Identification Number:
DI 28501 TN 01
Intended Audience:See Transmittal Sheet
Originating Office:ORDP ODP
Title:Reopenings and Revision of CDR Determinations
Type:POMS Transmittals
Program:Disability
Link To Reference:
 
PROGRAM OPERATIONS MANUAL SYSTEM
Part 04 - Disability Insurance
Chapter 285 - CDR Reopenings
Subchapter 01 - Reopenings and Revision of CDR Determinations
Transmittal No. 01, 12/2017

Audience

PSC: SCPS, CS, TSA, TST, DE, DEC, DTE, IES, RECONR
OCO-ODO: BET, CR, CTE, CTE TE, DE, DEC, DS, PETE, PETL, RECONE
OCO-OEIO: CR, ERE, FDE, RECONE
ODD-DDS: ADJ, DHU

Originating Component

ODP

Effective Date

Upon Receipt

Background

This transmittal contains an update of Program Operations Manual System (POMS) sections DI 28501.001 through DI 28501.030. Revisions include updates to the content to comply with the Social Security Administration’s (SSAs) plain language writing guidelines, updates to policy guidance, and updates to cross-references.

Summary of Changes

DI 28501.001 Continuing Disability Review (CDR) Reopening Overview and Definitions

We revised the title and made the following changes:

    • combined the guidance for reopening prior cessations under administrative finality from DI 28501.005 with this section,
    • updated text to comply with SSA’s plain language writing guidelines,
    • defined “reopening,” “revision,” “final determination or decision,” and “due process,”
    • clarified the steps to take to follow due process procedure,
    • updated policy guidance, and
    • added a References subsection.

DI 28501.005 Reopening of Prior Cessation Determination

We archived this section and combined the guidance for reopening prior cessations under administrative finality with section DI 28501.001.

DI 28501.010 Processing Continuing Disability Review (CDR) Reopenings under Administrative Finality

We revised the title and made the following changes:


    · updated text to comply with SSA’s plain language writing guidelines,

    · added guidance on what type of determinations the Disability Determination Services (DDS) can reopen,

    · updated guidance for processing CDR reopenings with modular disability folders (MDF),

    · added guidance for processing CDR reopenings with a certified electronic folder (CEF),

    · provided guidance for creating notices in all sections where we previously stated “Notice instructions will be provided in a later transmittal,”

    · updated or added routing guidance,

    · updated determination form and notice preparation instructions,

    · updated cross references, and

    · added a References subsection.



DI 28501.015 Reopening of Prior Favorable Initial Continuing Disability Review (CDR) Cases

We revised the title to clearly state the type of cases referred to in the POMS, and made the following changes:

    · updated text to comply with SSA’s plain language writing guidelines,

    · updated cross references, and

    · added a References subsection.


DI 28501.020 Unfavorable Reopening of Prior Continuance Determination

We revised the title and updated text to comply with SSA’s plain language writing guidelines.

DI 28501.025 Reopening and Revision of a Prior Continuing Disability Review (CDR) Reconsideration Determination
We revised the title and made the following changes:


    · updated text to comply with SSA’s plain language writing guidelines,

    · added instructions on when the DDS is able to make a CDR reconsideration determination,

    · added instructions for processing CEF cases,

    · updated names of referenced components, and

    · added instructions for processing cases when the DDS agrees with a determination to reopen a CDR case.


DI 28501.030 Routing Reopened Continuing Disability Review (CDR) Cases

We revised the title to reflect the type of cases that may be rerouted, and made the following changes:


    · updated text to comply with SSA’s plain language writing guidelines,

    · added instructions for how to route CEF cases,

    · revised guidance on how to route reopened paper CDRs, and

    · provided guidance on how to route reopened CEF CDRs.




DI 28501.001 Continuing Disability Review (CDR) Reopening Overview and Definitions

A. When a question of reopening arises during a CDR

There may be cases where a previous CDR determination was incorrect. If the rules of administrative finality allow, it may be appropriate to reopen and revise these determinations. The instructions in this section provide information that assists the disability determinations services (DDS) when considering the reopening of a prior favorable or cessation CDR determination. For more information on administrative finality, see subchapter GN 04000.000. For more information on reopening a “final determination or decision,” see DI 27505.001.

