PROGRAM OPERATIONS MANUAL SYSTEMPart DI – Disability InsuranceChapter 270 – Reconsideration Case ProcessingSubchapter 01 – IntroductionTransmittal No. 1, 09/12/2019
We are updating our instructions to provide clarified guidance about how to adjudicate reconsideration level cases at the Disability Determination Services (DDS). This guidance is the result of a workgroup convened to gather suggestions on clarifying and improving these procedures. The update reflects the comments we received about the need to address the regulatory provisions at 20 CFR 404.913 and 404.916. The updated procedures emphasize the importance of making a complete and independent review of the initial determination at the reconsideration level.
Summary of Changes
DI 27001.001 The Reconsideration Process
We updated text to clarify the instructions regarding how the reconsideration review is completed.
The revised draft includes the following changes:
Rewrote subsection A, to make it more consistent with the regulatory provisions at 20 CFR 404.913 and 404.916 and as succinct as the current text.
Rewrote subsection A, to include a note to clarify that the reviewers who makes the reconsideration determination must be different from the reviewers who made the initial determination.
Rewrote subsection A in plain language.
Rewrote subsection D by deleting duplicate information.
Rewrote subsection E.1. to include a note to clarify that adopting the initial level residual functional capacity of psychiatric review technique form does not require affirming the initial determination as written,
DI 27001.010 Development of Medical Evidence of Record (MER) at the Reconsideration Level
We updated text to clarify and included reminders for developing evidence at the reconsideration level.
Rewrote subsection A, to include a detailed list of reminders for evidence policies to consider at the reconsideration level.
Reconsideration is the first step in the appeals process for a claimant who is dissatisfied with the initial determination on his or her claim, or for individuals (e.g. auxiliary claimants) who show that their rights are adversely affected by the initial determination. A reconsideration involves a thorough, independent review of all evidence from the initial determination and any new evidence the claimant or another individual submits in connection with the request for reconsideration.
A reconsideration determination is made by:
An adjudicative team consisting of a disability examiner and a medical consultant or psychological consultant; or
A disability hearing officer.
The examiner and consultant must be different from the reviewers who made the initial determination.
A request for reconsideration must be filed within 60 days after the date the claimant receives notice of the initial determination.
For the Disability Determination Services (DDS) responsibilities in cases with a late filed request for reconsideration, see (DI
27010.001)—Appeal Filing Issues.
The claimant or his or her representative may file a request for reconsideration. For additional instructions on who may file a request for reconsideration, see (GN
03102.100C.1.)—The Reconsideration Process.
A request for reconsideration can be expressed or implied; however, it must be in writing. A writing, for these purposes, is any documentation, e.g., a letter, facsimile, or submission of additional evidence, which clearly implies disagreement with the initial determination.
A claimant or the claimant’s representative may request reconsideration by:
Completing and submitting an SSA-561 (Request for Reconsideration); or
Completing and submitting an i561 (Request for Reconsideration) online; or
Submitting any documentation (e.g., letter, facsimile, or additional evidence) indicating disagreement with the initial determination.
A request for reconsideration may be filed at any Social Security Administration (SSA) office. For additional information on certain other offices where an appeal request may be filed, see (GN 03102.100C.7)—The Reconsideration Process.
Contacting the 800 number or field office (FO) by telephone to inquire about the process, or to request forms, is not a reconsideration request.
An implied request for reconsideration is any writing or timely submission of additional evidence by a claimant or his or her representative which indicates disagreement with the initial determination.
For further instructions see (DI 81020.025B) — Processing Electronic Reconsideration Cases.
The reconsideration process provides the claimant:
An opportunity to present additional evidence;
A review of the evidence considered in making the initial determination and any other evidence presented;
An opportunity for a disability hearing in cases described in DI 29001.001—The Right to a Disability Hearing at the Medical Continuing Disability Review (CDR) Reconsideration Level;
A reconsidered determination based on all evidence of record;
An initial determination may be affirmed as written if all of the following conditions are met:
There is no allegation of a worsening of any previously documented impairment(s);
There is no allegation of any new impairment(s);
There has been no treatment for any impairment(s) since the prior determination; and
The prior determination was substantively and technically correct and the prior decision rationale correctly presented and resolved all pertinent issues to be adjudicated;and
There are no changes in the functional limitations.
