TN 2 (02-04)
SI 04020.010 What Is SSI Reconsideration
A. Introduction -- Role in the Appeals Process
Reconsideration is the mandatory first step in the administrative review process that is provided to a claimant who is dissatisfied with an initial determination unless a hearing is the first level of appeal (e.g., a revised initial determination that results in suspension, reduction or termination of only past benefits.)
1. Description of Reconsideration
Reconsideration involves a thorough reexamination of all evidence on record including evidence produced at an informal or formal conference. DO personnel at the claims representative level or higher conduct the reconsideration. The person conducting the case review/informal conference/formal conference will make the reconsidered determination. He/She must have had no involvement in the initial determination.
2. Effect of Reconsideration Determination
A reconsidered determination is final and binding at the time it is made, unless the:
Claimant or any other party to the determination requests a hearing before an Administrative Law Judge (ALJ) within the time period and a decision is made; or
Expedited Appeals Process (EAP) is used (see SI 04060.000); or
Reconsidered determination is revised.
3. Scope of Reconsideration
The scope of reconsideration is not confined to the issues in dispute. It consists of reexamination of all evidence of record. In addition, we undertake development if there is a reasonable basis to do so. Explore all leads for obtaining evidence. If any presumption or tolerance was applied to the issue at dispute in the reconsideration request, the field office must fully develop the issue. For example, the claims representative used a match with VA records to determine VA income. The claimant alleges the VA computer match is incorrect. The FO must fully develop the VA income in making the reconsideration determination.
4. Independent Decisionmaker
The decisionmaker must not have made or previously reviewed the initial determination being reconsidered. For purposes of this subchapter, the decisionmaker is the claims representative or higher level employee.
5. Types of Reconsideration
The three types of reconsideration are:
Formal conference; or
See DI 12026.000 for instructions regarding disability hearings (DDS reconsiderations in medical/blindness cessation cases).
6. Sources of Information
In addition to the POMS, sources of information used to reconsider initial determinations include:
The Social Security Act (the Act);
Social Security Rulings;
General Counsel Opinions; and
Other pertinent laws and rulings, such as State laws on supplementary
payments, State plans on resource limits and exclusions, etc.
The FO reconsiders nonmedical issues arising from initial determinations of SSI and certain concurrent SSI/RSDHI claims. These include substantial gainful activity (SGA), income and resources, and SSA's calculation of the amount of change in the federally administered State supplementary payment amount which results from a mass change.
Specifically, the FO:
Gives the claimant a full explanation of the issues involved;
Gives the claimant a full explanation of his/her right to reconsideration and, if appropriate, continuation of payments;
Explains the nature of reconsideration to the claimant including alternatives (case review, formal conference, informal conference);
Assists the claimant in executing a request for reconsideration;
Accepts any evidence offered;
Undertakes requested development, including development requested by other components;
Forwards requests for reconsideration and related materials on cases involving medical issues to the DDS and nonmedical issues to the PC as appropriate;
Renders nonmedical reconsidered determinations; and
Determines good cause for late filing of reconsideration requests and good cause for failure to file within the 10-day Goldberg-Kelly payment continuation period.
Makes the appropriate MSSICS input to process appeal requests. See MSOM Chapter 163 and 165 for more details.
The DDS reconsiders all medical and vocational issues in SSI and concurrent SSI /RSDHI claims.
3. Program Service Center (PSC)
The PSC reconsiders title II nonmedical claims and any other matter forwarded from the field office requiring a reconsideration determination.