B. Definitions

1. Reopening

A “reopening” is a formal review of a determination or decision that has become administratively final. Reopening may occur to admit new and material evidence or to correct an error. The DDS can reevaluate the evidence used in a prior determination or decision when an error is involved.

NOTE: The term “determination” refers to adjudications at the initial and reconsideration levels or by a disability hearing officer (DHO). The term “decision” refers to adjudications at the administrative law judge (ALJ) or the Appeals Council (AC) levels. For more information about these terms and definitions, see §§ 404.901, 404,917, 416.1401, and 416.1417.

2. Final determination or decision

A “determination” or “decision” (initial or revised) is “final” as of the date of the notice unless:

  • it is timely appealed (or a civil suit is filed);

  • it is appealed late but good cause for late filing of an appeal or civil suit is found;

  • the AC takes jurisdiction on its own motion within 60 days of the date of the ALJ decision;

  • the AC denies a request for review (does not issue a decision), in which case the ALJ decision is the final decision as of the date of the notice that the AC denied review; or

  • it is reopened and revised.

3. Revision

A “revision” is any change in the end result or basis of a “final determination or decision” made in the administrative review process.

4. Due process

Due process requires the DDS to provide the essential information to the beneficiary (and any representative payee) on the right to appeal and submit rebuttal evidence before taking any action that will unfavorably affect benefits.

C. Reopening and revising under the rules of administrative finality

Under administrative finality, determinations become final and binding immediately, unless they are timely appealed or later reopened and revised for special reasons. It prevents perpetual readjudication.

Under the rules of administrative finality, the Disability Determination Services (DDS) may reopen and revise a previous cessation to reflect a continuance or a change in the cessation date.

The DDS will only reopen final determinations. A determination is “final” as of the date of the determination notice, see DI 28501.001B. in this section. For information on reopening and revising a determination, see DI 27501.001 and DI 27501.005.

D. Due process notifications

Due process requires the DDS to inform the beneficiary (and his or her representative payee, if any) of the right to appeal and offer rebuttal evidence before taking any action that will unfavorably affect their benefits.

Provide due process notification by sending either a due process predetermination notice or a due process notice. Send the predetermination notice when benefit continuation language is not required. Provide due process in the determination notice in medical cessation cases when benefit continuation language is required.

When reopening a cessation to make a more favorable determination, do not send a predetermination due process notice.

When reopening a prior cessation determination due to an earlier or later cessation date, send a due process determination notice if the revised determination requires benefit continuation language.

For information on due process notifications for adverse reopenings, see DI 27525.001.

1. Predetermination notice

The predetermination notice applies to reopenings that do not require benefit continuation language. In adverse reopening determinations of concurrent Title II or Title XVI claims, the Title XVI due process requirements also apply to the Title II claim.

Send a predetermination notice if the prior determination involves one of the following:

  • change from blind to disabled;

  • failure to follow prescribed treatment, for Title II only cases;

  • fraud or similar fault (FSF);

  • failure to cooperate (FTC) when FTC arose at the field office (FO). In FTC cases identified by the DDS, statutory benefit continuation will be offered because these FTC cessations are considered medical determinations; or

  • whereabouts unknown (WU); the FO provides all notices. See DI 27540.030 and DI 28075.005G.

2. Due process determination notice

The due process determination notice applies to adverse medical CDR reopenings.

When reopening a prior cessation determination due to an earlier or later cessation date, send a due process determination notice if the revised determination requires benefit continuation language.

E. Reopening precluded by administrative finality

When administrative finality does not allow the DDS to reopen a previous determination or decision, they may prepare a current determination reflecting a new period of disability.

The onset of the current determination may be set within the previously adjudicated period only:

  • If the total evidence clearly supports the new onset, and

  • If the previous determination was made at the initial or reconsideration level.

An SSA-831 determination rationale and notices must be prepared according to the usual procedures.

NOTE: We will only pay benefits based on the current application.

