SI 04020: Reconsideration - SSI
TN 2 (02-04)
A. Definitions
1. Request
Any writing or timely submission of additional evidence by the claimant, his or her representative payee or appointed representative after receipt of notice of an initial determination which clearly implies a disagreement with that determination constitutes a request for reconsideration. A request for reconsideration can be expressed or implied, but it must be in writing. A mere request for information or an explanation is not a request for reconsideration. Likewise, an oral inquiry (phone call to the FO) or request for forms is not a valid request for reconsideration and does not protect a request for appeal. The FO must receive a written request for appeal.
NOTE: SSA will accept faxed appeal requests.
2. Writing
A writing, for appeal purposes, is the receipt of any documentation, e.g., a letter, facsimile, email or submission of additional evidence, which clearly implies the recipient’s disagreement with the initial determination. A signature is not required on the appeal request.
3. Dismissal
Dismissal of a request for reconsideration is the rejection of or refusal to accept the request. The effect is to make the prior action the final determination of the Commissioner. A dismissal is not subject to appeal
B. Policy
1. Time for Filing a Request
The appeal period is generally 60 days. (A claimant has 30 days to file exceptions with the AC in a case remanded by a Federal court). The 60 days start the day after the individual receives the notice of the determination or decision. The date the individual receives the notice is presumed to be 5 days after the date on the notice unless the individual can show us that he or she did not receive it within the 5 days. When the period for requesting the next appellate step ends on a Saturday, Sunday, legal holiday or any other day (all or part of which is a nonworkday for Federal employees by statute or Executive Order), the period is extended to include the next full workday. If an appeal is mailed to us, and using the date we receive it would result in the loss or lessening of the claimant’s rights, we may accept the U.S. Postal Service stamp cancellation or “postmark” date on the envelope in which it is mailed to us. 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 being appealed.
2. Extension of Time for Filing a Request
The time period for requesting reconsideration may be extended if requested in writing and if good cause is shown for missing the time limit. The field office makes the good cause determination for SSI reconsideration requests.
3. Good Cause for Failure to Request Reconsideration Timely
When individuals contact the FO or the 800 number answering sites and question or disagree with a determination after the 10-day or 60-day time limits have expired, advise the claimant that he or she must explain in writing the reason for missing the time limit. (See SI 02301.310 for benefit continuation.) The request for an extension of time must give the reasons why the request was not filed timely. See GN 03101.020 for more information on good cause.
If a title II/title XVI appeal is filed at the same time and on the same issue, the component responsible for making the reconsideration determination will make the good cause determination. (Good cause issues are resolved by the FO in disability claims.) The recipient cannot appeal a determination where good cause is not found.
Factors used in determining good cause include but are not limited to:
whether circumstances kept the claimant from appealing on time;
whether SSA actions were confusing or misleading;
whether the claimant understood the requirements of the Social Security Act resulting from amendments to the Act, other legislation, or court decisions; and
whether the claimant's physical, mental, educational, or linguistic limitations (including any lack of facility with the English language) prevented him or her from filing a timely request or from understanding or knowing about the need to file a timely request for appeal.
See GN 03101.020 for examples of circumstances where good cause may exist.
4. Who May File a Request
The claimant, his or her appointed representative or representative payee, or other third party on behalf of the claimant can file a request for reconsideration. The technician must provide a copy of the request for reconsideration to the claimant as notification that SSA received the appeal.
NOTE: Effective March 16, 2012, appointed representatives have the affirmative duty to use the iAppeals (i561, i501, and i3441) application to file a request for reconsideration or a request for hearing on a medically denied claim if they request direct fee payment on the matter. For more information about appointed representatives’ affirmative duties, see GN 03970.010.
5. Parties to a Reconsideration
The claimant or any other person who shows in writing that his or her benefit rights are adversely affected by the initial determination is a party to the reconsideration.
NOTE: A State is never a party to a reconsideration, i.e., file a reconsideration on behalf of the claimant or pursue a reconsideration on behalf of a deceased claimant. However, we may pay a State an underpayment due a deceased claimant if there is an IAR agreement.
6. Notice of Another Person’s Request for Reconsideration
If anyone other than the claimant, appointed representative, or representative payee files a request for reconsideration, we will send a notice to the claimant at his or her last known address. We will also send a notice to his or her representative. We will give the claimant an opportunity to present any evidence he or she thinks might be helpful to the reconsidered determination. See SI 04020.020D for more information on third party inquiries.
