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DI 42010.025: Effectuating Favorable ALJ Decisions - Onset in Period Covered by Prior Adjudicated Application

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  • Effective Dates: 04/08/2013 - Present
  • Effective Dates: 04/05/2018 - Present
  • BASIC (03-86)
  • DI 42010.025 Effectuating Favorable ALJ Decisions - Onset in Period Covered by Prior Adjudicated Application
  • Cross refer to DI 42010.230.
  • A. General
  • The ALJ has the authority to reopen and revise a prior initial, reconsidered or revised determination, or hearing decision under the rules of administrative finality. When a favorable ALJ decision is processed, payments will usually be based on the current application, unless the ALJ specifies that the prior determination or decision has been reopened and revised, or directs that payments be awarded on an earlier application, in accordance with the rules of administrative finality. See DI 27501.000 where an ALJ fails to specifically address the issue of reopening and revising a prior determination although doing so is permitted by the findings and the rules of administrative finality, an effectuating component may, on its own, reopen and revise a prior unappealed, initial or reconsideration determination (Awarding disability benefits based on the prior Application).
  • B. Preparing the determination
  • 1. ALJ reopens prior determination
  • If more than 4 years have elapsed since the initial notice was sent on a prior determination and the ALJ directs that payment be made on the prior adjudicated application without providing a basis for reopening and revision as required under the rules of administrative finality, expedite payment on the current application which was before the ALJ. Prepare an SSA-567 referring the file to an examiner for preparation of a memorandum to ODAR for clarification of the reopening issue. (See DI 42010.070)
  • If more than 4 years have elapsed since the initial notice was sent on a prior determination and the ALJ directs that payment be made on the prior adjudicated application without providing a basis for reopening and revision as required under the rules of administrative finality, expedite payment on the current application which was before the ALJ. Prepare an SSA-567 referring the file to an examiner for preparation of a memorandum to OHO for clarification of the reopening issue. (See DI 42010.070)
  • If less than 4 years have elapsed since the initial notice was sent on a prior determination and the ALJ directs that payment be made on the prior adjudicated application without providing a basis for the reopening, process the earlier application to payment as in DI 42010.020 above. Use the date of the prior application in Item 3 of the determination Form SSA-831-U5. The case will not be sent to ODAR for the purpose of having the ALJ provide a basis for the reopening.
  • If less than 4 years have elapsed since the initial notice was sent on a prior determination and the ALJ directs that payment be made on the prior adjudicated application without providing a basis for the reopening, process the earlier application to payment as in DI 42010.020 above. Use the date of the prior application in Item 3 of the determination Form SSA-831-U5. The case will not be sent to OHO for the purpose of having the ALJ provide a basis for the reopening.
  • 2. ALJ does not reopen the prior determination
  • If the ALJ decision establishes onset in the period covered by a prior adjudicated application, but does not reopen a prior, unappealed, initial or reconsideration determination, you may reopen and revise the prior determination (if doing so is supported by the ALJ's findings) and award disability benefits based on the prior application. Otherwise, (e.g., a reopening is not permitted under the rules of administrative finality, the ALJ ruled incorrectly on the reopening, or the reopening involves a prior court, AC, or ALJ decision), where possible follow the instructions in DI 42010.020 for preparing the determination form, and enter in item 3 (Filing Date) the date of the later application which was before the ALJ for a hearing. Then prepare an SSA-567 referring the case after payment to an examiner for preparation of a memorandum to ODAR for clarification of the reopening issue. (See DI 42010.070)
  • If the ALJ decision establishes onset in the period covered by a prior adjudicated application, but does not reopen a prior, unappealed, initial or reconsideration determination, you may reopen and revise the prior determination (if doing so is supported by the ALJ's findings) and award disability benefits based on the prior application. Otherwise, (e.g., a reopening is not permitted under the rules of administrative finality, the ALJ ruled incorrectly on the reopening, or the reopening involves a prior court, AC, or ALJ decision), where possible follow the instructions in DI 42010.020 for preparing the determination form, and enter in item 3 (Filing Date) the date of the later application which was before the ALJ for a hearing. Then prepare an SSA-567 referring the case after payment to an examiner for preparation of a memorandum to OHO for clarification of the reopening issue. (See DI 42010.070)
  • 3. Other
  • If the ALJ decision reopens a determination or decision made on a prior application, but incorrectly applies the rules of administrative finality, expedite payment on the current application which was before the ALJ. Prepare an SSA-567 referring the file after payment to an examiner for preparation of a memorandum to ODAR for clarification of the reopening issue. (See DI 42010.070)
  • If the ALJ decision reopens a determination or decision made on a prior application, but incorrectly applies the rules of administrative finality, expedite payment on the current application which was before the ALJ. Prepare an SSA-567 referring the file after payment to an examiner for preparation of a memorandum to OHO for clarification of the reopening issue. (See DI 42010.070)
  • Within 4 years after the date of the initial notice, a prior determination may be reopened if there is new and material evidence, including hearing testimony. Therefore, it will be unnecessary to refer the case to ODAR for clarification merely because the ALJ does not provide a rationale for reopening under the rules of administrative finality.
  • Within 4 years after the date of the initial notice, a prior determination may be reopened if there is new and material evidence, including hearing testimony. Therefore, it will be unnecessary to refer the case to OHO for clarification merely because the ALJ does not provide a rationale for reopening under the rules of administrative finality.
  • NOTE: If the ALJ misapplies the rules of administrative finality to reopen a prior determination more than 4 years after the date of the initial notice, i.e., in the absence of error on the face of the evidence or the other conditions for reopening at any time, action should be expedited to refer the case to ODAR, to ensure that the AC can take action within the 60-day period for its own motion review.
  • NOTE: If the ALJ misapplies the rules of administrative finality to reopen a prior determination more than 4 years after the date of the initial notice, i.e., in the absence of error on the face of the evidence or the other conditions for reopening at any time, action should be expedited to refer the case to OHO, to ensure that the AC can take action within the 60-day period for its own motion review.
  • If the ALJ issues an amended decision indicating that the prior determination is reopened and revised, prepare an amended award on the basis of the earlier application.
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