BASIC (04-00)

VB 02501.025 Appeals — Notice of Initial Determination

A. Policy - Notice of Initial Determination

SSA will send notice of an initial determination to the claimant at his/her last know address and to each of the following: representative payee, legal guardian, or appointed representative (if any).

Notice is generally not sent when:

  • Termination is due to the claimant's death; or

  • Redetermination results in a determination that eligibility for and amount of the SVB have not changed.

1. Essential Elements of the Notice

All initial determination notices must contain the following information:

  • What the initial determination is; and

  • The reasons for the determination; and

  • The right to appeal; and

  • How to file an appeal.

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 (see VB 00201.015) can file an 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, a beneficiary 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 (or later if "good cause" is established), SVB payments continue until there is a determination.

B. Policy - Defective Notice

1. General

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. Omission of Title II and Title XVI Denial Paragraphs

An application for SVB also serves as an application for monthly benefits under title II and SSI payments under title XVI. Awards and disallowance notices for SVB must include closeout language on the award or disallowance notice. Failure to include such language may result in open applications under title II and title XVI.

3. Mistake in Issuing Closeout Paragraph

If a title VIII claim is filed, and the CR inadvertently fails to explore potential entitlement to title II benefits, and the claimant receives title II denial language on the SVB award/denial notice, he/she has received an incorrect determination with respect to title II. The reopening provisions are applicable. In this situation, a mistake was made in issuing title II denial language and the title II aspects remain open.

4. 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 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.

If the file is not clear on whether an appeal paragraph was included, we will presume that it was added.

5. 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.

6. Administrative Finality

Administrative finality applies to defective notices the same as to initial determinations with correct notices, i.e., use the date of the