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This change was made on May 30, 2018. See latest version.
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DI 27515.015: Questioning the Prior Disability Determination

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  • Effective Dates: 08/16/2010 - Present
  • Effective Dates: 05/30/2018 - Present
  • TN 9 (10-93)
  • DI 27515.015 Questioning the Prior Disability Determination
  • A. Policy
  • 1. General
  • A final disability determination is controlling in the adjudication of a subsequent disability claim, provided there is a common issue(s) (See DI 27515.001A.1.a.) and there is no reason to question that prior determination
  • 2. When To Question A Prior Favorable Determination
  • * Question the prior favorable disability determination only where the situations below (see 2b) are thought to exist either because of the receipt of new information or because folder review for other reasons has surfaced questions.
  • * A prior favorable disability determination or decision will stand unless it is wrong and can be reopened and revised under the rules of administrative finality. See DI 27505.010B, DI 27505.010C and DI 27505.015A.
  • * See DI 27515.015B.2. and DI 27515.015B.3. when the prior favorable determination is incorrect but reopening is not possible.
  • 3. When Not To Question A Prior FavorableDetermination
  • A prior favorable determination will not be questioned unless reason exists to believe situations in DI 27505.010B.1., DI 27505.010B.2. and DI 27505.015A. exist.
  • NOTE: A folder should not be routinely reviewed to determine the correctness of a decision.
  • 4. When A Prior Favorable Determination is Questioned
  • Processing of a potential adoption claim involving a prior questioned determination meeting the criteria in DI 27515.015A.2.b. will depend on whether that determination was an initial, reconsidered or revised determination, of a SHO, ALJ, or AC decision and whether it can be reopened and revised within the time limits of the rules for administrative finality in DI 27505.001ff.
  • 5. What to Develop
  • Most reopenings and revisions based on adverse medical decisions require that MIRS standard be applied (DI 28005.001D). Development to support such findings should be done per DI 28030.020ff).
  • B. Procedure
  • 1. Reopenings
  • A questioned initial, reconsidered or revised claim can be reopened if the following guidelines apply:
  • If the Determination/ Decision was...
  • Then...
  • an Initial,Reconsidered, or revised claim determination
  • * reopen and revise the determination and provide due process if appropriate per DI 28080.001-.050.
  • * prepare a revised determination in accordance with DI 27530.025 and DI 27530.015.
  • * prepare a consistent determination on the subsequent claim.
  • a DHO determination
  • * forward the title XVI and title II claims to the DHU that made the prior determination.
  • * identify reason for referral and specify the evidence that impacts on determination.
  • * see DI 33015.055 for DHU instructions.
  • and ALJ or AC
  • * forward the title II and title XVI claims to the Associate Regional Commissioner (ARC), Programs, for coordination with the Office of Disability Adjudication Review (ODAR).
  • * forward the title II and title XVI claims to the Associate Regional Commissioner (ARC), Programs, for coordination with the Office of Hearings Operations (OHO).
  • NOTE: Referrals should be limited, must be strongly supported by the evidence in file and clearly documented and defined in referral to the ARC, Programs.
  • * Identify the specific reason for questioning the final decision in the referral.
  • * adopt the prior decision as the final decision of the Secretary if ODAR responds that no action can be taken to reopen a decision and process the determination as directed under DI 27515.015B.2 and 3.
  • * adopt the prior decision as the final decision of the Secretary if OHO responds that no action can be taken to reopen a decision and process the determination as directed under DI 27515.015B.2 and 3.
  • 2. Prior XVI Unfavorable Determination
  • Prior Title XVI determination or decision cannot be reopened. Processing will depend on whether the questioned final determination or decision was favorable or unfavorable to the claimant. See the chart below of processing:
  • If the Determination/ Decision was...
  • Then...
  • new and material evidence is received with a title II claim
  • * Prepare a favorable title II determination.
  • * Instruct the FO to solicit a new application for title XVI and develop an necessary. (See DI 27510.005B).
  • a change in the definition of disability or disability requirement
  • * Prepare a favorable title II determination.
  • * Determine if new and material evidence is received with the title II claim.
  • * Determine if the QC (or DWB/CDB eligibility) requirement continued to be met after the period adjudicated in the title XVI claim.
  • * Solicit a new title XVI application. (See DI 27510.005B).
  • no new evidence and no change in definition is made, but claimant meets QC requirements
  • Prepare a title II determination for the unadjudicated period through the earlier of the date QC requirement last met, the date DWB/CDB eligibility last met, or through the date of the current determination.
  • no new evidence and no change in definition is made, but claimant-QC requirements not met
  • * Send the title II claim and title XVI determination (folders) to ODIO /PSC via SSA-408 without the title II determination.
  • * Cite this reference as reason for referral.
  • * State that the new claim presents no new facts material to the issue of disability.
  • * Request ODIO/PSC to send the title XVI and title II folders to the FO upon completion of their action of the title II claim.
  • * FO's will prepare a res judicata denial.
  • 3. Prior Favorable XVI Determination
  • See chart below for processing:
  • If the Determination/ Decision is...
  • Then...
  • favorable and based on a title XVI claim which is over 2 years old
  • Do not reopen the determination except for fraud or similar fault.
  • that the claimant has medically improved and can do SGA or an error exception to MIRS applies
  • * Prepare a title XVI cessation determination see DI 28005.205 for cessation date.
  • * Adopt the title XVI cessation determination to establish a closed period of disability on the title II claim with the ending date coinciding with the title XVI cessation date.
  • that claimant worked more than 12 months at SGA, the work stopped; and claimant still disabled
  • * Adopt the title XVI determination.
  • * Establish onset with the latter of:
  • the first day of the month after the last month of SGA, or
  • the date the individual first meets insured status.
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