Identification Number:
DI 12005 TN 6
Intended Audience:See Transmittal Sheet
Originating Office:ORDP ODP
Title:Reconsiderations - Initial Claims
Type:POMS Transmittals
Program:Disability
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM
Part DI – Disability Insurance
Chapter 120 – Appeals Processing
Subchapter 05 – Reconsiderations - Initial Claims
Transmittal No. 6, 12/06/2019

Audience

PSC: CS, DE, DEC, DTE, ICDS, IES, ISRA, RECONR, SCPS, TSA, TST;
OCO-OEIO: BET, CR, ERE, FCR, FDE, RECONE, RECONR, RECOVR;
OCO-ODO: BET, CR, CST, CTE, CTE TE, DE, DEC, DS, PETE, PETL, RCOVTA, RECONE, RECOVR;
ODD-DDS: REF;
FO/TSC: CS, CS TII, CS TXVI, CSR, CTE, DRT, FR, OA, OS, RR, TA, TSC-CSR;
OHO/OAO: OHAAC, OHACO (SAWDY), OHAHOs, OHAROs;

Originating Component

ODP

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

DI 12005.001 Documenting a Request for Reconsideration of an Initial Disability Claim

Include the following instructions in DI 12005.001 B.1.

NOTE: When the Office of Quality Review (OQR), selects a case for review, an undated copy of the DDS prepared notice is stored in the certified electronic folder (CEF). After OQR’s review is completed, OQR prints, dates, and mails the notice. OQR does not add the date to the image of the notice in the CEF. Instead, eView displays the notice release date in the “Notice Release Date” field found under the “Case Review” link on the Case Data screen.

DI 12005.001 Documenting a Request for Reconsideration of an Initial Disability Claim

CITATIONS:

Social Security Act, Section

NOTE: If a claimant files a new disability application and has a prior disability claim for the same title and benefit type pending at any level of administrative review, see DI 51501.001 Procedural Change for Subsequent Disability Applications Effective July 28, 2011.

A. Field office (FO) explanation of the determination and reconsideration process

A claimant who is dissatisfied with the initial determination on his or her claim may call, write, or visit an FO for an explanation of the determination. When a claimant requests an explanation, describe, to the claimant, as objectively as possible, how the Social Security Administration (SSA) handled the claimant's case, the basis for the determination, and his or her appeal rights. Explain that if he or she appeals, SSA can review all issues, including those decided favorably. This means that the claimant’s disability status may change from “disabled” to “not disabled”, or that the established onset date (EOD) may be the same, earlier, or later than the EOD established in the initial determination. See DI 25501.260 Establishing the Established Onset Date (EOD) in Reconsideration and Appeal Claims.

If the claimant decides to request reconsideration after receiving the explanation, follow the instructions in this subchapter to develop and process the request.

When a claimant requests reconsideration of an initial disability determination, the FO explains the reconsideration process and obtains the appropriate appeal forms (the SSA-561 Request for Reconsideration, or the SSA-3441-BK Disability Report-Appeal). The claimant’s case then receives an independent and thorough reexamination of all evidence on record including any new evidence received after the initial determination.

NOTE: To process a request for reconsideration of a medical cessation or an adverse reopening of a favorable initial determination due to medical/vocational reasons, follow the instructions in DI 12026.001 Reconsideration of a Continuing Disability Review (CDR) Based on Medical Cessation or Adverse Medical Reopening.

B. Reconsideration procedure

1. Review the initial claim

Review the certified electronic folder (CEF) or paper modular disability folder (MDF) to ensure that the Disability Determination Services made an initial determination. Also review the Online Retrieval System (ORS) and any pertinent queries for additional information before scheduling an interview with the dissatisfied claimant.

NOTE: When the Office of Quality Review (OQR) selects a case for review, an undated copy of the DDS notice is stored in the electronic folder. After OQR's review is complete, OQR prints,dates, and mails the notice. OQR does not add the date to the image of the notice in the electronic folder. Instead, eView displays the notice release date in the "Notice Release date" field found under the "Case Review" link on the Case Data screen.

