POMS Reference

DI 12010: Hearings Level Review - Initial Claims

TN 3 (07-10)

A. Policy for FO reversal of nonmedical determination

The FO reviews the request for hearing and any new evidence to determine whether the reconsidered nonmedical determination was correct, if the determination was made by the FO. If warranted, the FO may reverse an adverse determination to a wholly or partially favorable nonmedical determination.

B. Procedure when new evidence is submitted

1. Case review

Review the claim folder(s) thoroughly to eliminate sending unwarranted appeals to Office of Hearings Operations (OHO).

2. Reversal of prior denial

If the FO determines that the reconsidered nonmedical determination may be reversed, take the following actions:

a. Determination

Reopen and revise the reconsideration denial and document the new determination on the appropriate form e.g., SSA-821-BK (Work Activity Report-Employee), SSA-820-F4 (Work Activity Report (Self Employed Person), SSA-553 (Special Determination), SSA-8450 (District Office Record of SSI Reconsideration). If the case is electronic, fax the forms into eView.

Follow DI 12005.010F for the notice requirements, making the required inputs, technical reactivation of the prior claim, updating development, and routing.

b. Notice – reversal of non-medical denial

  • Use the Modernized Claims System (MCS) or the Modernized Supplemental Security Income Claims System (MSSICS) whenever possible to release the appropriate notice. Otherwise use the Document Processing System (DPS).

  • Send the claimant an interim notice titled “Reversal of Nonmedical Denial” located in the DPS Initial Claims folder, to advise him or her of the reversal and that processing of the initial application will resume.

  • Send a copy of the interim notice to the same OHO office to which the HA 501-U5 (Request for Hearing) was sent. OHO will send a notice to the claimant stating that the request will be dismissed in 30 days unless the claimant contacts OHO.

  • Retain a copy of the interim notice for the claim folder(s).

c. Development - Title II

Update and complete any outstanding medical and vocational development.

d. Development - Title XVI

Take the following actions to update development and review nonmedical issues:

  • Update and complete any outstanding medical and vocational development.

  • Review all nonmedical issues and resolve any questionable issues that preclude payment.

e. Routing

  • Send the folder to the disability determination services (DDS) or processing center (PC) for an initial disability determination upon completion of FO action.

  • Annotate the route slip as appropriate, e.g., “Initial Title II and/or Title XVI Disability/Blindness Determination Needed.”

3. Affirmation of prior denial

Send the folder to the hearing office within 7 days for action on the hearing request if it is determined that the prior reconsideration denial was appropriate.