Identification Number:
EM-24007
Intended Audience:All DDSs, ESTs, DPBs, DPUs, ROs, CO, FOs
Originating Office:ORDP ODP
Title:Instructions for Adverse Medical Reopenings and Reconsiderations of Adverse Medical Reopenings at Initial and Reconsideration Levels
Type:EM - Emergency Messages
Program:Title II (RSI); Title XVI (SSI); Disability
Link To Reference:See References at the end of this EM
 
Retention Date: 09/13/2024

A. Purpose

This emergency message (EM) provides instructions and clarification to the disability determination service (DDS), field office (FO), and disability hearing unit (DHU) on the procedure to process adverse medical reopenings (AMRs) and reconsiderations of adverse medical reopenings (RAMRs). Additionally, this EM provides detailed instructions on the documentation, coding, and recognition of an AMR, as well new system enhancements for processing reconsiderations of these claims. The instructions in this EM provide guidance on AMRs and RAMRs that result in a denial, cessation, or closed period of disability but do not apply to AMRs or RAMRs due to a change of onset only.


B. Background

While most reconsideration cases that are eligible for a disability hearing are appeals of continuing disability review (CDR) cessations, appeals of AMRs of initial and reconsideration level claims are also eligible for a disability hearing. An individual has the right to request a disability hearing if they have been receiving disability benefits and we make an initial or revised determination based on medical factors that they are not disabled because the impairment(s) has ceased, did not exist, or is no longer disabling. 20 CFR § 404.914, 416.1414. The first level of an appeal for a disability cessation is called a reconsideration. The reconsideration level of a disability cessation involves two steps: a pre-hearing (PH) level review by the DDS and a disability hearing review by a disability hearing officer (DHO).

C. What is an AMR?

An AMR occurs when we reopen an initial or reconsideration-level allowance determination and, based on medical factors, revise it to a denial, later onset, or closed period determination. An AMR results in a loss of benefits to the individual. An AMR does not include (1) adverse reopenings based on non-medical factors, such as substantial gainful activity (SGA) or FO determinations, or (2) medical reopenings that are not adverse, such as a reopening of a denial determination based on additional evidence that remains a denial.

NOTE: The policy discussed in this EM excludes adverse revisions following a quality review in cases in which the individual was never receiving benefits.

D. What is an RAMR?

A RAMR occurs when an individual requests a reconsideration of an AMR. An individual has the right to request a reconsideration and receive a disability hearing, if they have been receiving disability benefits and we make an initial or revised determination based on medical factors that they are not disabled because the impairment has ceased, did not exist, or is no longer disabling. In simple terms, when an individual has been receiving disability benefits and we determine they are not disabled during a CDR or an AMR, the individual may make a timely request for reconsideration of the determination. The reconsideration of a disability cessation involves two steps: a PH level review by the DDS and a disability hearing review by a DHO.

A disability hearing is not afforded to an individual who requests a RAMR due to a change of onset. If an individual requests a RAMR due to change of onset (in other words, change of onset date to a more unfavorable date), the individual should complete the SSA-561 (Request for Reconsideration), and the claim should follow the regular reconsideration process covered in DI 12005.000 Reconsiderations – Initial Claims and DI 27001.000 Reconsideration Case Processing.

E. AMR of Initial-Level Claims: DDS Instructions for Adding a List Code to Item 26 and a Remark to Item 34 of the SSA-831

When the DDS processes an AMR of an initial-level claim, the DDS must document the SSA-831 with a list code and a remark to indicate that the case is an AMR.

Follow the instructions in DI 27530.000 to complete the SSA-831. When the DDS completes the SSA-831 for an AMR, add list code 300 to item 26, and include the following remark in item 34:

“Adverse Medical Reopening. Revises previous determination dated _____”

The list code and the remark will help identify these cases in a subsequent request for reconsideration and help ensure proper processing by the FO, DDS, and DHU.


F. FO Instructions for When an Individual Requests a RAMR of an Initial-Level Claim

When the individual wants to request a RAMR, they are entitled to a disability hearing conducted by a DHO. The following instructions are for RAMRs of initial-level claims. The FO must follow the instructions in DI 12026.015 and review the folder and notice to establish the type of determination the individual is appealing.