F. References

DI 12027.015 Cases Excluded from Statutory Benefit Continuation (SBC)

DI 25501.250 Establishing an Established Onset Date by Reopening Prior Disability Filings and Previously Adjudicated Periods

DI 27501.000 General

DI 27505.000 Rules for Reopening

DI 27505.015 Fraud of Similar Fault - Reopenings

DI 27536.010 Required Information for Reopening Continuing Disability Review Determinations

DI 40115.005 Definitions and Processing Instructions for Changing Initial Disability Determinations in the Processing Center (PC)

DI 81030.120 Reopenings – Certified Electronic Folders (CEF)

GN 04000.000 Administrative Finality

GN 04001.040 Role of Notice in Reopening

GN 04020.010 Unrestricted Reopening for Determinations or Decisions Involving Fraud of Similar Fault

SI 04070.000 Administrative Finality – SSI

DI 28501.010 Processing Continuing Disability Review (CDR) Reopenings under Administrative Finality

A. Reopening final determinations

The Disability Determination Services (DDS) may only reopen final determinations. A determination is “final” as of the date of the determination notice. For more information about reopening and revising a determination, see DI 27501.001.

NOTE: If the DDS did not send a determination notice, prepare a revised determination following the usual CDR determination procedures.

B. Processing an electronic CDR reopening

1. Reopening an electronic CDR

To process a CDR reopening with a certified electronic folder (CEF) the DDS must:

  1. Make appropriate changes to the case (for example, correct an onset date, ending date, or basis code),

  2. Enter: “This reopens and revises determination of (mm/dd/yy).” on Item 24 of the revised Form SSA-832, (Cessation of Disability or Blindness Determination and Transmittal – Title XVI) or Form SSA-833, (Cessation of Disability or Blindness Determination and Transmittal – Title II),

  3. Enter: “See revised determination of (mm/dd/yy).” in Item 24 of the prior SSA-832 or SSA-833,

  4. Upload the revised SSA-832 or SSA-833, to Section A – Payment Documents/Determinations (Yellow Front) of the CEF,

  5. Add “Do Not Process” next to the prior SSA-832 or SSA-833, in Yellow Front section of the CEF,

  6. Prepare any necessary rationales. The rationale should include:

    • an explanation of the basis for the revision,

    • information about any scheduled medical re-examination diaries,

    • an explanation of periodic review, and

    • any other information significant to the case.

  7. Prepare and release appropriate notice, if applicable, based on guidance given in DI 28501.010C or DI 28501.010D in this section.

    NOTE: The DDS does not prepare notices for fully favorable revisions.

Add “Do Not Process” next to any incorrect notices.

Once the reopening is complete, the system automatically completes several actions including annotating prior claims with “reopened” in the Claims Action History Page and displaying a message on a prior folder that has been reopened along with any intervening claim(s) that has been reopened, “Decision(s) in this folder have been reopened. For more information about processing electronic reopenings, see DI 81020.115.

2. Routing instructions

Consider several different factors when choosing the routing location for an electronic CDR reopening, including the following:

  • type of case,

  • type of action needed, and

  • whether the determination is favorable or unfavorable.

For more information on how to route an electronic CDR reopening, see DI 28501.030B.

C. Processing Title II only reopening and revision cases with a paper modular disability folder (MDF)

Process the Title II paper MDF cases based on the revised determination.

1. Fully favorable revision

a. Preparing Form SSA-833

On the revised SSA-833: Item 24: “This reopens and revises the prior cessation determination of (mm/dd/yy).”

On the prior SSA-833: Item 24: “See revised determination of (mm/dd/yy).”

b. Rationale preparation

The reopening rationale must:

  • state the conditions for reopening the prior determination(s) (for example, new and material evidence or error on the face of the evidence),

  • explain why the prior determination is incorrect,

  • discuss the finding pertinent to the reopening determination (for example, medical or vocational), and

  • if new and material evidence is the basis for reopening, discuss how the evidence is material to the prior period. Also, discuss how the evidence changes the findings covered by the prior determination.

