TN 4 (06-05)

SI 04070.005 Title XVI Administrative Finality Definitions

A. Definitions

As used in this chapter, these terms have the following meanings:

1. Administrative Finality

Administrative finality is the concept that determinations of eligibility to receive payments and payment amounts become final and binding on both parties immediately, unless they are timely appealed or later reopened and revised for special reasons. It protects both parties from having to readjudicate claims ad infinitum.

2. Determination

A determination is an adjudication of eligibility and/or payment amount by a decisionmaker below the level of administrative law judge (ALJ). With respect to nonmedical elements of eligibility, this occurs in the field office (FO).

3. Initial Determination

An “initial determination” is the first determination on an application, posteligibility (PE) event or periodic redetermination of eligibility.

(See GN 03101.040A. – Appeals – Initial Determination) and (SI 04010.010A . – What Is and Is Not an Initial SSI Determination) for a complete definition of the term “initial determination.”

See SI 04010.010B. for a list of examples of actions that are initial determinations.

See SI 04010.010C. for a list of examples of actions that are not initial determinations.

4. Deemed Initial Determination

An initial determination is deemed to occur (i.e., no notice is sent) on the first day of each month that a recipient is shown on the record as eligible and the payment amount remains unchanged. If there is no payment in any given month, there is no deemed initial determination for that month or for following months in which no payments are made. Deemed initial determinations always follow actual initial determinations of eligibility or payment amount, beginning in the month following an actual initial determination as long as there is no break in eligibility or change in payment amount. See SI 04070.010A.3. and SI 04070.030A.SI 04070.030C. for a discussion of deemed initial determinations.

IMPORTANT NOTE: The concepts of deemed initial determinations and effective months of notices of initial determinations apply only to nonmedical factors of eligibility and for purposes of administrative finality. They do NOT apply to disability determinations, i.e. medical factors of disability.

5. Reconsidered Determination

A reconsidered determination is the mandatory first step in the administrative review (“appeal”) process that is provided to a claimant who is dissatisfied with an initial determination, unless a hearing is the first level of appeal. (See SI 04020.010 – What Is SSI Reconsideration) for a discussion of reconsidered determinations.

6. Revised Determination

A revised determination is one in which either the end result or a finding with respect to a factor of eligibility of a prior determination has been changed.

7. Decision

A decision is an adjudication of a claimant's appeal of a determination by an Administrative Law Judge (ALJ) or the Appeals Council (AC). A Revised Decision is one in which either the end result or a finding with respect to a factor of eligibility involved in a prior decision has been changed.

8. Threshold Review

Threshold Review is the preliminary review of a claims file to determine whether or not a determination or decision should be reopened without further investigation or development. A decision not to reopen following a threshold review is not appealable.

9. Affirmative Action In Writing

Affirmative Action In Writing is the establishment of a record in writing by SSA or a claimant that questions the correctness of a determination or decision. (See SI 04070.015B. for additional information)

10. Reopening

Reopening is the process of investigating and reexamining a claim which may result in revision of a prior determination or decision after the most recent determination or decision has become final.

Reopening implies the possibility of error, even if none is later found.

11. Fraud

For the definition of fraud, please see GN 04105.005B.

12. Similar Fault

For the definition of similar fault, please see GN 04105.005. For additional information about similar fault, see SI 04070.020B.

To Link to this section - Use this URL:
SI 04070.005 - Title XVI Administrative Finality Definitions - 04/27/2017
Batch run: 05/05/2017