SI 04005: Administrative Review (Appeals) Process - SSI
TN 1 (07-99)
Citations:
Sections 702(a)(5) , 1631 , and 1633 of the Social Security Act
Social Security Act (the Act) (42 U.S.C. 902(a)(5), 1383, and 1383(b));
A. Policy - Levels of Administrative Review
Under the Act and regulations, a person who disagrees with an initial determination or decision may request further review. This is called an appeal. The appeal consists of several levels of administrative review that must be requested within certain time periods and at the proper level. The levels of administrative review are reconsideration, administrative law judge (ALJ) hearing, and Appeals Council (AC) review. The AC review ends the administrative review process. If an individual is still dissatisfied, he or she may request judicial review which is done by filing an action in Federal court.
If the individual does not request review within the time period, he or she may lose the right of further review unless he or she can show good cause for failure to make a timely request for review.
1. Reconsideration
If an individual disagrees with the initial determination, reconsideration is the first step in the administrative review process.
The method of reconsideration for title XVI consists of a case review, informal conference, or formal conference. The method used depends on the issue involved. In SSI disability/blindness claims, medical issues can only be reconsidered through case review. Nonmedical issues can be reconsidered through either case review or informal conference. Generally, if we are taking an adverse action, the recipient can request case review, informal conference or a formal conference. See SI 04020.000 ff. for a full explanation of the reconsideration review.
2. ALJ Hearing
In general, a hearing before an ALJ, is the next level of appeal after we have made a reconsideration determination. There are exceptions to this general rule. For more information, see SI 04030.010C.2. and SI 04070.050A.4. and SI 04070.050A.5.
3. Appeals Council
If the individual disagrees with either the ALJ decision or the dismissal of a hearing request, he or she may ask the AC to review the action. The AC may dismiss or deny the request for review, or it may grant the request and either issue a decision or remand the case to an ALJ. The AC may also review an ALJ decision (within 60 days of the hearing decision or dismissal) on its own motion. The AC has final review authority for SSA.
4. Expedited Appeals Process (EAP)
An individual may request EAP but only after appealing at least through the reconsideration step. See SI 04060.000 for more details on the EAP process. EAP may be used in those cases in which the individual does not dispute SSAs version of the facts in his or her claim. Rather, he or she challenges the constitutionality of the law underlying the determination. SSA, and all parties to the determination, must agree to using EAP.
5. Federal Court Review
The AC review completes the administrative review process. If an individual is still dissatisfied, he or she may request judicial review which is done by filing a civil action in a Federal district court.
B. Policy - Multiple Issues at Different Levels of Appeal
1. Disposition of ALJ Decision
It is possible for a case to have different issues at different levels of appeal. Once the ALJ issues a decision and notifies the individual, the case goes to the FO for effectuation of the ALJ decision. The FO then sends a notice on those issues that were not addressed by the ALJ. This notice will provide the claimant with a reconsideration as the next level of appeal. The ALJ's notice will provide the claimant with AC review as the next level of appeal.
2. New Issue Before the ALJ
The ALJ may consider a new issue at the hearing even though it arose after the hearing request and even though it has not been considered in an initial or reconsidered determination. The ALJ will notify all parties to the hearing about the new issue.
C. Policy - Nature of the Process
Administrative review is conducted in an informal, nonadversarial manner. At each step of the appeals process, the claimant/appellant may present any information that he or she believes may be helpful in the case. Subject to the limitations of the AC (the AC may limit the issues it considers if it notifies the individual and other parties of the issues it will review), it is SSAs policy to consider all information supplied by the claimantappellant and information in SSAs files. The claimantappellant may present information personally or be represented by an attorney or other qualified person.
D. Definitions
1. Administrative Finality
Administrative Finality is the concept that a determination or decision becomes final and binding when rendered, unless it is timely appealed or later reopened and revised. This term is used throughout the appeals subchapters.
2. Decision
A decision is a written notice of a formal action at or above the ALJ level.
3. Merits Determination or Decision
When used in the context of appeals, a merits determination or decision merely refers to a determination or decision that has further administrative and judicial review. (See SI 04005.020C.)
4. Vacate
To vacate means to set aside the previous action. For example, an ALJ or the AC may vacate a dismissal of a request for review. The AC may also vacate a dismissal on its own motion. (See SI 04005.020C.)
E. References
Reconsideration process, SI 04020.000 ff.
ALJ hearing process, SI 04030.000 ff.
AC review, SI 04040.000 ff.
Expedited appeals process, SI 04060.000 ff.
Disability appeals process, DI 12005.000, DI 12010.000, and DI 12026.000 ff.
Medicare, Parts A and B appeals process, HI 01200.000 ff.