7. Methods of Reconsideration
a. Initial Determination on an Application
In SSI disability/blindness claims, medical issues can only be reconsidered through case review performed by the DDS. Reconsideration of non-medical issues can be through either case review or informal conference by the FO.
b. Post Eligibility (PE) Adverse Initial Determinations
Generally, the recipient has the right to request reconsideration and has the choice of case review, formal conference or informal conference by a FO decisionmaker.
The determination that a claimant’s disability or blindness has ceased because of medical improvement carries the right to a disability hearing.
c. Determination to Increase or Reinstate Benefits
The recipient has a right to case review or informal conference by a FO decisionmaker (non-medical determination).
8. Evidence Received After Initial Determination Has Been Rendered
If evidence is submitted by the claimant or representative after the initial determination has been rendered, we construe the submission as a request for reconsideration. We make and issue a reconsidered determination.
9. Extending the Life of the Application Based on a Timely Appeal
If you file an application before the first month you meet all the other requirements for entitlement, the application will remain in effect until we make a final determination on your application unless there is an ALJ decision on your application. If there is an ALJ decision, your application will remain in effect until the ALJ decision is issued. See SI 00601.010C.
10. Dismissal of a Request for Reconsideration
A request for reconsideration may be dismissed for a number of reasons. When an appeal is dismissed, complete the appropriate appeal screens (ADIS and APLS). Grounds for dismissal include:
a. Request Not Based On An Initial Determination
If the issue is not an initial determination, accept the reconsideration request and then dismiss it.
b. Filed by improper requestor
If the individual who is filing the request is not a proper party or does not otherwise have a right to request an appeal but he or she insists on filing, take the appeal and dismiss it.
c. Filed prematurely
Inform the claimant that an appeal can be filed only after SSA has made a determination on his or her claim. Provide the claimant with a SSA-561-U2 for filing once he or she receives the notice. If an initial determination has been made but the notice has not yet been issued or is in transit, accept the reconsideration.
d. Request filed late
If the request for appeal is filed more than 60 days after the claimant received notice of the initial determination and good cause for late filing cannot be found; dismiss it. See SI 04020.020B.3. for more on good cause.
For MSSICS cases, the notice date entered on the ACAD screen is used to determine whether or not late filing or payment continuation could apply (for reduction, suspension, or termination events). If the request is filed outside the appeals period, additional screens are placed in the path to address the late filing and possible payment continuation issues.
e. Request withdrawn
Claimant indicates in writing that he or she wishes to withdraw the request. Enter withdrawal information on appeal screens AWDE (Withdraw Appeal Evaluation) and AWDW (Withdraw Appeal Explanation).
f. Claimant died after the request was filed
Claimant dies and we have no information to show that a survivor may be paid benefits due you or that you authorized IAR to a State pursuant to section 1631(g) of the Act. See SI 04020.020B.11. for more information on dismissal upon death of the claimant.
NOTE: There are other possible reasons for closing a request for appeal. For example, claimant's address is unknown or the FO completed a SSA-561-U2 rather than a HA-501-U5. Or, another reason for initial denial is found. For example, a medical denial is appealed and pending at DDS when a fugitive felon determination is made denying benefits for the entire period. The reconsideration is dismissed.
11. Exceptions to Dismissal Upon Death of the Claimant
Exceptions include:
The deceased was receiving interim assistance reimbursement (IA R) funds; or
There are unpaid medical expenses in a State where SSA makes Medicaid eligibility determinations and the Medicaid agency requests a determination (see SI 01730.000); or
The request involves the amount or existence of an overpayment but not a waiver request. A reconsidered determination should be rendered since recovery from the estate is possible; or
There is a parent of a deceased individual who was a blind or disabled child when the underpayment was made or a spouse if either are eligible to receive an SSI underpayment (see SI 02101.000 for general rules regarding underpayments due to deceased individuals); or
C. Procedure -- Reconsideration Requests by Claimants or Recipients
1. Development
Assist the claimant in completing the SSA-561-U2. It is not required that the claimant complete the SSA-561-U2 provided SSA receives something in writing showing the claimant is dissatisfied with the initial determination. If SSA receives a writing, the implied request for appeal will be documented on the appropriate MSSICS screens. Send the acknowledgment notice available on DOCS.