For more information about reopening rationale preparation, see DI 27536.001.

c. Determination notice preparation

The DDS does not prepare notices for fully favorable revisions.

d. Routing instructions

Route the folder to the:

  • Office of Disability Operation (ODO) for appropriate notice preparation if the individual is age 54 and under, or

  • Program Service Center (PSC) processing center (PC) 1 through 6 for appropriate notice preparation if the individual is older than age 54 or deceased.

    For more information on the PC SSN jurisdiction, see GN 01070.245.

2. Less than fully favorable revision

A less than fully favorable revision does not include a change from “blind” to “disabled.” For more information on how to reopen basis change only case, see DI 28501.010B.4.

A less favorable reopening of a cessation may include:

  • a cessation to an earlier cessation date;

  • an allowance to a denial;

  • an allowance to a closed period; and

  • a previously established on set to a later onset of disability.

If the reopening changes an allowance to a denial, an allowance to a closed period, or establishes a later onset, follow instructions in subchapter DI 27500.000. These reopenings would use the SSA-831. Such reopenings are rare because of the time limits for reopening. When a favorable determination is precluded from reopening because the period for reopening has expired, process in accordance with CDR procedures. For more information on conditions for reopening a final determination or decision, see DI 27505.001.

a. Preparing Form SSA-833

On the revised SSA-833:

  • Item 24: “This reopens and revises the previous determination of (mm/dd/yy).”

  • Item 29: DDS/DL (Completion of Item 29 is optional if DDS prepares and releases notices.)

On the prior SSA-833: Item 24: “See revised determination of (mm/dd/yy).”

b. Determination notice preparation

Prepare an appropriate determination notice using DI 27540.010B.2. Attach a rationale as described in DI 28501.010C.1.b. in this section and include a personalized disability explanation as described in DI 26530.055 and DI 28095.040.

For more information on numbered paragraphs, see NL 00708.100.

c. Routing instructions

Route the folder to the field office (FO) for the appeals period. Attach an SSA-408 (Route Slip) with the remark “CDR Adverse Reopening.” For more information about routing Title II only less than favorable decisions, see DI 28501.030C.

3. Revision to later cessation date

a. Preparing Form SSA-833

If the DDS sent a due process notice:

On the revised SSA-833:

  • Item 24: “This reopens and revises the previous determination of (mm/dd/yy).”

  • Item 29: DDS/DL (Completion of Item 29 is optional if DDS prepares and releases notices.)

On the prior SSA-833: Item 24: “See revised determination of (mm/dd/yy).”

If the DDS did not send the due process notice:

Prepare a revised determination following usual CDR determination procedures; see DI 28084.055.

b. Determination notice preparation

Prepare a determination notice with language modified from NL 00705.201. Use lead-in paragraph 4170 instead of paragraph 4159. If the DDS previously sent a required predetermination due process notice because statutory benefit continuation (SBC) does not apply, do not use paragraph 4059. Attach a rationale as described in DI 28501.010C.1.b. in this section and include a personalized disability explanation as described in DI 26530.055 and DI 28095.040.

For more information on numbered paragraphs, see NL 00708.100.

c. Routing instructions

Route the folder to the FO for the appeals period. Attach an SSA-408 (Route Slip) with the remark “CDR Adverse Reopening.” For more information about routing Title II only less than favorable decisions, see DI 28501.030C.

4. Basis change only

a. Preparing Form SSA-833

On the revised SSA-833:

  • Item 24: “This reopens and revises the previous determination of (mm/dd/yy).”

  • Item 29: DDS/DL (Completion of Item 29 is optional if DDS prepares and releases notices.)

On the prior SSA-833: Item 24: “See revised determination of (mm/dd/yy).”

b. Determination notice preparation

Verify that the DDS sent a due process notice.

NOTE: The DDS cannot process the claim before 15 days (10 days, plus 5 days for mailing time) expires unless you receive a written statement from the beneficiary stating that he or she will not be submitting additional evidence.

If the DDS sent the due process notice:

Prepare a determination notice using language from NL 00705.261. Attach the personalized rationale as described in DI 28501.010C.1.b and include a personalized disability explanation as described in DI 26530.055 and DI 28095.040.

