TN 4 (08-03)

A. Introduction

Determinations or decisions made after the date of the Circuit Court decision and before the effective date of the AR may be subject to readjudication. The claimant must request readjudication. The claimant may do this either in response to a notice sent to him or her or may do it on his or her own initiative. A request for readjudication should be granted if the adjudicator’s review of the information about the claim shows that application of the AR could change the prior determination or decision. See GN03501.015C.1. Just because readjudication is granted does not mean that the result of the prior determination will change when the AR is applied to the prior claim. Any readjudication will be limited to consideration of the issue(s) covered by the AR.

B. Policy

1. Readjudication

Readjudication may apply to claimants with pending claims (i.e., cases awaiting adjudication on administrative review or adjudicated cases in which the time to request administrative review has not expired) and applies to claimants with lapsed claims (i.e., those in which a timely appeal has not been pursued). See the section under Limits on Readjudication for handling cases in which an appeal is pending or a subsequent application has been filed. (See GN 03501.015B.2.)

2. Limits on Readjudication

• Limit the readjudication to the issue(s) covered by the AR.

• The period covered by a readjudication is the same period that was covered by the previous determination or decision being readjudicated. If benefits are allowed for this period as a result of readjudication, the adjudicator’s decision must also cover the period through the date of the revised determination or decision. Therefore, in this situation the adjudicator and/or FO (as appropriate) must fully develop and adjudicate the claim up to the present.

• If there is an appeal pending on either the application that was the basis for the request for readjudication or on an application subsequently filed, the AR is applied on that appeal and there is no need to return the case to the point of last adjudication for readjudication. However, if for any reason the appeal does not result in a new determination or decision in which the AR is applied, e.g. AC decision not to review or AC/ALJ dismissal, then the case would be returned to the place that last adjudicated it for a decision on the readjudication request and possible readjudication.

• If a subsequent claim is pending, the readjudication request may be held until adjudication of the claim based on a subsequent application is completed. If the decision on the subsequent claim fully considers application of the AR for the entire period covered by the application upon which the readjudication request is based, no further action on the request will be necessary.

• If the entire period is not covered by the decision on a subsequent claim, the claim must be returned to the last point of adjudication of the prior claim for action on the request for readjudication.

C. Procedure

In medical/vocational issue cases, the component responsible for readjudication is the component where the case was last adjudicated (e.g., DDS, ODAR). Refer the case to the component where the claim was last adjudicated, unless an appeal or a subsequent claim is pending. If an appeal or subsequent claim is pending, see “Limits on Readjudication” above for special handling. Normally, the component that last adjudicated the case will decide whether readjudication under the AR is warranted and, if so, will perform the readjudication. In non-disability and non-medical/vocational disability issue cases, the readjudication responsibility will follow existing FO, ODAR or other component procedures.

1. Allow request for readjudication if all of the following conditions are met:

• A claimant lived in the applicable circuit at the time when the prior determination or decision was made on the claim that is the subject of the request for readjudication; and

• That determination or decision was made on or after the date of the circuit court decision; and

• The AR was not previously applied to the claimant’s case; and

• The adjudicator’s review of the information about the claimant’s case shows that the issue or issues that were the subject of the AR are involved in the claimant’s case.

If readjudication is granted, the adjudicator will issue a revised determination or decision without regard to the normal rules for reopening. This readjudication will be limited to the issue(s) covered by the AR. The revised determination or decision will be effectuated as if it were issued on the date of the original determination or decision. If the determination or decision based on the readjudication is partially or fully favorable, the adjudicator must develop and adjudicate the case through the date of the revised determination or decision (i.e., up to the present).

If you are unable to allow the request for readjudication under the above criteria, send the claimant the notice contained in GN 03501.015D.3.

2. Denial of a request for readjudication:

Denial of a request for readjudication (with no appeal rights provided) is appropriate when it is clear that application of the AR could not change the prior determination or decision based on the criteria noted above. For instance, denial of a request for readjudication would be appropriate if the prior disability denial determination was made at step 1 of the sequential evaluation process, and the AR, by its terms, is only applicable to step 5 denials. A request for readjudication should not be denied based on more in-depth, less clear cut, adjudicative judgments concerning whether application of the AR could change the prior determination or decision. Instead, those types of issues should be determined after the request for readjudication is granted.

If the adjudicator reviewing the request determines, in accordance with the criteria noted above, that application of the AR to the claimant’s case could not change the determination or decision, the adjudicator should send a notice to the claimant advising him or her that the request for readjudication is denied. (See GN 03501.015D.3. and GN 03501.015D.4. under “Appeal Rights and Notice Language”).

