DI 28501.001: Continuing Disability Review (CDR) Reopening Overview and Definitions

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~~Effective Dates: 01/23/1990 - Present~~
Effective Dates: 12/12/2017 - Present
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NOTE: The audience for all sections and subchapters within this chapter is as follows: DO/BO/TSC—OS, RR; PSC—CRTA, DE, DEC, DTE, IES, RECONR; ODO—DE, DEC, DS, IS, ISTA, RECONE; INTPSC—CIES, ERE, FCR, FDE, RECONE; DDS—ADJ, DHU
BASIC (03-86)
TN 1 (12-17)
~~DI 28501.001 Question of Reopening Arises~~
DI 28501.001 Continuing Disability Review (CDR) Reopening Overview and Definitions
Cases may be encountered in which the DDS finds a previous continuing disability determination was wrong. In such situations, reopening and revision may be appropriate, unless such action is precluded by the rules of administrative finality.
A. When a question of reopening arises during a CDR
There may be cases where a previous CDR determination was incorrect. If the rules of administrative finality allow, it may be appropriate to reopen and revise these determinations. The instructions in this section provide information that assists the disability determinations services (DDS) when considering the reopening of a prior favorable or cessation CDR determination. For more information on administrative finality, see subchapter GN 04000.000. For more information on reopening a “final determination or decision,” see DI 27505.001.
B. Definitions
1. Reopening
A “reopening” is a formal review of a determination or decision that has become administratively final. Reopening may occur to admit new and material evidence or to correct an error. The DDS can reevaluate the evidence used in a prior determination or decision when an error is involved.
NOTE: The term “determination” refers to adjudications at the initial and reconsideration levels or by a disability hearing officer (DHO). The term “decision” refers to adjudications at the administrative law judge (ALJ) or the Appeals Council (AC) levels. For more information about these terms and definitions, see §§ 404.901, 404,917, 416.1401, and 416.1417.
2. Final determination or decision
A “determination” or “decision” (initial or revised) is “final” as of the date of the notice unless:
* it is timely appealed (or a civil suit is filed);
* it is appealed late but good cause for late filing of an appeal or civil suit is found;
* the AC takes jurisdiction on its own motion within 60 days of the date of the ALJ decision;
* the AC denies a request for review (does not issue a decision), in which case the ALJ decision is the final decision as of the date of the notice that the AC denied review; or
* it is reopened and revised.
3. Revision
A “revision” is any change in the end result or basis of a “final determination or decision” made in the administrative review process.
4. Due process
Due process requires the DDS to provide the essential information to the beneficiary (and any representative payee) on the right to appeal and submit rebuttal evidence before taking any action that will unfavorably affect benefits.
C. Reopening and revising under the rules of administrative finality
Under administrative finality, determinations become final and binding immediately, unless they are timely appealed or later reopened and revised for special reasons. It prevents perpetual readjudication.
Under the rules of administrative finality, the Disability Determination Services (DDS) may reopen and revise a previous cessation to reflect a continuance or a change in the cessation date.
The DDS will only reopen final determinations. A determination is “final” as of the date of the determination notice, see DI 28501.001B. in this section. For information on reopening and revising a determination, see DI 27501.001 and DI 27501.005.
D. Due process notifications
Due process requires the DDS to inform the beneficiary (and his or her representative payee, if any) of the right to appeal and offer rebuttal evidence before taking any action that will unfavorably affect their benefits.
Provide due process notification by sending either a due process predetermination notice or a due process notice. Send the predetermination notice when benefit continuation language is not required. Provide due process in the determination notice in medical cessation cases when benefit continuation language is required.
When reopening a cessation to make a more favorable determination, do not send a predetermination due process notice.
When reopening a prior cessation determination due to an earlier or later cessation date, send a due process determination notice if the revised determination requires benefit continuation language.
For information on due process notifications for adverse reopenings, see DI 27525.001.
1. Predetermination notice
The predetermination notice applies to reopenings that do not require benefit continuation language. In adverse reopening determinations of concurrent Title II or Title XVI claims, the Title XVI due process requirements also apply to the Title II claim.
Send a predetermination notice if the prior determination involves one of the following:
* change from blind to disabled;
* failure to follow prescribed treatment, for Title II only cases;
* fraud or similar fault (FSF);
* failure to cooperate (FTC) when FTC arose at the field office (FO). In FTC cases identified by the DDS, statutory benefit continuation will be offered because these FTC cessations are considered medical determinations; or
* whereabouts unknown (WU); the FO provides all notices. See DI 27540.030 and DI 28075.005G.
2. Due process determination notice
The due process determination notice applies to adverse medical CDR reopenings.
When reopening a prior cessation determination due to an earlier or later cessation date, send a due process determination notice if the revised determination requires benefit continuation language.
E. Reopening precluded by administrative finality
When administrative finality does not allow the DDS to reopen a previous determination or decision, they may prepare a current determination reflecting a new period of disability.
The onset of the current determination may be set within the previously adjudicated period only:
* If the total evidence clearly supports the new onset, and
* If the previous determination was made at the initial or reconsideration level.
An SSA-831 determination rationale and notices must be prepared according to the usual procedures.
NOTE: We will only pay benefits based on the current application.
F. References
DI 12027.015 Cases Excluded from Statutory Benefit Continuation (SBC)
DI 25501.250 Establishing an Established Onset Date by Reopening Prior Disability Filings and Previously Adjudicated Periods
DI 27501.000 General
DI 27505.000 Rules for Reopening
DI 27505.015 Fraud of Similar Fault - Reopenings
DI 27536.010 Required Information for Reopening Continuing Disability Review Determinations
DI 40115.005 Definitions and Processing Instructions for Changing Initial Disability Determinations in the Processing Center (PC)
DI 81030.120 Reopenings – Certified Electronic Folders (CEF)
GN 04000.000 Administrative Finality
GN 04001.040 Role of Notice in Reopening
GN 04020.010 Unrestricted Reopening for Determinations or Decisions Involving Fraud of Similar Fault
SI 04070.000 Administrative Finality – SSI

POMS Reference

DI 28501.001: Continuing Disability Review (CDR) Reopening Overview and Definitions