PROGRAM OPERATIONS MANUAL SYSTEMPart DI – Disability InsuranceChapter 275 – Reopenings, Res Judicata, and Collateral EstoppelSubchapter 16 – Refilings for the Same Period (Res Judicata Cases)Transmittal No. 18, 04/25/2024
Audience
Originating Component
ODP
Effective Date
Upon Receipt
Background
We updated our instructions for field office Res Judicata development and processing. We added instructions for handling reconsideration for these cases.
Summary of Changes
DI 27516.001 Field Office Res Judicata Development and Processing
We revised titles to be more descriptive.
Subsection D – We added information for processing a reconsideration on an initial res judicata denial.
Subsection E – We clarified the instructions regarding an allegation of misinformation.
Subsection F – We added a statement regarding DDS and FO jurisdiction over subsequent title II claims.
Citations : Social Security Act, sections 205(a) and (b)(3) ; Public Law 101-508, section 5107; Regulation - 20 C.F.R. 404.957(c)(1)
Res judicata, a rule in civil law and an administrative policy, provides that once an issue is decided it does not need to be decided again. We apply res judicata at all levels of the claims adjudication process to avoid deciding an issue that we have previously decided based on the same facts, same issues, same parties, and same adjudicative period.
References: GN 03101.160 Res Judicata, GN 04040.010 Res Judicata
A subsequent Title II claim should be denied using the legal principle of res judicata when a previous determination or decision denying a prior Title II claim:
becomes final (i.e., there was no timely appeal);
adjudicated the prior claim through the date the non-disability requirements for entitlement were last met (i.e., the date last insured (DLI) for disability insurance benefits (DIB); the end of the prescribed period for disabled widow's or widower's benefits (DWB); or attainment of age 22 for childhood disability benefits (CDB)); and
considered the same facts, issues, and period.
Ensure that all of the following conditions are met before using res judicata as the basis for denial of the subsequent Title II claim:
The law or regulations pertaining to the alleged disabling condition have not changed, see DI 27516.010;
The subsequent claim presents no new facts or issues that were not considered in making the prior determination or decision (such as an unadjudicated period);
There is no allegation of a new impairment with an onset during the previously adjudicated period;
The claimant does not allege that they failed to timely appeal an adverse initial or reconsideration Title II determination because of good faith reliance on incorrect, incomplete, or misleading information given by the Social Security Administration (SSA) or the Disability Determination Service (DDS). For additional information, see Social Security Ruling (SSR) 95-1p;
The claimant does not allege and the evidence does not support a failure by the claimant to timely appeal the previous adverse determination, decision, or dismissal because of the claimant’s mental incapacity. For additional information, see SSR 91-5p;
If all of the conditions in subsection B are met, the claim is the field office's (FO) jurisdiction. When res judicata applies to the subsequent Title II claim in the FO or DDS:
Enter the “S1” denial code on the Benefit Continuity Factors (BECF) screen in the Modernized Claim System (MCS);
Enter the decision status of “03” and the listing code of “243” on the Decision Input (DECI) screen; and
Process via Earnings Computation (EC). Process via the Manual Adjustment Credit and Award Data Entry system
(MACADE) if the S1 denial will not process through EC, see SM 00380.000.
If the DDS made the initial res judicata determination and the claimant appeals the determination, the DDS has jurisdiction to make the reconsideration determination.
If the FO made the initial res judicata determination and the claimant appeals the determination, the FO has jurisdiction to make the reconsideration determination. For more information on jurisdiction, see GN 03102.175.
NOTE: The notice in a res judicata case informs the claimant that the final determination or decision reached on the prior application applies and that the only appeal available is on the question of whether the same person, facts and issues were present for the same period in both the prior and subsequent claims.
SSA will not deny a subsequent application or dismiss an appeal request based on res judicata for determinations made on or after July 1, 1991, if the applicant demonstrates:
The claimant (or another person whose rights may have been adversely affected by the prior determination) failed to appeal timely an adverse initial or reconsideration determination because of misinformation relating to the consequences of reapplying for benefits in lieu of filing an appeal; and
An officer or employee of SSA or the DDS provided the misinformation.