    1. Identifying an AMR

      As a threshold matter, the FO must first determine whether the case involves an AMR. The FO will specifically look for the following on the notice and in the case folder of an individual who disagrees with an AMR:

        · The determination notice sent to the individual will contain instructions to complete a Form SSA-789 under the “If You Disagree with the Decision” heading and language for a disability hearing in the “How an Appeals Works” heading;

        · The list code 300 in Item 26 of the 831; and

        · The remark, “Adverse Medical Reopening: Revises prior determination dated _____”, will be in Item 34 of the SSA-831.

    2. FO Responsibilities when an Individual Requests a RAMR

      The FO will follow the instructions in DI 12026.020 to explain the disability hearing process to the beneficiary or recipient, and their rights and responsibilities.

    3. Forms to Collect for a RAMR

      When a claimant files a reconsideration of an AMR (i.e., RAMR), the FO will collect the SSA-789 Request for Reconsideration – Disability Cessation – Right to Appear, and the other required appeal forms listed in DI 12026.020A.4., to include:

        · SSA-789 Request for Reconsideration – Disability Cessation Right to Appear (NOTE: Do not use an SSA-561-U2 (Request for Reconsideration) form because the SSA-789 contains information and questions not covered by the SSA-561-U2.)
        · SSA-795 Statement of Claimant or Other Person for request for statutory benefit continuation
        · SSA-795 Statement of Claimant or Other Person of good cause for late filing
        · SSA-827 Authorization to Disclose Information to the Social Security Administration (SSA)
        · SSA-3441-BK Disability Report – Appeal
        · SSA-3881-BK Questionnaire for Children Claiming SSI Benefits (if applicable)

The iAppeal process only allows completion of the SSA-561, not the SSA-789. If the claimant requests an RAMR through iAppeal, the FO should follow instructions in DI 12026.020A.4.a. and DI 12026.020B and the guidance in this EM to ensure the claimant completes the correct reconsideration forms before transferring the claim to the DDS. This does not include adverse reopenings based on non-medical factors, such as SGA or FO determinations.

G. FO Processing Instructions for RAMR of an Initial-Level Claim

After completing the steps above, the FO will process the appeal through the Modernized Claims System (MCS)/Modernized Supplemental Security Income Claims System (MSSICS) and the Electronic Disability Collect System (EDCS). The FO will add the EDCS flag 24 “Special Case Handling” and add a message in the Certified Electronic Folder (CEF) stating, “Reconsideration of Adverse Medical Reopening” and transfer the case to the DDS.

The DDS will convert these cases to paper upon receipt. After the DDS reaches a determination, the DDS will return the case to the FO as a paper case for processing.

H. DDS Instructions for Processing RAMR of an Initial-Level Claim

While adverse reopenings are not CDRs, as of 01/20/2024, Disability Case Processing System (DCPS) processes these cases as reconsiderations of CDRs so that the CDR reconsideration pathway of a PH review followed by a DHO review is followed when applicable. Despite being recognized as CDR reconsiderations in DCPS, the DDS will evaluate these cases by following the initial sequential evaluation process as described in DI 22001.001D. They will then follow the CDR reconsideration pathway of a PH review followed by a DHO review when applicable.

At the DDS, the Case Control Clerk (CCC) will identify the case as a RAMR by reviewing the EDCS flag 24 “Special Case Handling” and message in the CEF of “Reconsideration of Adverse Medical Reopening.”

Once identified as a RAMR, the CCC will:


    · “no determine” (ND) the case to stop electronic processing;

    · create a paper CDR PH case; and

    · flag the case within DCPS as an “RC of Adverse Medical Reopening”.


This will allow the case to be worked following the CDR reconsideration pathway (meaning following the PH to DHO process) while allowing initial sequential evaluation and generating an SSA-831 as well as appropriate DH level 1207-OPI Disability Hearing Officer’s Decision/SSA-1209 Disability Hearing Officer’s Decision, Title XVI Disabled Child (DC) Continuing Disability forms, and DH level notices at closure.