If the DDS did not send the due process notice:

Prepare a notice following the guidance in DI 27525.005B. The DDS cannot send the final determination notice until after the due process notice is sent.

For more information on numbered paragraphs, see NL 00708.100.

c. Routing instructions

Route the folder to the FO unless the referring office requests return of the folder.

5. No change in basis or end result

a. Preparing Form SSA-832

If there is no change in the basis or end result, the DDS must document the file with any additional evidence received since the original determination. Do not revise the SSA-832.

b. Rationale preparation

Do not prepare a rationale if there is no change in determination.

c. Determination notice preparation

If individual is unaware of the reopening:

Do not send a determination notice.

If the individual is aware of the reopening:

Prepare the determination notice using language from NL 00705.256. Attach a rationale as described in DI 28501.010C.1.b and include a personalized disability explanation as described in DI 26530.055 and DI 28095.040.

d. Routing instructions

Route the folder to the referring or other appropriate office.

D. Processing Title XVI only and reopening and revision cases with paper MDF

1. Fully favorable revision

a. Preparing Form SSA-832

If the DDS sent a determination notice on the original determination:

On the revised SSA-832:

  • Item 24: “This reopens and revises the previous determination of (mm/dd/yy).”

  • Item 29: DO/DL – if the DDS sent a determination notice on the original determination. (Completion of Item 29 is optional if DDS prepares and releases notices.)

On the prior SSA-832:

Item 24: “See revised determination of (mm/dd/yy).”

If the DDS did not send a determination notice on the original determination:

Prepare a revised determination following usual CDR determination procedures.

b. Determination notice preparation

The DDS does not send a determination notice for fully favorable revisions.

The FO must send a determination notice.

c. Routing instructions

Route the Title XVI only and concurrent folders to the FO.

For Title XVI only folders:

Attach an SSA-408 (Route Slip) with the remark “Title XVI CDR Favorable Reopening. Effectuation of Payment Required.”

For concurrent folders:

Attach an SSA-408 (Route Slip) with the following remarks: “Concurrent Title II/XVI CDR Favorable Reopening. Payment effectuation for Title XVI is required. Upon FO completion of Title XVI payment effectuation, route folder to PC 1-6 (DPB) or PC 7-8” and “Attn: Disability Examiner/Disability Processing Specialist.”

2. Less than fully favorable revision

a. Preparing Form SSA-832

On the revised SSA-832:

  • Item 24: “This reopens and revises the previous determination of (mm/dd/yy).”

  • Item 29: DDS/DL (Completion of Item 29 is optional if DDS prepares and releases notices.)

On the prior SSA-832:

  • Item 24: “See revised determination of (mm/dd/yy).”

b. Determination notice preparation

Prepare a determination notice for the appropriate type of determination using DI 27540.015.B.2. Attach a rationale as described in DI 28501.010C.1.b. in this section.

c. Routing instructions

Route the folder to the FO for the appeals period. Attach an SSA-408 (Route Slip) with remark “CDR Adverse Reopening.”

3. Revision to later cessation

a. Preparing Form SSA-832

If the DDS sent a determination notice on original determination

On the revised SSA-832:

  • Item 24: “This reopens and revises the previous determination of (mm/dd/yy).”

  • Item 29: DDS/DL (Completion of Item 29 is optional if DDS prepares and releases notices.)

On the prior SSA-832: Item 24: “See revised determination of (mm/dd/yy).”

If the DDS did not send a determination notice on original determination:

Prepare a revised determination following usual CDR determination procedures.

b. Determination notice preparation

Prepare a determination notice with language from modified NL 00705.201.

Use lead-in paragraph 4038 instead of paragraph 4159. Attach a rationale as described in DI 28501.010C.1.b.

For more information on numbered paragraphs, see NL 00708.100.

c. Routing instructions

Route the folder to the FO for the appeals period. Attach an SSA-408 (Route Slip) with remark “CDR Adverse Reopening.”

4. Basis change only

If the original decision was correct but the regulation basis code originally established was not, revise the determination to reflect the correct basis code.

a. Preparing Form SSA-832

On revised SSA-832:

  • Item 24: “This reopens and revises the previous determination of (mm/dd/yy).”

