TN 13 (11-11)

A. Definition of adverse adjustment

An adverse adjustment results when a claim meets the following criteria:

1. The family maximum provision results in a reduction in the past or present benefit payment rates of an earlier entitled beneficiary due to:

   • Entitlement of a new beneficiary, see GN 01010.310B.1.; or

   • Re-entitlement or resumption of a prior beneficiary (see GN 01010.310B.2. or GN 01010.310B.3.; and

2. The claim involves a “late filer” who is not part of the same household as the adversely affected beneficiary.

   For more information about adverse adjustments, see GN 01010.310.

B. Advance Due Process Notification

• When a new claim results in an adverse adjustment in the benefits of a currently entitled or previously entitled beneficiary, provide the affected beneficiary advance due process notification either in person, via telephone or in writing.

• If you give notification by person or telephone, annotate the claims file using the report of contact (RPOC) in the Modernized Claims System (MCS) to annotate the information provided to the claimant. If the electronic RPOC is not available, use the paper SSA-5002 and fax it into the Non-Disability Repository (NDR).

• When notification is given in writing, prepare the appropriate notice using the Document Processing System (DPS) to explain the effect that the new claim has on his or her benefits and other pertinent information as provided in GN 01010.330A.

  NOTE: Do not extend appeal rights in the advance due process notification for an adverse adjustment. This is only a notice of proposed adjustment action. The processing center (PC) will issue a formal written notice with appeal rights when the adjustment action is processed.

C. Content of notice for future and past benefits affected

Any currently entitled beneficiary whose future and past benefits (outside of a protected period see RS 00615.760B.3) can be adversely affected, must receive an advance due process notification. Include the following in the dialogue or notice:

• The name of the new claimant(s) and the basis for his or her entitlement (for adopted children see GN 01010.330A.4.);

• NOTE: If any of the new claimants are in delayed status, include their names in the advance notice.

• A summary of the evidence supporting the new claimant's entitlement;

• The effect the entitlement will have on the beneficiary's monthly benefit amount, including the approximate date the adjustment will be made;

• Statement that the adversely affected beneficiary will have 10 calendar days in which to protest the proposed action and present rebuttal evidence;

• That if the beneficiary protests and elects to continue to receive benefits at the unadjusted rate, he or she may do so until a formal determination is made;

• That if the adverse adjustment is sustained, the continued unadjusted rate will also be subject to the O/P recovery provisions including waiver, reconsideration, etc.; and

• Statement that, if we do receive the protest within the allowed time period, we will send another notice with more information about our action.

See NL 00703.121 for the advance due process exhibit notice for Adverse Claims.

D. Content of notice for only past benefits affected

Any previously entitled (i.e., terminated) beneficiary whose past benefits (outside of a protected period see RS 00615.760B.3) will be adversely affected must also receive advance due process notification. This also applies when we will reduce his or her past benefits and the currently entitled beneficiary's ongoing rate is not affected (i.e., a closed period award for the late filer). Include the following in the dialogue or notice:

• The name of the new claimant(s) and the basis for his or her entitlement (for adopted children see GN 01010.330A.4.);

  NOTE: If any of the new claimants are in delayed status, include their names in the advance notice.

• A summary of the evidence supporting the new claimant's entitlement;

• The effect the entitlement will have on the beneficiary's past benefits;

• That the adversely affected beneficiary will have 10 calendar days to protest the proposed action and present rebuttal evidence; and

• Explanation that, if we do not receive a protest within the time period, we will send another notice with more information about our action.

See the adverse adjustment exhibit in NL 00703.128, for a written due process notice.

E. New claimant is an adopted child

If the adverse claimant is an adopted child living in another household, do not disclose the new adoptive name. Instead, show the child's first name, relationship to the number holder (NH) and the child's age in the notice. This will protect the privacy rights of the adopting parents and will ordinarily provide sufficient information to the adversely affected beneficiaries to satisfy due process requirements.

If the adversely affected beneficiary protests the adopted child's entitlement, provide a full explanation of the basis for the child's entitlement without disclosing the adoptive name. If the adversely affected beneficiary demands to know the adoptive name, see PC instructions in GN 01010.335A.3.c.

F. FO Action following notification

• For written notices, allow 15 calendar days from the date of the notice to allow for mail delivery before adjudicating the new claim (in foreign claims allow 30 days).

• Document the MCS RPOC screen file that you provided notification in person, over the telephone or in writing. If a written notice was necessary, hold the new claim until the 15-day period has expired unless you receive a response earlier.

• If the beneficiary does not respond to the written adverse adjustment notice within 15 calendar days, assume there is no protest and process the claim under normal procedures.

• Document the claims file with the beneficiary's response and effectuate the new claim under normal procedures when the beneficiary responds within the 15-day period, but no further development is required to resolve the issue. (e.g., when notified of an adverse adjustment by telephone, the beneficiary states he or she does not plan to protest).

• If further development is required, complete the development necessary to resolve the issue and process the new claim accordingly.

G. References

• GN 01010.335 PC Procedures for Handling Adverse Adjustments

• NL 00703.120 Notice to Beneficiary(ies) When a Claim Has Been Filed That will Require an Adverse Adjustment to the Beneficiary's(ies) Benefits

• NL 00703.128 Advance Adverse Adjustment — Only Past Due Benefits Affected