Other than the 12-month period for reopening for any reason (see HALLEX HA 01290.030), an administrative law judge (ALJ) may reopen a determination or decision that is otherwise final, for good cause as follows:

• •

  Within four years from the date of the notice of the initial determination in a claim under title II; or

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  Within two years from the date of the notice of the initial determination in a claim under title XVI.

If a claimant requests reopening after the specified time for reopening has expired, the ALJ will deny the request (unless a basis for reopening at any time under 20 CFR 404.988 and 416.1488 exists). The ALJ must notify the claimant in writing of the denial and the rationale for it.

Good cause for reopening a determination or decision exists under the following circumstances:

1. 1. 

   New and material evidence is furnished;

2. 2. 

   A clerical error in the computation or recomputation of benefits was made for a claim under title II, or a clerical error was made for a claim under title XVI; or

3. 3. 

   The evidence that was considered in making the determination or decision clearly shows on its face that an error was made.

However, in the Fourth Circuit, cases must be handled in accordance with Acquiescence Ruling (AR) 90-4(4). In these cases, SSA must reopen an otherwise final administrative determination at any time when a claimant had no one legally responsible for prosecuting the claim at the time of the prior adjudication and establishes he or she lacked the mental capacity to understand the procedures for requesting review, unless SSA holds an evidentiary hearing and determines that mental incompetence did not prevent the claimant from filing a timely appeal.

To satisfy the regulatory standard for reopening, evidence is “new and material” when:

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  The evidence is not part of the claim(s) record as of the date of the determination or decision;

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  The evidence relates to the period on or before the date of the determination or decision; and

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  The evidence shows facts that would have resulted in a different conclusion as to eligibility, entitlement, or benefit amount than originally reached had the evidence been introduced or available at the time of the determination or decision.

For more information, see the Appeals Council Interpretation at HALLEX HA 02510.009.

EXAMPLES:

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  New medical evidence shows that the claimant's impairment met an impairment listed in 20 CFR Part 404, Subpart P, Appendix 1, during the previously adjudicated period and that an allowance based on the prior application is warranted.

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  New medical evidence shows that an original medical prognosis did not prove to be accurate, and that an allowance based on a prior application is warranted; e.g., the prior adjudicator believed that the claimant's broken hip would be healed within 12 months but later medical evidence shows that the broken hip had not healed sufficiently within 12 months to permit the claimant to return to substantial gainful activity.

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  New earnings information, which was not previously on SSA records, indicates that the date last insured identified in the previous determination or decision was incorrect, and that the correct date last insured would result in a different conclusion as to eligibility, entitlement, or benefit amount than originally reached.

A clerical error is a mathematical error, misapplication of benefit tables, etc., that resulted in an incorrect payment of a monthly benefit or an incorrect lump-sum death payment. It ordinarily occurs in the computation or recomputation of benefits.

Error on the face of the evidence is an obvious error that clearly causes an incorrect determination or decision. The following are examples of error on the face of the evidence:

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  The adjudicator relied on the wrong person's medical report or earnings record.

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  In a title II only claim, onset of disability was established after the claimant last met the special earnings requirements.

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  Benefits in a cessation case were terminated as of the month disability ceased, rather than being terminated as of the close of the second month following the month in which disability ceased.

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  Evidence in the possession of SSA at the time of a determination or decision clearly shows that the determination or decision was incorrect.

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  A Supreme Court decision found a law that we applied to be unconstitutional. See Social Security Ruling 17-1p.

EXAMPLE

While a claim was being processed, the claimant submitted a medical report to the Social Security field office that would have resulted in a different conclusion. However, the medical report was not associated with the claim file until after the determination or decision became final.

A change of legal interpretation or administrative ruling may be the result of a change in a regulation, a decision of the United States Supreme Court, a court order in a class action case, or the issuance of an SSR or an AR.

A change of legal interpretation or administrative ruling is not “good cause” to reopen a determination or decision under the two or four-year rules. Although a change of legal interpretation or administrative ruling may be a basis for reopening within 12 months of the date of the initial determination, reopening for this reason is appropriate only if the result would be favorable to the claimant.

If a statute has been amended, any reopening depends on the provisions of the amendment itself. The amendment will provide the effective date of the change and indicate its effect on any prior determinations or decisions.