  • Item 29: DDS/DL (Completion of Item 29 is optional if DDS prepares and releases notices.)

On the prior SSA-832: Item 24: “See revised determination of (mm/dd/yy).”

b. Determination notice preparation

Verify that the DDS sent a due process determination notice.

If the DDS sent the due process notice:

If title II only, prepare the determination notice using language from NL 00705.261. If title XVI only, prepare the determination notice using language from NL 00705.266. In concurrent cases, add disclaimer paragraph 842. If the revision is less favorable, attach a rationale as described in DI 28501.010C.1.b. in this section.

If the DDS did not send a due process notice:

Prepare one following the guidance in DI 27525.005B. The DDS cannot send the final determination notice until the predetermination notice is sent.

For more information on numbered paragraphs, see NL 00708.100.

c. Routing instructions

Route the folder to the FO for the appeals period. Attach an SSA-408 (Route Slip) with remark “CDR Adverse Reopening.”

5. No change in basis or end result

If there is no change in the basis or end result, the DDS must document the file with any additional evidence received since the original determination.

a. Preparing Form SSA-832

If there is no change in determination, do not revise the SSA-832.

b. Rationale preparation

Do not prepare a rationale if there is no change in determination.

c. Determination notice preparation

If the individual is not aware of the reopening:

In concurrent or Title XVI only cases, a determination notice is not required.

If the individual is aware of the reopening:

In Title XVI only cases, prepare a determination notice using language from NL 00705.256. Attach a rationale as described in DI 28501.010C.1.b.

d. Routing instructions

Route the folders to the referring office.

E. References

DI 32010.001 General – Continuing Disability Review (CDR) – Routing Instructions

DI 32010.080 Continuing Disability Review (CDR) Favorable Reopening and Revision Cases – Routing Instructions (Paper Cases Only)

DI 81020.115 Processing Reopenings

DI 81020.250 Closing and Routing Electronic Continuing Disability Review (eCDR) Cases

DI 81030.120 Reopenings – Certified Electronic Folders (CEF)

GN 04440.236 Notices Requiring a Technical Corrective Action (TCA)

GN 04440.237 Determination Forms Technical Corrective Action (TCA)

DI 28501.015 Reopening of Prior Favorable Initial Continuing Disability Review (CDR) Cases

A. Prior favorable initial determination

When a prior favorable initial determination is incorrect, reopening is appropriate when there is “good cause” and the rules of administrative finality allow. For example, good cause for reopening exists when there is new and material evidence or there is an error on the face of evidence. For more information on errors on the face of evidence or new and material evidence, see DI 27505.010, DI 28020.355, and DI 28020.365.

We do not require good cause when reopening of an incorrect determination occurs within one year from the date of the notice of the initial determination. However, certain adverse reopenings and revisions cannot occur unless the medical improvement (MI) regulations allow a finding that disability has ceased or does not exist. For more information about MI in CDR cases, see DI 28005.001.

B. Prior favorable CDR determination

The Disability Determination Services (DDS) may reopen a case if a prior favorable CDR determination is incorrect and such action is not precluded by the rules of administrative finality.

Reopen the case only when the prior favorable CDR determination is wholly unsupported by the evidence, not because of a difference in judgment.

C. Administrative finality does not allow reopening

When the rules of administrative finality do not allow reopening, the disability examiner must initiate a CDR claim and prepare a determination of continuance or cessation using the usual CDR procedures.

D. References

DI 27501.001 Reopenings and Revisions: Pertinent Definitions and Related Policy

DI 27501.005 Reopening and Revising a Determination or Decision

DI 27505.015 Fraud of Similar Fault - Reopenings

DI 81030.120 Reopenings – Certified Electronic Folders (CEF)

GN 04020.010 Unrestricted Reopening for Determinations or Decisions Involving Fraud or Similar Fault

GN 04440.250 Reviewing Cases That Have Been Inadvertently Effectuated

DI 28501.020 Unfavorable Reopening of Prior Continuance Determination

A. Revision of a prior favorable continuance under administrative finality

If a prior favorable continuance is incorrect, the Disability Determination Services (DDS) must complete any outstanding development of the case. If the evidence shows that the prior determination needs revision and the rules of administrative finality allow, the DDS should take the following actions:

  • follow the rules of due process in DI 27525.000, and

  • prepare a revised determination using the evidence received from the outstanding development.

