Effective Dates: 03/23/2015 - Present Previous | Next

TN 2 (03-15)

DI 27525.015 Providing Due Process in Erroneous Payment Cases

A. Erroneous award notice or payment following a denial determination

If the disability determination services (DDS) made a denial determination, but the claimant receives an erroneous award notice or payment due to clerical error, the DDS should reopen and revise the denial determination. See “Erroneous Notice/Payment Cases” in DI 27520.025.

Take the following actions:

  • •

    give the claimant due process as described in this section;

  • •

    if the claimant received only a denial notice, do not give due process before stopping payment; and

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    if we sent multiple notices and at least one was an allowance notice, give due process.

1. Title II only cases

Take the following actions:

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    send the claimant a due process predetermination notice per DI 27525.001B.1.;

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    modify the predetermination notice language in DI 27525.025 as appropriate;

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    include a summary of the evidence and reason for denial; and

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    explain that we found the claimant not disabled but mistakenly sent him or her an award notice or payment.

2. Title XVI only cases

Take the following actions:

  • •

    send the claimant a notice per “Title XVI-Only Reopening Notices” in DI 27540.015;

  • •

    explain that we found the claimant not disabled but mistakenly sent him or her an award notice or payment; and

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    include Goldberg-Kelly (GK) benefit continuation language per “Title XVI-Only – Goldberg/Kelly Payment Continuation Applies” in section DI 27540.030.

3. Concurrent Title II and Title XVI cases

For concurrent Title II and Title XVI adverse reopenings, see “Providing Due Process in Adverse Reopenings Involving Title XVI and Concurrent Title II and Title XVI Cases” in DI 27525.010.

NOTE: We do not consider these adverse reopenings due to clerical error as medical cessations; therefore, do not apply the medical improvement review standard (MIRS). See DI 27520.026D. Statutory benefit continuation (SBC) does not apply to either Title II or Title XVI adverse reopenings. GK benefit continuation, however, applies to Title XVI adverse reopenings. See DI 27540.030.

B. Field office improperly effectuates an allowance determination before the Office of Quality Review completes its review

When we select an allowance determination for the Office of Quality Review (OQR) review and that review results in a denial, but the field office (FO) improperly effectuates the allowance determination before OQR completes its review, the DDS will reopen the allowance determination. For reopening instructions, see DI 27520.026.

1. DDS reopens allowance determination within 60 days from the date of the improper award notice

If the DDS reopens the allowance determination within 60 days from the date of the improper award notice and revises the determination to a denial, give the claimant due process as follows:

a. Title II only cases

Take the following actions:

  • •

    send the claimant a due process predetermination notice per DI 27525.001B.1.;

  • •

    modify the predetermination notice language in DI 27525.025 as appropriate;

  • •

    include a summary of the evidence and reason for denial; and

  • •

    explain that we improperly sent the claimant an award notice.

b. Title XVI only cases

Take the following actions:

  • •

    send the claimant a notice for an adverse reopening and revision, per DI 27540.015;

  • •

    explain that we improperly sent the claimant an award notice; and

  • •

    include GK benefit continuation language, per DI 27540.030.

c. Concurrent Title II and Title XVI cases

For concurrent Title II and Title XVI adverse reopenings, see DI 27525.010.

NOTE: We do not consider adverse reopenings within 60 days from the date of the improper award notice as medical cessations; therefore, do not apply the MIRS. See DI 27520.026D. SBC does not apply to either Title II or Title XVI adverse reopenings. GK benefit continuation, however, applies to Title XVI adverse reopenings. See DI 27540.030.

2. DDS reopens allowance determination more than 60 days from the date of the improper award notice

If the DDS reopens the allowance determination more than 60 days from the date of the award notice, follow normal reopening and due process procedures as follows:

  • •

    send a due process decision notice to the claimant if you revise the determination to a less favorable determination. See “Due process decision notice” in DI 27525.001B.2. and “Reopening Notice Instructions” in DI 27540.000; and

  • •

    SBC applies to Title II and Title XVI adverse reopenings resulting in medical cessations. See “Operating procedures” in DI 27501.005D and “Reopening Notice Instructions” in DI 27540.000.

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0427525015
DI 27525.015 - Providing Due Process in Erroneous Payment Cases - 03/23/2015
Batch run: 01/15/2019
Rev:03/23/2015