The DDS should accept the FO finding on an issue of mental capacity or misinformation. Process these claims as exceptions to res judicata. Procedures in DI 27516.005C apply.

Refer to DI 27516.010.

Where a new fact or issue is established by the FO, the DDS follows the procedures in DI 57516.005C.

If, however, the claimant alleged new and material evidence, the DDS must consider the new and prior claims as follows:

• •

  Develop the NEW evidence if the claimant does not provide it.  Follow standard development procedures;

• •

  Considering the prior final determination with the new evidence, determine whether the new evidence would have changed the outcome.

IMPORTANT: In all cases where new evidence is considered in the medical evaluation of the claim, we require a signed medical assessment form documenting the medical consultant (MC)/psychological consultant (PC) review. The MC/PC should attest to a DDS res judicata denial (evidence is not new or material), a denial considering the new and material evidence, or a favorable finding based on new and material evidence and the medical development through the date of adjudication.

Annotate the SSA-831 (Disability Determination and Transmittal) as follows:

• •

  Item 26 (List No.) - “243” (subsequent claim -- prior claim medically denied through date non-disability factors last met); and

• •

  Item 34 (Remarks) - “Res judicata not applicable.”

For prior folder not located cases, the DDS develops the period under consideration and makes a medical determination.

For all medical denial determinations, the DDS will obtain MC/PC signatures and issue standard personalized disability explanation (PDEs) and personalized decision notices (PDNs).  See DI 26530.001 for instructions on preparing a PDE.  See DI 26535.005 for PDN instructions.

If new and material evidence or consideration under less restrictive disability criteria or another exception prevents application of res judicata, and the evidence supports a finding that the claimant became disabled prior to the date non-disability requirements were last met, the DDS will develop evidence from the date the non-disability requirements were last met through current adjudication. See DI 24501.002B for instructions on developing evidence from date the non-disability requirements were last met through current adjudication.

Complete the following:

1. a. 

   Item 16a (Primary Diagnosis) - Enter a four-digit diagnosis code. If a diagnosis code is not known, enter four zeros "0000".

2. b. 

   Item 19 (Claimant Not Disabled) - Check block B and insert either date last insured, end of prescribed period, or date attained age 22, as appropriate.

3. c. 

   Item 22 (Regulation Basis Code) - Enter “S1” (res judicata).

4. d. 

   Item 25A - Check block A.

5. e. 

   Item 26 - (List No.) - Enter “243” (subsequent claim or prior claim medically denied through date nondisability factors last met).

6. f. 

   Items 30 and 31 (Disability Examiner - DDS/Date)

7. g. 

   Items 32 and 33 (MC or PC signature) – generally not needed for res judicata. See DI 27516.005B for when an MC/PC signature is needed.

8. h. 

   Item 34 (Remarks) - Enter “Res judicata .”

To process the res judicata determination:

1. a. 

   Clear the case to the FO and show folder movement clearance.

2. b. 

   Record the “S1” denial code determination on the State Agency Operating Report.

Follow instructions in DI 27516.005E. (in this section), noting the following exceptions:

1. a. 

   Check block 25 (Revised Det) and 25 A. B. (Recon); and

2. b. 

   Enter “Recon Affirmation -- Res judicata applied” in item 34 (Remarks).

If the res judicata denial was inappropriate, the DDS will make a substantive initial determination on the evidence.