Identification Number:
GN 03104 TN 6
Intended Audience:See Transmittal Sheet
Originating Office:ORDP OISP
Title:Appeals Council Review (Title II and Entitlement Under Title XVIII)
Type:POMS Transmittals
Program:Title II (RSI),Medicare
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM
Part GN – General
Chapter 031 – Appeals
Subchapter 04 – Appeals Council Review (Title II and Entitlement Under Title XVIII)
Transmittal No. 6, 01/03/2019

Audience

PSC: CA, CS, DE, DS, ICDS, IES, ISRA, RECONR, SCPS, TSA, TST;
OCO-OEIO: CR, FCR, FDE, RECONE, RECONR, RECOVR;
OCO-ODO: CR, CST, CTE, CTE TE, DE, DEC, DS, FCR, FDE, PETE, PETL, RCOVTA, RECONE, RECOVR;
ODD-DDS: REF;
FO/TSC: CS, CS TII, CS TXVI, CSR, CTE, DT, FR, OA, OS, RR, TA, TSC-CSR;

Originating Component

OISP

Effective Date

Upon Receipt

Background

This is a Quick Action Transmittal. These revisions do not change or introduce new policy or procedure.

Summary of Changes

GN 03104.400 Processing Appeals Council (AC) Decisions — Title II or Title XVI

Subsection B.4.- Added reference DI 402010.065

GN 03104.400 Processing Appeals Council (AC) Decisions — Title II or Title XVI

A. Policy

For Title II awards, the Claims Authorizer (CA) uses the Modernized Claim System (MCS) when available to process the claim. If MCS is not available, the CA prepares an EF-101. The Benefit Authorizer (BA) uses MADCAP to complete the award notice.For Title XVI awards, the system generates a notice for disability awards. For non-disability awards, the field office (FO) sends a manual notice.

For unfavorable Title II and XVI AC decisions, no notice is sent by the field office or processing center.

B. Procedure

1. AC revises/reverses decision

For title II notice language; refer to NL 00720.015 for MADCAP and NL 00725.000 for MCS paragraphs to include in the award notice. For title XVI award notice preparation, refer to NL 00802.000. Send copies of the award notice to the claimant (and his/her representative if any). In SSI cases, see SI 04030.070 for instructions regarding redeterminations after reversals.

2. AC decision involves SEI or wages

If the AC's decision affects reporting or deleting of self-employment income or wages, make changes using the Earnings Modernization Item Correction screens.

3. Non-claims situations

Notify the individual of the action taken on his/her earnings record using the appropriate MADCAP (NL 00720.015) or MCS (NL 00725.000) paragraphs.

4. Questionable AC decision

The AC decision must be effectuated as received unless it appears to contain a non-judgmental error. In such cases, immediately send a memorandum to Office of Analytics, Review, and Oversight, Office of Appellate Operations (OAO) with detailed rationale for requesting reopening under the rules of administrative finality. For guidelines, see GN 03103.260 for Title II, DI 42010.065 for Title II disability, and SI 04030.060 for Title XVI.

5. AC decisions affected by legislation or change of position

Refer to GN 04001.100 for a more detailed discussion.

6. Retention of claims file in OAO after unfavorable AC action

If the AC denies the request for review or issues an unfavorable decision, it will forward the claims file to the Social Security National Records Center (SSANRC). If the claims file is needed, contact the SSANRC.


GN 03104 TN 6 - Appeals Council Review (Title II and Entitlement Under Title XVIII) - 1/03/2019