The PH reviewer will continue to follow case processing instructions in DI 29000.000 and refer to the DCPS user guides for additional processing instructions.

The DDS will forward to the DHO for a disability hearing all PH determinations that are less than fully favorable (which includes any determination which is not a fully favorable reversal of the determination under appeal). For fully favorable PH determinations, the DDS will mail the paper CDR PH folder, including the SSA-831, to the FO. The FO will receive the paper folder with the SSA-831 and process the determination.

I. DHO Instructions for Processing RAMR of an Initial-Level Claim

While these cases are not CDRs, as of 01/20/2024, DCPS functionality will recognize these cases as reconsiderations of CDRs for DCPS processing purposes. Despite being recognized as reconsideration CDRs, the DHO will evaluate these cases by following the initial sequential evaluation as described in DI 22001.001D. DCPS recognition of these cases as CDRs will allow the cases to follow the CDR reconsideration pathway of a PH review followed by a DHO review when applicable.

The DHO will continue to follow DI 33000.000 and the DCPS user guide, as well as the following additional instructions:


    · Complete the SSA-1209-BK in child cases or the SSA-1207-BK-OP1 in adult cases with special instructions as noted in the DCPS user guide and

    · Include the following remarks on the SSA-831, Item 34: “Disability Hearing for a Recon of an Adverse Medical Reopening”.


The DHO will mail the paper CDR DH folder, including the SSA-831, to the FO. The FO will receive the paper folder with the SSA-831 and process the determination.

J. Review of Trailer Material: DDS Proposes to Adversely Reopen a Reconsideration-Level Determination

If the DDS receives evidence after a reconsideration determination is final, such as in the form of trailer material, the adjudicator who made the final determination will review the evidence. The adjudicator must review all electronic material and paper trailer material to determine if the case should be reopened. If reopening the reconsideration determination is appropriate, the beneficiary or recipient is afforded an opportunity to have a disability hearing before the adverse medical determination is issued. The DDS will follow the instructions in section K of this EM.

K. DDS Instructions for Processing an AMR of a Reconsideration-Level Claim

The AMR of a claim that was previously allowed at the reconsideration-level takes a different route than an AMR of an initial-level claim. If the DDS determines that the claim should be reopened, the DDS examiner will reopen the prior reconsideration determination. The beneficiary or recipient is afforded an opportunity to have a disability hearing before a DHO prior to issuing the determination. A reopening of a reconsideration-level claim has previously been evaluated at a reconsideration level, which satisfies the first PH level step in this process. This reopened claim will go directly to the DH level, and not the PH level.

After the case is reopened, the Case Control Clerk (CCC) will:

    · ND the case to Stop Electronic Processing; and
    · Create a PAPER CDR DH case.

The DDS will:
    · assign the Paper CDR DH case; and
    · flag it within DCPS as an “RC of Adverse Medical Reopening”.
    This will allow the case to follow the CDR RC process, while following initial sequential evaluation and generating an SSA-831, as well as appropriate DH level 1207-OP1/1209 forms and DH level notices at closure.

    L. DHU Instructions for Processing an AMR of a Reconsideration-Level Claim

    The DHO will send a predetermination notice, with an SSA-765 (Response to Notice of Revised Determination) to the beneficiary or recipient (as covered in DI 33020.025B.3.a.), notifying them of the adverse determination and offering the option of a disability hearing and an opportunity to submit additional evidence. If they want a disability hearing or to submit additional evidence, the beneficiary or recipient should complete and return the SSA-765 within 10 days. If the SSA-765 is not timely returned, the DHU will make a determination based on the evidence already on file. The DHO is responsible for issuing the determination regardless of whether the claimant responds to the predetermination notice.

    The DHO will continue to follow DI 33000.000 and the DCPS user guide, as well as the following additional instructions:


      · The DHO will complete the SSA-1209-BK in child cases and the SSA-1207-BK-OP1 in adult cases with special instructions as noted in the DCPS user guide.