For instructions, see (DI 27021.010) – Affirmation of a Prior Disability Determination.
NOTE: These bulleted conditions do not apply for DI 24510.066B. Adoption of Initial Level RFC Assessment or Adopting the initial level RFC or PRTF does not require affirming the initial determination as written.
Once a reconsideration case on an initial claim has been received from the FO, the disability examiner is responsible for reviewing the case to determine if additional development is warranted. If further case development is warranted, the disability examiner:
Determines whether the folder shows all necessary development, including appropriate follow-up, for the initial claim. If any required development action was overlooked, complete that development.
Obtains additional information needed to document new allegations or a worsening of the claimant’s condition including information that was required but not obtained before the initial determination (e.g., SSA-3373 Function Report, Medical Evidence of Record (MER), and work history).
Contacts all medical sources from which the claimant received examination or treatment since the initial determination for any new medical evidence.
Sends unsigned medical reports secured in connection with the initial determination which are material to the reconsidered determination to the medical source(s) for signature; and
Has a DDS medical or psychological consultant who was not involved in the initial determination review the medical evidence and provide a new medical assessment or, if supported by the evidence, an affirmation of the initial level medical assessment.
NOTE: Disability examiners must follow up with sources that were contacted, but did not submit MER, at the initial level.
For further instructions see:
DI 27021.010 – Affirmation of a Prior Disability Determination
DI 27015.001 -- Completing Form SSA-831–U3 for Reconsideration Cases
DI 24510.066B – Options to Simplify Case Processing
DI 81020.025—Processing Electronic Reconsideration Cases
For development and documentation instructions see:
DI 28005.001—Legal Standard for Determining If Disability Continues
DI 29005.001—Reconsideration Standards and Development Guidelines
DI 22505.035—Follow-up on Requests for Medical Evidence of Record (MER)
DI 29000.000 – Reconsideration of Continuing Disability Review (CDR) Cases, and Reopenings Applicable to Disability Hearings (Pre-DHU Processing) – Table of Contents
The DDS makes accurate and complete reconsideration determinations that include sufficient evidence to assess impairment severity and limitations.
The reconsideration process involves a thorough, independent examination of all evidence of record, including any new evidence received after the initial determination. The person reviewing the case makes an independent reconsideration determination, based on the evidence of record. The examiner and physician must be different from the reviewers who made the initial determination.
The rules that apply for developing evidence at the initial level also apply at the reconsideration level of review. However, disability examiners must submit MER requests to sources that were contacted, but did not submit MER, at the initial level, see DI 22505.001
For additional instructions on MER development, see DI 27001.001E.2. — The Reconsideration Process.
If the DDS determines a folder from a prior filing is necessary to adjudicate the reconsideration review, the DDS must request the prior folder, see DI 20505.010.
For example-- If the evidence mentions a recent hospital discharge, the adjudicator must request updated records and consider a change in circumstance.
Request medical evidence from each medical source that the claimant identifies as having evaluated, examined, or treated him or her, see DI
Develop all evidence related to the claimant's impairment(s). Do not develop evidence clearly unrelated to the impairment(s), (e.g., cold, flu, toothache).
Contact the claimant during reconsideration development to determine if there have been any changes since the last filing. If the initial claimant reports are current, there is no need to request additional reports. The adjudicator must consider any allegations of worsening impairment and clarify the finding with the claimant.
The determination must contain sufficient evidence to assess impairment severity.
If a claimant’s medical source(s) cannot or will not provide sufficient medical evidence about a claimant’s impairment(s), you may purchase one or more CEs.
The reconsideration determination is independent of the initial determination. The reconsideration level determination is not based on FTC issues at the initial level.
The reconsideration determination is a de novo review, the examiner has to go through all of the appropriate steps of development.
Provide the claimant all necessary opportunities to cooperate at the reconsideration level.
Sufficiency of medical evidence must be considered during the additional adjudicative period of the reconsideration process. See DI 22511.009.