NOTE : Misinformation is incorrect, incomplete, or misleading information that an SSA or DDS officer or employee gave orally, in writing, or in the form of printed material (i.e., a letter or notice) and that relates to the consequences of reapplying for benefits instead of filing an appeal.
For additional instructions on misinformation, see GN 00204.008.
If the claimant alleges that they failed to appeal an adverse determination because of good faith reliance on incorrect, incomplete, or misleading information given by SSA or the DDS relating to the consequences of reapplying instead of appealing, then the FO will take the following actions:
Develop evidence per GN 03101.120C; and
Make a determination concerning the alleged misinformation.
For additional information, see instructions
DI 27505.001 Conditions for Reopening a Final Determination or Decision
GN 03101.020 Good Cause for Extending the Time Limit to File an Appeal
If the FO determines that misinformation does not exist:
Deny the subsequent claim on the basis of res judicata, or forward the claim to the DDS if the DDS has jurisdiction; and
Send the claimant a notice with appeal rights only on the correctness of applying res judicata and provide an explanation of why misinformation does not exist.
If the FO determines that the claimant received misinformation, the FO forwards the case to the DDS for a substantive determination on the subsequent claim.
The DDS adjudicator will make a disability determination on the subsequent claim and complete an SSA-831 (Disability Determination and Transmittal) in the usual manner.
NOTE: Since the claimant received misinformation, the effect of adjudicating the subsequent application is that the period adjudicated in the determination on the prior claim must be adjudicated again with full appeal rights. Adjudicate the previously adjudicated period as if the claimant had filed a timely appeal request, even though the subsequent application is not an appeal request. Any award of benefits would be based on the subsequent application.
If the claimant files a subsequent application and does not allege misinformation, then the FO processes the subsequent application and applies the res judicata policies and procedures in subsection B and C in this section.
If SSA has already denied a subsequent application or dismissed an appeal request because of res judicata and then determines that misinformation was given, vacate the denial or dismissal. NOTE: To vacate means to set aside the previous action. Then:
SSA or the DDS, as appropriate, will issue a determination based on the merits of the subsequent application, see GN 03101.120C.6.
The determination or decision on the merits is made at the level of the administrative review process at which the claim was first denied or dismissed because of res judicata.
The DDS has jurisdiction over subsequent Title II claims in which res judicata does not apply, and over cases in which a medical review is needed to determine whether res judicata applies (e.g., whether there is new and material evidence).
The FO has jurisdiction over claims meeting all of the conditions in subsection B, in this section; for instructions on returning those claims to the FO, see DI 81020.127.
The FO will transfer electronic claims which the DDS has jurisdiction to the DDS for a determination, see DI 81010.085.
To ensure that the subsequent claim is readily identifiable by the DDS:
Annotate the prior filing information section of the SSA-3367 Disability Report – Field Office, with the pertinent facts regarding the prior filing.
Add a message (without an expiration date) to the certified electronic folder (CEF) stating: “DDS jurisdiction : potential denial on basis of res judicata. DDS review necessary.” For instruction on posting messages to the CEF, see DI 81020.090.
Obtain the prior claim folder(s) if the prior filing is an official paper folder housed in a Modular Disability Folder (MDF).
Document the claims folder to show any Supplemental Security Income (SSI) involvement, including the location of the SSI folder.
For additional information on documenting prior claims activity, see DI 11005.085. If the prior title II folder cannot be located, do not reconstruct the folder.
For information on the electronic process when unable-to-locate (UTL) folders, see DI 81010.242. If the search is unsuccessful, complete the UTL Report of Contact and include a copy in the current folder.
NOTE: When the prior claim is pending at the Appeals Council (AC), and the subsequent claim needs a DDS medical determination because one of the criteria in subsection B, in this section, is not met, add the “subsequent claim” flag, see DI 81010.080B to the case prior to transferring to the DDS. Social Security Ruling 11-1p may apply if the subsequent claim is under the same title of the Social Security Act and for the same benefit type. Follow the appropriate instructions to process the subsequent claim, see DI 51501.001 or DI 12045.027.