      · For AMR of a reconsideration, on the SSA-831:

          o On item 34 include the following remark: “Adverse Medical Reopening: Revises prior determination dated _____” and

          o Add list code 300 in Item 26 of the 831.

      · Release the determination notice for the reopened claim.

    The DHU will mail the paper CDR DH folder, including SSA-831, to the FO. The FO will receive the paper folder with the SSA-831 and process the determination.

    M. FO and DDS Instructions for RAMR: Special Situations

      1. Incorrect Appeal Form Completed: If upon receipt at the DDS, the DDS finds that the claimant filed an SSA-561 instead of an SSA-789, the DDS will send an assistance request (AR) to the FO asking the FO to follow instructions within the Note of DI 12026.020A.4.a. and DI 12026.020B to obtain the correct reconsideration forms.
      2. RAMR with Closed Period Determinations: The National Disability Determination Services System (NDDSS) will not accept an NXP closed period diary on continuance determinations. To work around this issue, the DDS/DHO and FO are to do the following:

    The DHO will:
        · Keep the closed period diary on the 831
            o DCPS will recognize these cases as needing a 7-year diary and the system will send the 7-year diary to NDDSS
        · Include the following remark on the SSA-831: “Revised systems input required – FO must request PC update diary to closed period.”
        · Since these will be paper cases, include the following note to the route slip: “Recon of Adverse Medical Reopening Closed Period. Revised systems input required – FO must request PC update diary to closed period.”

    The FO will:
        · Contact the processing center (PC) to have them update the diary to reflect the closed period.

    Resources:
    Direct all program-related and technical questions to your Regional Office (RO) support staff. RO support staff may refer questions, concerns, or problems to ^ODP Controls.

    References:

    DI 12005.000 Reconsiderations – Initial Claims
    DI 12026.001 Reconsideration of a Continuing Disability Review (CDR) Based on Medical Cessation or Adverse Medical Reopening
    DI 12026.015 Field Office (FO) Actions when an Individual Disagrees with the Medical Cessation or Adverse Medical Reopening Determination
    DI 12026.020 Field Office (FO) Responsibilities When an Individual Wants to Request Reconsideration of a Medical Continuing Disability Review (CDR) Determination
    DI 12026.021 Completion of the SSA-789 Request for Reconsideration - Disability Cessation Right to Appear
    DI 12026.030 Field Office (FO) Actions after the Reconsideration Continuing Disability Review (CDR) Determination
    DI 26510.060 Completing Item 25 (Revised Determination) on the SSA-831
    DI 26510.065 Completing Item 25A (Adjudicative Level) on the SSA-831
    DI 27001.000 Reconsideration Case Processing
    DI 27001.001 The Reconsideration Process
    DI 27015.001 Completing Form SSA-831-U3 for Reconsideration Cases
    DI 27501.001 Reopenings and Revisions: Pertinent Definitions and Related Policy
    DI 27530.000 Reopenings – Completion of Form SSA-831-U5
    DI 27530.015 Completing Form SSA-831 in Title II Reopening Cases
    DI 27530.025 Completing Form SSA-831 in Title XVI Reopening Cases
    DI 27540.040 Reopening and Revision at the Reconsideration Level
    DI 29000.000 Reconsideration of Continuing Disability Review (CDR) Cases, and Reopenings Applicable to Disability Hearings (Pre-DHU Processing)
    DI 29001.005 The Scope of the Disability Hearing
    DI 29005.005 Disability Determination Services (DDS) Pre-hearing (PH) Action upon Receipt of Request for Reconsideration
    DI 29025.000 Preparation of Continuing Review Cases and Reopenings Applicable to Disability Hearings (Pre-DHU Processing)
    DI 33000.000 Disability Hearing Unit Procedures
    DI 33001.001 The Disability Hearing Process – Title II and Title XVI
    DI 33020.005 Routing Cases After the Disability Hearing
    DI 33020.025 Reopenings by the Disability Hearing Officer (DHO)
    DI 33530.005 Disability-Related List Codes
    EM-24007 - Instructions for Adverse Medical Reopenings and Reconsiderations of Adverse Medical Reopenings at Initial and Reconsideration Levels - 03/13/2024