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GN 03960.047: Reviewer Referrals for Recalculation of the Amount of Past-Due Benefits

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  • Effective Dates: 11/14/2012 - Present
  • TN 3 (03-95)
  • GN 03960.047 Reviewer Referrals for Recalculation of the Amount of Past-Due Benefits
  • A. Process - reviewer refers for recalculation
  • The process for reviewer referrrals for recalculation of the amount of past-due benefits varies depending on whether the requester disagreed with the calculation, or the requester or reviewer wants an explanation of or more information about the calculation
  • 1. Requester disagreed with the calculation
  • If the requester disagreed with the calculation of the amount of past-due benefits on which the fee under the agreement is based, the reviewer refers the claim(s) file with a copy of the administrative review request for consideration as an appeal or as a request to reopen and revise the determination or decision about the amount of past-due benefits. Generally, a RECONR then processes the request.
  • NOTE: GN 03960.040C.2.a. and GN 03960.040C.2.b. explain why a reviewer may refer a case for a recalculation.
  • EXCEPTION ONE: Both GN 03960.045D and GN 03960.047D apply when the requester does not disagree with SSA's revision of the amount of past-due benefits or past-due benefits payable, made after SSA notified the claimant and the representative of the amount of the fee under the agreement.
  • EXCEPTION TWO: If the reviewer receives a request for administrative review in which SSA used unverified WC or PDB amounts to calculate the offset, the past-due benefits amount, and the amount of the representative's fee under the fee agreement process, he/she should return the claim file to the PC module and ask the CA to recalculate the past-due benefits amount and representative's fee using verified WC or PDB payment amounts.
  • 2. Requester or reviewer questioned the calculation
  • When the requester or reviewer simply wants an explanation of, or more information about, the calculation of the amount of past-due benefits on which the fee under the agreement is based, i.e., there is no request for an appeal including an informal or implied request, the reviewer refers the claim(s) file with a copy of the administrative review request to either the:
  • * PC module, asking that a BA ensure the accuracy of the determination of title II past-due benefits; or
  • * FO, asking that a CR ensure the accuracy of the determination of title XVI past-due benefits.
  • a. Past-due benefits amount correctly calculated
  • When the BA or CR confirms that the past-due benefits amount on which the fee is based was correctly calculated, he/she advises the reviewer and provides:
  • * the SSA-1129-U3;
  • * the explanation of proration of withheld past-due benefits, if there are one or more auxiliary beneficiaries living in a separate household from the claimant;
  • * the Supplemental Security Income Display (SSID) with the complete payment computation history; or
  • * the manually completed computation forms; and
  • * a brief narrative explanation if an unusual situation is involved or the BA or CR anticipates that the reviewer may not readily follow the calculation.
  • b. Past-due benefits amount incorrectly calculated
  • If the BA or CR discovers an error in the previous determination, he/she adheres to GN 03960.045A and does one of the following.
  • * The BA or CR revises the determination following GN 03960.047C.1., unless another SSA official has sole authority to adjudicate the issue (e.g., an ALJ issued a decision specifying a period of entitlement on which the past-due benefits due the claimant are based; however, the BA or CR now believes the period of entitlement is incorrect). In that event, the BA or CR provides the reviewer with the documentation listed in a. above and recommends referral to the proper official.
  • * When SSA may not revise or has already revised its determination(s), the BA or CR advises the reviewer of the correct amounts of past-due benefits and the fee under the terms of the agreement. The BA or CR also provides the reviewer with the documentation listed in GN 03960.047A.2.a. above. The reviewer then takes the action in GN 03960.047B or GN 03960.047D.
  • B. Process - determination not revised
  • The reviewer conducts administrative review as described in GN 03960.040C.3., GN 03960.040C.4., or GN 03960.047C.5., and GN 03960.055B.6., GN 03960.055B.7., or GN 03960.055B.8. for PC reviewers, when SSA does not revise its determination or decision.
  • C. Process - determination revised
  • When SSA revises its determination or decision about the amount of past-due benefits on which the fee is based, the person charged with authority to adjudicate that issue or the PC and the reviewer do the following.
  • 1. Adjudicator or PC actions
  • The adjudicator or responsible PC employee:
  • * Prepares notice of the revised determination or decision that includes:
  • * the amount of the fee which results from the agreement; and
  • NOTE: In title II cases, use NL 00720.050 paragraphs ATY804, ATY834, and ATYR05. In title XVI cases, use GN 03940.085, paragraph ATTM59, or ATTM63.
  • * the explanation of the parties' right to request administrative review of the amount of the revised fee within 15 days of receiving the notice.
  • NOTE: In title II cases, use NL 00720.050 paragraph ATY808 or ATY809. In title XVI cases, use GN 03940.085, paragraph ATTM69.
  • * Sends notice to the claimant, any affected auxiliary beneficiary(ies), the representative, and the decision maker.
  • * Advises the reviewer of the revision by sending him/her copies of the notices.
  • 2. Reviewer action
  • The reviewer notifies the parties that SSA will not act further on the request for administrative review.
  • D. Process - determination already revised
  • When SSA already revised its determination or decision about the amount of past-due benefits or past-due benefits payable but only after notifying the claimant and the representative of the amount of the fee under the agreement, the reviewer conducts administrative review (as GN 03960.055B.6., GN 03960.055B.7., or GN 03960.055B.8. describes for PC reviewers).
  • * The reviewer does not evaluate the representative's services if GN 03960.040C.2.c. applies.
  • * The reviewer evaluates the representative's services if GN 03960.040C.2.d. applies. The reviewer considers the correct amount of the fee which results from the agreement to assess whether the fee is reasonable under GN 03960.050C.2.
  • E. References
  • The reconsideration process, GN 03102.100 (title II) and SI 04020.010 (title XVI).
  • Jurisdiction for reconsideration requests and reopening, GN 03102.175 (title II).
  • Responsibilities of various offices in the title XVI appellate process, SI 04005.010.
  • Hearings and Appeals Council review, GN 03103.001 and GN 03104.100 (title II) and SI 04030.010 and SI 04040.010 (title XVI).
  • Hearings and Appeals Council review, GN 03103.001 and GN 03104.100 (title II) and SI 04030.010 and SI 04040.010 (title XVI).
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