SSA-573. See NL 00703.900 through NL 00703.917 for exhibit letters.

D. Policy - disallowance folder documentation

SSA must have a record of the date we send a notice to determine the time period for filing an appeal and the content to document our determination. Folder documentation is not necessary for notices that are available on the Online Retrieval System (ORS).

E. Procedure - special disallowance situations

1. Disability denial involved

Use SSA-L236A CDB Notice of Disapproved Claim (NL 00701.063) for a spouse's, mother's, or father's claim when a CDB claim is denied and the youngest child in care is age 16 or older.

2. Disallowance - failure to submit essential evidence

  1. Make it clear that the disallowance is the result of the claimant's failure to furnish the evidence requested by the FO;

  2. Tell the claimant that giving us the evidence may result in action favorable to the claimant;

  3. Advise the claimant that the FO will give any necessary assistance in obtaining such evidence. Encourage the claimant to ask for assistance or submit any additional evidence if a request for reconsideration is filed.

3. Disallowance of request for underpayment

Send the notice of disallowance to the person who makes the request for the underpayment, e.g., files the SSA-1724, Claim for Amounts Due, in the case of a deceased beneficiary.

4. Date of birth different from that alleged

If a claima