TN 13 (06-11)

GN 03101.040 Appeals of the Initial Determination

A. Initial determination defined

An initial determination:

  • is SSA's formal, written disposition of any legal or factual issue affecting an individual's right to benefit payments or any other right (such as a period of disability) provided by the Social Security Act. Claimants only have a right to appeal actions taken by SSA that are initial determinations;

  • can be made by any employee in SSA who is delegated authority to make determinations; and

  • is subject to administrative and judicial review and is final and binding unless the claimant requests an appeal within 60 days or SSA revises the initial determination.

B. A change in factual situation

  • We may always make a new initial determination whenever a change occurs in the factual situation despite how much time elapses from the date of that change.

  • The fact that we determine that a claimant meets the requirements for entitlement does not preclude us from making another determination that the claimant no longer meets those requirements at some subsequent date.

  • The new determination is effective with the date of the change in the factual situation.

EXAMPLE: We made an initial determination in June 1993 entitling beneficiary to DIB effective July 1993. (There is no indication that workers compensation (WC) is involved.) In March 1998, we receive evidence of a WC award in February 1994. We can make a new initial determination (not a revised determination) and impose WC offset effective February 1994.

C. A failure to make a determination

Failure to make a determination with respect to any claim or post entitlement issue is not an initial determination, when such failure comes to our attention, adjudicate the claim or post entitlement issue.

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GN 03101.040 - Appeals of the Initial Determination - 06/17/2011
Batch run: 04/25/2016