2. Conduct the interview, if necessary

The claimant can submit a request for reconsideration via iAppeal, a written request, or an in-person interview. When the claimant requests a reconsideration in writing or via iAppeal, an interview with an FO employee may not be necessary. Review iAppeal and written submissions for completeness, and, as appropriate, load the reconsideration request information into the Modernized Claim System (MCS), the Modernized Supplemental Security Income Claims System (MSSICS), or both.

When necessary, conduct the interview as discussed in GN 03101.120 Appeals – FO Interview with Dissatisfied Claimant .

Also, explain that the claimant:

  • has the right to present additional evidence to support his or her claim and may request FO assistance in determining what evidence is needed and how to get the evidence;

  • has the right to representation (see GN 03910.040 Appointment and Revocation of Appointment of Representative); and

  • may be required to attend a consultative medical examination (CE). Stress the importance of attending the CE and of cooperating in securing and submitting medical evidence that the DDS may request.

3. Document the appeal request in MCS and MSSICS

Establish the appeal request via the Dallas Appeals Program or manually enter the information into the MCS and MSSICS appeal screens as appropriate.

EXCEPTION: If the claimant submits an appeal of an FO determination (for example, failure to cooperate or substantial gainful activity (SGA)) and the FO reverses the initial denial, see DI 81010.145 Processing Reconsideration Requests of Field Office (FO) Determinations and DI 12005.010 Processing a Reconsideration Request for an Initial Non-Medical or Technical Denial.

  • If the deciding issue in concurrent Title II/Title XVI cases is the same (e.g., medical/vocational denial), complete the appeal screens for each title. For exception cases (e.g., MCS or MSSICS exclusions), obtain one form SSA-561 (Request for Reconsideration) and specify in the “CLAIM FOR” text that it applies to both claims.

  • If the reconsideration request is limited to one t itle only, document the claim folder(s) to reflect the reason(s) the claimant is not requesting reconsideration for both claims.

NOTE: If an application involves claiming Title II and Title XVI benefits, or claiming more than one Title II disability benefit, and the claimant appeals any medical issue for any of the benefits, the entire claim is under review, including any favorable determination regarding disability status. Therefore, transfer the case as a concurrent claim to DDS.

The FO may still effectuate the favorable determination, but the claimant should be aware that our determination regarding the medical issue is not final.

If the other claim was a technical denial that is not under appeal, do not forward the technically denied claim to DDS as the issues under appeal are not the same.

  • If the claimant has limited the appeal in multiple claim situations (DIB/DWB or DIB/CDB), document this on the appeal request in the space provided for the appeal reason. If in concurrent cases the claimant limits his or her appeal to Title XVI-only, see SI 00510.001 Overview of the Filing for Other Program Benefits Requirement.

  • If the issues differ in concurrent claims (e.g., technical denial on the Title XVI claim and medical denial by the DDS on the Title II claim), and the claimant disagrees with both decisions, complete the appropriate MCS and MSSICS appeal screens. If you cannot complete the appeal screens in MCS or MSSICS, obtain an SSA-561 and process the appeals in accordance with the procedures applicable under the respective program.

  • If the case is an MCS/MSSICS exclusion, and the claimant has not already submitted a written request as described in GN 03102.100C.2. The Reconsideration Process, obtain an SSA-561.

  • If the claimant submits non-medical evidence, refer to DI 81010.135 Storing Non-Medical Evidence in the Electronic Folder (EF).

  • If the claimant submits medical evidence, follow DI 81010.125 Receiving Medical Evidence in the Field Office

NOTE: A manually loaded appeal request must be printed and stored on the Print and Store (PRST) screen to ensure that a copy is stored in the Online Retrieval System (ORS). For appeals brought into MCS/MSSICS via the Dallas Appeals Program, the program automatically completes the PRST screen for the user, saving the appeal request to ORS.

C. References


DI 12005 TN 6 - Reconsiderations - Initial Claims - 12/06/2019