B. Exception to medical improvement (MI) applies

There may be cases in which the “error” exception to MI applies. If the DDS based the cessation determination on applying the “error” exception and the individual’s ability to perform substantial gainful activity (SGA) (where administrative finality does not allow a reopening), process the cessation determination according to the continuing disability review (CDR) determination procedures by completing the following:

  1. Form SSA-832 (Cessation of Disability or Blindness Determination and Transmittal – Title II) or SSA-833 (Cessation of Disability or Blindness Determination and Transmittal – Title XVI),

  2. Rationale,

  3. Predetermination due process (if applicable), and

  4. Determination notice.

For more information on exceptions to MI, see DI 28020.001.

For more information on CDR cases involving Group II exceptions, see DI 28020.900. For more information on reopening cases where the Medical Improvement Review Standard (MIRS) applies, see DI 28020.375.

DI 28501.025 Reopening and Revision of a Prior Continuing Disability Review (CDR) Reconsideration Determination

A. Reconsideration determination issued by the Disability Determination Services (DDS) or proper developing component

1. The DDS or proper developing component needs to reopen a reconsideration

The DDS will only reopen CDR reconsiderations if the determination is fully favorable. A disability hearing officer (DHO) makes all other types of CDR determinations. For more information about component responsibilities, see DI 29001.010.

If the rules of administrative finality allow a reopening when a determination is not fully favorable, the DDS or proper developing component will complete the following:

If a certified electronic folder (CEF):

  1. Prepare and add an SSA-887 (Summary of Evidence) to Section E – Disability Related Development (Blue),

  2. Add, “Folder forwarded for review and possible reopening” under the “Alerts & Messages” tab, and

  3. Forward CEF to Disability Hearings Unit (DHU).

If a Modular Disability Folder (MDF):

  1. Prepare an SSA-887 (Summary of Evidence) to return the case to the PC,

  2. Annotate the SSA-408 (Route Slip) with “Folder Forwarded for Review and Possible Reopening.”, and

  3. Transmit the paper case to the DHU.

Upon receipt of the folder, a DHO or supervisory hearing officer (SHO) will review the case. If a reopening is appropriate, the DHU will afford due process and offer the individual a disability hearing before taking any action to reopen.

2. Processing center (PC) requests the DDS reopen its reconsideration determination

a. If the DDS disagrees with reopening the determination

If a PC requests the DDS reopen its reconsideration determination and the DDS disagrees, the DDS will take the following actions:

If CEF:

  1. Add, “Folder forwarded for review and possible reopening” under the “Alerts & Messages” tab,

  2. Prepare a SSA-5002 (Report of Contact) to explain why the DDS will not reopen the reconsideration determination. Add SSA-5002 to Blue section, and

  3. Forward CEF to DHU.

If MDF:

  1. Prepare a SSA-408 returning the case to the PC. Annotate the SSA-408 to show why the DDS is forwarding the folder, and

  2. Prepare a SSA-5002 to document why the DDS will not reopen the reconsideration determination.

b. If the DDS agrees with reopening the determination

If the DDS agrees to reopen a reconsideration determination under the rules of administrative finality, the DDS will take the following actions:

If CEF:

  1. Prepare a Form SSA-5002 (Report of Contact) to explain why the DDS will reopen the reconsideration determination. Add SSA-5002 to Blue section,

  2. Add the remark, “Folder forwarded for review and possible reopening.” under the “Alerts & Messages” tab, and

  3. Forward the CEF to the DHU.

If MDF:

  1. Realign the folder,

  2. Prepare a SSA-5002 (Report of Contact) (to explain why the DDS will reopen the reconsideration determination,

  3. Annotate the SSA-408 to show why the DDS is forwarding the folder, and

  4. Transmit the folder to the DHU.

When the DDS forwards the case to the DHU, the DDS does not need to prepare a Summary of Evidence (SSA-887).