If the claimant telephones the FO and requests reconsideration, mail the SSA-561-U2 to the claimant to complete and return to establish a writing.
Ask the claimant to submit any evidence in his or her possession at the time of the interview. In disability/blindness claims where the disputed issue is medical, review the claimant's non-medical eligibility factors before processing the reconsideration. Follow the guidelines in SI 00603.000 for simultaneous and deferred development guidelines.
Although the amount of time to submit additional information depends on the nature of the information or evidence and the difficulty in obtaining it, assist the claimant in obtaining it if it will take an inordinate amount of time (i.e., more than 10 workdays). If the information is not obtained within 30 days, send the claimant a closeout letter giving him or her an additional 15 days to submit it. After 15 days, conduct the case review and render a reconsidered determination.
See GN 03102.225 for instructions on completing the SSA-561-U2.
2. Dismissal
When you dismiss a request for reconsideration:
Notify the claimant (and representative, if any) of the dismissal and the reasons using an SSA-L8165-C1 (Important Information). Do not include the appeal paragraph.
Follow the instructions at NL 00802.030 in completing the SSA-L8165-C1. A dismissal is not an initial determination, therefore, an appeal paragraph is not included.
Update the ADIS screen for MSSICS cases or the UAPD screen for non-MSSICS cases.
3. Dismissal of a Reconsideration Request--Possible Cause to Reopen
Even if good cause for late filing is not established, examine the case to determine whether there is a basis for reopening and revising the determination. See SI 04070.000 for reopening and revising determinations.
4. Withdrawal of Request for SSI Request for SSI Reconsideration
Advise a claimant (and representative, if any) who wants to cancel or withdraw a request for reconsideration that reconsideration is a prerequisite for a hearing and that by withdrawing the request for reconsideration the claimant will lose all future appeal rights on the claim.
If he or she insists on withdrawing the reconsideration request, obtain a withdrawal request from the claimant. Make sure that the request indicates that the claimant understands the effects of the withdrawal. This explanation is also required when the request for withdrawal is received by mail. Enter withdrawal on UAPD for non-MSSICS cases or ADIS, AWDE, and AWDW screens for MSSICS cases.
If the appeal request is withdrawn, the initial determination becomes final.
CAUTION: IT IS NEVER APPROPRIATE TO SUGGEST WITHDRAWAL OF A REQUEST FOR RECONSIDERATION.
5. Individual Dies While Reconsideration is Pending
Do not process the reconsideration further unless the exceptions set forth in SI 04020.020B.11. exist.
a. If Additional Development is Needed:
Contact the appropriate representative of the State agency, parent, or surviving spouse who may be eligible for an underpayment or whose payment amount or eligibility might be affected. Advise of the pending reconsideration request and the effects it might have;
Ascertain if the individual wishes to proceed with the reconsideration;
If the individual does not wish to proceed with the reconsideration, input on UAPD for non-MSSICS cases or ADIS, AWDE and AWDW for MSSICS cases, the individual’s decision to withdraw and the explanation.
CAUTION: DO NOT ACCEPT OR APPROVE THE WITHDRAWAL IF THERE IS ANY DOUBT AS TO THE ACCURACY OF A PAYMENT MADE
b. If a Reconsidered Determination is Rendered:
Send the required notice (SSA-L8455-U2, favorable determination or SSA-8456-U2 unfavorable determination) to the person whose right to payments is affected by the determination.
Indicate on the notice that the reconsideration was requested by the deceased claimant.
D. Procedure -- Third Party Requests
1. Inquirer Calls at the FO
If the inquirer calls the FO to request a reconsideration on behalf of a claimant and the caller is other than an appointed representative or representative payee:
Explain the requirements regarding disclosure and representation of claimants.
Give him or her a form SSA-1696-U4 and a form SSA-561-U2, a copy of the pamphlet “Your Right to Representation.”
Fill in only the claimant’s name on the first two forms.
Instruct the inquirer to contact the claimant or recipient and have the forms completed and returned to the FO within 15 working days.
If the appeal is being established in MSSICS, complete the ANCR screen and RPOC screen describing the contact.
Follow up in 15 days with the claimant or recipient, not the inquirer.
Manually prepare a notice that states the following:
"We are writing to tell you that we learned from (1) that you want to appeal your Supplemental Security Income (SSI) case.