D. Appeal Rights and Notice Language

No appeal rights attach to a denial of a request for readjudication. Appeal rights apply when a request for readjudication is granted even if it is ultimately determined upon readjudication that application of the AR does not change the result in the prior determination or decision made in the case.

1. A claimant with a current claim who received a determination or decision and does not request readjudication.

A claimant with a current claim who received a determination or decision on or after the date of the circuit court decision, and before the date of the publication of the AR, and does not request readjudication under the AR is entitled to have the AR applied on timely appeal of that determination or decision. Normal appeal rights would apply to decisions made on appeal, and no special notice language is needed.

2. Readjudication request granted

When a claimant requests readjudication and it is granted, the claimant has 60 days after the date he or she receives the revised determination or decision to appeal the revised determination or decision on his or her claim made under the AR in accordance with the readjudication procedures. The appeal rights are generally limited to consideration of the issue(s) covered by the AR.

Notice Language: If the prior determination remains unchanged as a result of readjudication, include this language in the notice: “You asked us to look at our earlier decision on your claim because you thought the (fill-in) acquiescence ruling could change the prior determination or decision we made. We have decided that application of the (fill-in) acquiescence ruling does not change the prior determination or decision in your case. [Insert here an explanation of why the AR does not change the prior determination or decision.] If you believe this decision is not correct you have 60 days from the date you receive this notice to request appeal of our decision applying the AR to your claim.”

3. Readjudication request denied

Do not provide appeal rights if you deny the request for readjudication (because the individual does not meet the criteria shown at GN 03501.015C to allow a request for readjudication to be granted) for a person whose time to appeal the prior determination lapsed prior to the time of his or her request for readjudication under the AR. The denial of a request for readjudication to have an AR applied is not an initial determination subject to appeal. Include the following in your notice:

Notice Language: “You asked us to look at the earlier decision in your claim because you thought the (fill-in) acquiescence ruling could change the prior decision. We have looked at your case and decided that application of the (fill-in) acquiescence ruling could not change the prior determination or decision. (Insert here an explanation of why the AR could not change the prior determination or decision. See the criteria contained in GN03501.015C.) The earlier decision remains the final decision of the agency in your case.”

4. Readjudication requested within the 60-day appeal period for the prior determination or decision, and the request is denied—Prior determination or decision not appealed.

If a claimant received a determination or decision and requests readjudication under the AR within the 60-day appeal period for that decision, but does not request an appeal of the decision, and you deny the request for readjudication, the claimant should be given a new 60-day appeal period on the original decision. The date of the notice denying the request for readjudication under the AR begins the new 60-day period. Include the following in your notice:

Notice Language: “You asked us to look at the earlier decision in your claim because you thought the (fill-in) acquiescence ruling could change the prior decision we made on your claim. We have looked at your case and decided that application of the (fill-in) acquiescence ruling could not change the prior determination or decision. The earlier decision remains in effect. If you believe the earlier decision is not correct, you have 60 days after the date you receive this notice to request appeal of that decision.”

5. Readjudication results in less than a fully favorable decision

When a claimant requests readjudication and the readjudication changes the prior determination, but it results in an award of some, but not all, benefits requested in the application, the claimant will have 60 days from the date he or she receives this notice to request appeal of this decision applying the AR to his or her claim. Include the following language in your notice:

Notice Language

“You asked us to look at the earlier decision on your claim because you thought the (fill-in) acquiescence ruling could change the prior determination or decision we made. We have looked at your case and decided that application of the (fill-in) acquiescence ruling does change the prior determination or decision in your case but we can not grant all benefits you requested in your application. (Insert an explanation of why all the benefits requested cannot be allowed.) If you believe this decision is not correct you have 60 days from the date you receive this notice to request appeal of our decision.”

6. Readjudication results in a fully favorable decision

When a claimant requests readjudication and the readjudication changes the prior decision or determination resulting in a granting of all benefits requested in the application, include this language in the notice.

Notice Language

“You asked us to look at the earlier decision on your claim because you thought the (fill-in) acquiescence ruling could change the prior determination or decision we made. We have looked at your case and decided that application of the (fill-in) acquiescence ruling does change the prior determination or decision in your case and we will grant all benefits you requested in your application.” If you believe this decision is not correct you have 60 days from the date you receive this notice to request appeal of our decision.”