GN 03102: Reconsideration (Title II and Entitlement Under Title XVIII)
TN 7 (01-13)
A. Introduction to the reconsideration process
This subchapter contains general policies and procedures for developing and processing reconsideration requests under title II and reconsideration requests on Medicare entitlement under title XVIII. For appeal policies and procedures for other issues, see the following instructions:
for title XVI reconsiderations, see SI 04020.000,
for reconsiderations of medical denials, see DI 81010.150,
for reconsideration of benefits for special veterans, see VB 02502.001,
for the Centers for Medicare and Medicaid Services (CMS) processing of appeals of the amount paid or covered services for Medicare Parts A and B, see HI 00208.070 and HI 01205.005,
for appeals of Medicare Income Related Monthly Adjustment Amounts (IRMAA), see HI 01140.000, and for the appeal process for Medicare Part D subsidy determination, see HI 03040.001.
B. Definitions for the reconsideration process
1. Reconsideration
Reconsideration is the mandatory first step in the administrative review process that the Social Security Administration (SSA) provides to a claimant dissatisfied with an initial determination. Exceptions to the mandatory reconsideration step and in which a hearing is the first level of review are listed in 20 CFR 404.930(a) (2), (6), and (7).
Reconsideration involves a thorough reexamination of all evidence on record. The person reviewing the case will make the reconsideration determination based on all evidence used in the initial determination and any additional evidence or information submitted with the appeal. The reviewer must not have been involved in the initial determination.
2. Processing Centers (PC)
PC refers to all program service centers (PSC), the Office of Disability Operations (ODO), and the Office of Central Operations (OCO). For a list of title II non-medical reconsideration requests that are the jurisdiction of the PCs, refer to GN 03102.175B.
C. Policy for reconsideration requests
1. Who has the right to a reconsideration
Any party to the initial determination or any party who shows in writing that his or her rights may be adversely affected by the initial determination has the right to a reconsideration. For more information about the appeal of an initial determination, see GN 03101.040.
2. Who may request a reconsideration
The claimant, his or her appointed representative, representative payee, or other third party on behalf of the claimant can file a request for reconsideration. The SSA employee must provide to the claimant a copy of the request for reconsideration as notification that SSA received the appeal.
NOTE: Effective March 16, 2012, appointed representatives have the affirmative duty to use the iAppeals (i561 (Internet Request for Reconsideration), i501 (Internet Request for Hearing by Administrative Law Judge), and i3441 (Internet Disability Report-Appeal)) application to file a request for reconsideration or a request for hearing on a medically denied claim if they request direct fee payment on that matter. For more information on the policy on affirmative duties for representatives, see GN 03970.010B.
3. What constitutes a writing for a reconsideration request
Any writing (SSA-561-U2, letter, facsimile, or email) or timely submission of additional evidence after receiving a notice of initial determination by the claimant, his or her representative payee, or his or her appointed representative which clearly implies disagreement with the initial determination constitutes a request for reconsideration. A signature is not required on a written request for reconsideration.
A claimant may submit the iAppeals i561 to request a reconsideration for a medical or non-medical issue. For information on the iAppeals process for title II claims, see GN 03101.125 and GN 03101.127.
A request for reconsideration must be in writing. An oral inquiry such as a phone call to the national 800 number network or to a field office (FO) to request forms is not a valid request for reconsideration and does not protect the date of an appeal.
4. What is not a request for reconsideration
A mere request for information or an explanation of SSA’s determination does not constitute a request for reconsideration.
Actions that are not initial determinations are not subject to reconsideration. For examples of actions that are not initial determinations, see GN 03101.080.
5. Dismissal of a request for reconsideration
Dismissal of a request for reconsideration is the rejection of or refusal to accept the request. The action makes the prior determination the final determination of the Commissioner. A dismissal is not subject to appeal. For more information on grounds for dismissal of an appeal, see GN 03102.200B.
6. Time period to request reconsideration
The appeal period is generally 60 days. The 60 days start the day after the individual receives the notice of the determination or decision. SSA presumes the date that the individual receives the notice is 5 days after the date on the notice, unless the individual can show us that he or she did not receive the notice within the 5 days.
Exceptions:
Do not add 5 days for mailing when you hand the notice to the claimant.
Extend the time to include the next full workday when the period for requesting the appeal ends on a Saturday, Sunday, legal holiday or any other day, all or part of, which is a non-workday for Federal employees.
Use the stamp cancellation or “postmark” date on the envelope for a mailed appeal if the receipt date would result in the loss or lessening of the claimant’s rights or benefits. If the postmark is unreadable or there is no postmark, we consider the appeal timely filed if we receive it by the 70th day after the date on the notice of the determination or decision. For instructions on good cause for extending the appeal period, see GN 03101.020.
7. Where to submit a request for reconsideration
A claimant can submit a request for reconsideration to any SSA office, Veterans Administration Regional Office in the Philippines, or any Railroad Retirement Board Office if the claimant has at least 10 or more years or after December 31, 1995 has at least 5 years of railroad service (see RS 01601.110A.1.).
8. SSA cannot reconsider an initial determination on its own motion
SSA may not reconsider a determination on its own motion. However, without a request from the claimant, SSA may correct an error in an initial determination under the rules of administrative finality. For more information on administrative finality, see GN 04001.000.
9. Reconsideration filed early
a. Initial determination not made
Send the claimant a letter that explains that we have not made a decision and that he or she can file an appeal after we make a decision. See the exhibit letter for an appeal requested before a decision is made on a case in NL 00703.470.
b. Notice pending release or in transit
If a notice is pending release or is in transit, e.g., SSA made the initial determination and the notice appears on Online Retrieval System (ORS), but the claimant has not received it, accept the appeal.
10. Reconsideration filed late
a. Claimant submits request for reconsideration or submits additional evidence after the 60–day period for requesting reconsideration
Accept the request for reconsideration. SSA may extend the time limit for requesting a reconsideration if the request for an extension is in writing and the claimant shows good cause for missing the time limit. In most cases, the component responsible for making the reconsideration determination will make the good cause determination. The claimant cannot appeal a determination where SSA did not find good cause. For instructions on obtaining and processing a good cause statement, see GN 03101.020.
b. Claimant submits additional evidence after the 60–day period for requesting reconsideration
Accept the evidence and develop for good cause. See GN 03101.020 for instructions on obtaining and processing a good cause statement.
11. Notice of reconsidered determination
The notice advises the claimant of the determination and its basis, and informs him or her of the right to a hearing. If appropriate, an explanation of the Expedited Appeals Process is included. For instructions on reconsideration notices of determination, see GN 03102.425. For instructions on the expedited appeals process, see GN 03107.100.
D. References
SI 04020.000 Reconsideration - SSI
GN 03101.070 Appeals of Actions Which Are Initial Determinations
DI 12005.000 Reconsiderations – Initial Claims
DI 12025.000 Reconsideration – Postentitlement
VB 02502.000 Reconsideration
GN 03108.000 Medicare Procedures
DI 80830.050 Initial Claims and Reconsideration Actions