"What We Will Need
"We gave you (2) two forms for you to fill out, and return to us. These
forms are:
“SSA-561-U2, Request for Reconsideration (a signature is not required), and
“SSA-1696-U4, Appointment of Representative (a signature is required).
"We haven't received the completed forms.
"What You Should Do
"You should fill out and send us the SSA-561-U2 if you want to appeal. If you want (3) or someone else to help you with your appeal, fill out and send us the SSA-1696-U4 too.
"Please read the enclosed pamphlet and fact sheet, "Your Right to
Question the Decision Made On Your SSI Claim' and "Social Security and Your Right to Representation.'
"If we don't receive the completed SSA-561-U2 or hear from you by (4), we will assume you do not want to appeal our decision.
"If You Have Any Questions
"If you have any questions or need help filling out these forms, you may call, write or visit any Social Security office. If you visit our office, please have this letter with you and ask for (5) . The telephone number is (6) .
" (7) .
"Enclosures:
Pub 05-10075"
Fill-ins:
name of the person who contacted the FO, in format: "John Doe"
him or her
last name of the person who contacted the FO, in format: "Mr. Doe"
date (the expiration of the 60-day period in which to request the appeal), e.g., December 16, 2002
name of FO contact, in format: "Marie Dole"
FO contact's phone number
Optional: Also, if you plan to visit an office, you may call ahead to make an appointment. This will help us serve you more quickly when you arrive at the office.
Include the factsheet “Your Right to Representation." If there is no response within 15 workdays, close out the file. If the claimant responds, follow procedures appropriate to the response.
2. Inquirer Contacts the FO by Letter
If the FO receives a written request for an appeal on behalf of the claimant from a third party, two notices will be necessary:
a. Notice to the Claimant and his or her Representative or Representative Payee which states the following:
"We are writing to tell you that we learned from (1) that you want to
appeal your Supplemental Security Income (SSI) case.
"What You Should Do
"With this letter, we're sending two forms. These forms are:
"SSA-561-U2, Request for Reconsideration (a signature is not required, and
"SSA-1696-U4, Appointment of Representative (a signature is required).
"You should fill out and send us the SSA-561-U2 in the enclosed envelope if you want to appeal the SSI case. If you want (2) or someone else to help you with your appeal, fill out and send us the SSA-1696-U4, too.
"Please read the enclosed pamphlet and fact sheet, 'Your Right to
Question the Decision Made On Your SSI Claim' and ‘Your Right to Representation.'
"If we don't receive the completed SSA-561-U2 or hear from you by (3), we will assume you do not want to appeal our decision.
"If You Have Any Questions
"If you have any questions or need help filling out these forms, you may call, write or visit any Social Security office. If you visit our office, please have this letter with you and ask for (4) . The telephone number is (5) .
" (6) .
"Enclosures:
SSA Pub. 05-10075
SSA-561-U2
SSA-1696-U4
Pre-Addressed Envelope"
Fill-ins:
name of the person who contacted the FO, in format: "John Smith"
last name of the person who contacted the FO, in format: "Mr. Smith"
date (the expiration of the 60-day period in which to request the appeal), e.g., December 16, 2002
name of FO contact, in format: "Marie Dole"
FO contact's phone number
Optional: Also, if you plan to visit an office, you may call ahead to make an appointment. This will help us serve you more quickly when you arrive at the office.
Enclose forms SSA-561-U2 and SSA-1696-U4, and the factsheet “Your Right To Representation,” and a preaddressed envelope. If you are sending the notice to the claimant’s representative, do not include a preaddressed envelope.
b. Letter to the Inquirer which states the following:
"We are writing to you because you told us that (1) wants to appeal (2) Supplemental Security Income (SSI) case, but we haven't heard from (3) .
"What You Should Do
"You should ask (4) if (5) still wants us to review the case and if (6) wants you to help (7) . Tell (8) that (9) must file the appeal by (10) .
"What We Will Need
"If (11) wants you to help, (12) must fill out, sign and return the enclosed form to us right away. This form is the SSA-1696-U4, Appointment of Representative. Until we get this completed form, we cannot talk to you about this case.
"If You Have Any Questions
"If you or (13) have any questions, or if (14) needs help filling out the form, either of you may call, write or visit any Social Security office. If you visit our office, please have this letter with you and ask for (15) . The telephone number is (16).
" (17) .
