TN 3 (01-89)

Citations:

Act-sections 205(a) and 1102

Regulations No. 4 Subpart J, 404.987-404.996

A. Policy Principle

The authority to reopen and revise determinations and decisions comes from the Social Security Act and the regulations.

1. Statutory Authority - RSDHI Programs

1. Section 1102 of the Social Security Act provides: “The Secretary . . . of Health and Human Services . . . shall make and publish such rules and regulations, not inconsistent with this Act, as may be necessary to the efficient administration of the functions with which each is charged under this Act.”

2. Section 205(a) of the Social Security Act provides: “The Secretary shall have full power and authority to make rules and regulations and to establish procedures, not inconsistent with the provisions of this title, which are necessary or appropriate to carry out such provisions . . . .”

2. Regulations

Subpart J of Regulations No. 4, sections 404.987-404.996 prescribes the rules that SSA will follow in reopening and revising determinations or decisions.

NOTE: Determinations as to the entitlement and continuing entitlement to hospital insurance and supplementary medical insurance benefits are also made under the authority indicated above, pursuant to section 1872 of the Social Security Act and 42 C.F.R. 405.701(c).

3. Related Policy

For a discussion of the rules of administrative finality governing SSI claims, see SI 04070.001ff; for claims for reimbursement for services covered under title XVIII, follow the applicable CMS manuals.

B. Operating Policy

The controlling instructions for implementing the rules on reopening and revising determinations are in the POMS.

• Local instructions and expedients on administrative finality prepared by FO’s, RO’s, PSC’s (including INTPSC and ODO), etc., do not take precedence over the POMS instructions. If local instructions conflict with the POMS, the adjudicator will always follow the POMS.

• All local instructions must be cleared in advance through the Office of Retirement and Survivors Insurance, Adjudicative Policy and Appeals Branch, 3-E-26 Operations Building, 6401 Security Boulevard, Baltimore, Maryland 21235-6401.

C. Introduction

When a determination or decision is made with respect to entitlement, amount, or the actual payment of benefits (GN 03101.070) the individual to whom that determination or decision applies should be able to rely on its correctness. The regulations prescribe that determinations and decisions made by SSA can be reopened and revised only for certain reasons and/or within certain time periods.

D. Definitions

1. Determination

Initial or reconsideration level of adjudication.

2. Decision

The hearings and Appeals Council (AC) level of adjudication.

3. Reopen

Reopen means to take another look, even if the determination or decision is not revised.

NOTE: Reopening is at the discretion of SSA and is not a right afforded to the claimant upon request, even if the claimant makes the request within one year of the notice of the initial determination. However, in all cases it is SSA’s policy to honor the request to review the case to see if reopening applies. SSA informs the claimant if we decide not to reopen and why (GN 04001.090).

4. Revision

Revision of a determination or decision occurs when:

1. The end result is changed (e.g., disallowance changed to an award); or

2. Based on new and material evidence, the basis for the determination is changed (even though the end result may not differ).

   EXAMPLE: SSA revises a determination as to the quarters of coverage a claimant has even though it is determined that the claimant is still not insured and, thus, not entitled.

NOTE: It is SSA’s policy to revise a determination if reopening applies and the evidence shows the prior determination was incorrect. (See GN 04020.080 for a discussion of reopening and revising when it would have a dual effect.)

5. Hearing

Personal appearance before the administrative law judge (ALJ), not the face-to-face hearings which are held at the reconsideration level in disability medical cessation cases.