B. Reconsideration decision issued by a disability hearing officer (DHO)

Only a DHO, an administrative law judge (ALJ), or a member of the Appeals Council (AC) can reopen a reconsideration decision issued by a DHO.

Therefore, refer any reopening issues on a DHO's decision to the DHU. If the Office of Hearing Operations (OHO) issued the reconsideration decision, refer the reopening issue to OHO.

DI 28501.030 Routing Reopened Continuing Disability Review (CDR) Cases

A. Guidelines for routing a reopening of a prior CDR determination

Use the following routing guidelines when the prior CDR determination is reopened and revised under the rules of administrative finality.

B. Certified electronic folder (CEF)

Route cases based on decision (DEC) codes as follows, unless selected for review by the Office of Quality Review (OQR):

Situation

Destination

Case Note

DEC = CO

Title II – No action necessary

Processing Center (PC) 1 through 8

Title XVI – No action necessary

L0(zero)E

Concurrent – No action necessary

PC 1 through 8

Title II, Title XVI, Concurrent – Action necessary

Field Office (FO)

Describe the necessary action

DEC = CE

Title II, Title XVI, Concurrent

FO

NOTE: To determine the appropriate destination for PC 1 through 8, see DI 32010.001B.

NOTE: If unsure of the necessary action for the CDR case, route the case to the FO so they can determine the best course of action and proper routing procedure.

C. Modular Disability Folder (MDF)

Situation

Destination

SSA-408 (Route Slip) Entry

Favorable Reopening

Returnable Error

Office of the Originating Error Return

Indicate type of case

Title II Only – Additional Evidence

PC 1 through 6 (Disability Procession Branch (DPB)), or PC 7-8

“Title II CDR Favorable Reopening, Attn: Disability Examiner/Disability Processing Specialist”

Title XVI Only –Additional Evidence

FO

“Title XVI CDR Favorable Reopening. Effectuation of Payment Required.”

Concurrent (two folders)

FO

“Concurrent Title II/XVI CDR Favorable Reopening. Payment effectuation for Title XVI is Required. Upon FO completion of Title XVI payment effectuation, route folder to PC 1 through 6 (DPB) or PC 7 through 8.”

Add, “Attn: Disability Examiner/Disability Processing Specialist”

Concurrent (one folder)

FO

“Concurrent Title II/XVI CDR Favorable Reopening. Payment effectuation for Title XVI is required. Upon completion, route folder to PC 1 through 6 (DPB) or PC 7 through 8.”

Add, “Attn: Disability Examiner/Disability Processing Specialist”

Less than Fully Favorable Reopening

Returnable Error

Office of the Originating Error Return

Indicate type of case

Title II, Title XVI, or Concurrent

FO

Indicate type of case

“CDR Adverse Reopening”

NOTE: Route cases selected for quality assurance (QA) review to OQR.

NOTE: For adverse reopening determinations, an individual may elect to continue receiving benefits through the administrative law judge (ALJ) level. For more information, see DI 28001.070 Benefit Continuation – Policy).

D. If case has an MDF and a CEF

Always send the MDF comparison point decision (CPD) folder to the same office that you transfer the CEF. For both folders, include messages about what action is necessary, if any. Follow the routing instructions as given in DI 28501.030B in this section. If OQR selects a case for review, route as appropriate.

E. References

DI 32010.080 Continuing Disability Review (CDR) Favorable Reopening and Revision Cases – Routing Instructions (Paper Cases Only)

DI 32010.085 Continuing Disability Review (CDR) Adverse Reopening Cases – Routing Instructions (Paper Cases Only)

DI 81020.250 Closing and Routing Electronic Disability Review (eCDR) Cases

DI 81030.090 Certified Electronic Folder (CEF) Alerts, Flags and Messages

GN 04440.201 General Rules for Routing and Correcting Deficient Cases



DI 28501 TN 01 - Reopenings and Revision of CDR Determinations - 12/13/2017