"Enclosures:
"SSA-1696-U4
"Pub. 05-10075
"Pre-Addressed Envelope"
Fill-ins:
-
name of claimant, in format:
"John Smith"
his or her
him or her
-
claimant's last name, in format:
"Mr. Smith"
he or she
he or she
him or her
him or her
he or she
the expiration of the 60-day period in which to request the appeal, e.g., December 16, 2002
-
claimant's last name, in format:
"Mr. Smith"
he or she
-
claimant's last name, in format:
"Mr. Smith"
he or she
-
name of FO contact, in format:
"Marie Dole"
FO contact's phone number
Optional: Also, if you plan to visit an office, you may call ahead to make an appointment. This will help us serve you more quickly when you arrive at the office.
Include a copy of the fact sheet mentioned in SI 04020.020D.1., an SSA-1696-U4, and a preaddressed envelope.
3. Inquiry from a Member of Congress
Ordinarily, a congressional inquiry is merely a request for information or an explanation. However, in some cases, the inquiry or the claimant’s letter (a copy of which may be enclosed with the congressional inquiry) constitutes an expressed or implied request for reconsideration. You will need to decide whether the inquiry constitutes an implied request based on the wording of the claimant’s letter. Resolve doubts in favor of finding it to be an implied request in which case, complete the SSA-561 and attach a copy of the congressional inquiry.
a. Notice to the Claimant
In such cases, send a letter to the claimant advising that the congressional inquiry is being accepted as a request for reconsideration. In the notice, state the following:
"We are writing to you because (1) asked about our determination dated (2) on (3) Supplemental Security Income (SSI) case.
"We will use (4) letter as (5) request for an appeal. Please tell us how you want to appeal. We have listed the ways to appeal below. These are the same ways to appeal that we listed in the letter dated (6) .
"How To Appeal
" (7).
"What You Should Do
"With this letter, we're sending a Form SSA-561-U3, Request for Reconsideration. Before we can review this case, you must fill out and return the SSA-561-U3. This form tells us the way you want to appeal. Please send it to us in the enclosed envelope by (8) .
"If You Have Any Questions
"If you have any questions, or if you need help filling out the form, you may call, write or visit any Social Security office. If you visit our office, please have this letter with you and ask for (9) . The telephone number is (10) .
" (11) .
"Enclosures:
SSA-561-U2
Pre-Addressed Envelope"
Fill-ins:
-
Name of member of Congress using Senator/Representative, as appropriate, in format:
"Senator Mark Hardy"
date of the determination being appealed, e.g., December 16, 2002
-
a. your
b. full name of claimant, possessive, in format: "John Smith's"
last name of member of Congress, in format: "Senator Hardy's"
-
a. your
b. last name of claimant, possessive, in format: "Mr. Smith's"
date of the last notice we sent the claimant that included language on "How to Appeal"
See NL 00804.224 for SSI cases for the language on how to appeal and if you want help with your appeal;
a date that is 15 days from the date this letter is mailed
name of field office (FO) contact, in format: "Marie Dole"
FO contact's phone number
-
Optional: Also if you plan to visit an office, you may call ahead to make an appointment. This will help us serve you more quickly when you arrive at the office.
Enclose SSA-561-U2, pamphlet and fact sheet and a preaddressed envelope.
Give the claimant 15 days from receipt of the letter to choose the type of reconsideration he or she prefers. If you do not receive a response within that time, follow up with the claimant by telephone if possible. If you cannot contact the claimant by telephone, send a followup letter.
If you receive no response either by telephone or letter within 15 days (remember to allow 5 days' mailing time), promptly conduct a
reconsideration by means of a case review.
Complete a form SSA-561-U2 indicating the choice of case review, but do not sign the form.
Attach a copy of the correspondence received from the Member of Congress (MC) (including enclosures, if any) and an RC describing the attempts to contact the claimant.
Complete the Non-Claimant requestor screen with the necessary information.
b. Notice to Member of Congress
-
If the Reconsidered Determination is the same as the Initial Determination
Give the MC a complete explanation separate from the claimant's SSA-L8456-U2, a copy of which should be enclosed with the response to the MC. Include a reminder to the claimant on the SSA-L8456-U2 that the reconsideration was requested on his or her behalf by the MC. Have the district manager or the branch manager sign the letter.
-
If the Reconsidered Determination is Different from the Initial Determination
Explain in the letter to the MC how the changed determination affects the claimant in terms of the specific complaint.
Upon completion of the reconsideration, effectuate the determination by normal procedures.