TN 11 (11-12)

A. Policy for establishing the established onset date (EOD) within a previously adjudicated period

If the current claim is an allowance and the alleged onset date (AOD) is in a previously adjudicated period, the disability adjudicator must consider reopening the prior determination(s). When establishing the EOD in a previously adjudicated period, the prior determination(s) must meet the rules for reopening and revision of a prior determination or decision, unless an exception for establishing the EOD in the previously adjudicated period applies. For a list of the exceptions, see DI 25501.250A.5. in this section.

1. Initiating a reopening

Generally, we reopen or revise a determination or decision when:

• a party to the determination or decision requests reopening in writing or by filing a new claim with an AOD in a previously adjudicated period; or

• the Social Security Administration (SSA) or the Disability Determination Services (DDS) questions the correctness of a prior determination or decision; and

• The party to the determination or decision meets the rules for reopening.

For the rules (time limits and conditions) for reopening, see DI 27505.001A.

2. Rules for reopening

Only an SSA component at the same or higher adjudicative level may reopen an administratively final determination or decision. DDS may only reopen and revise determinations made at the DDS level (see DI 27510.005).

Generally, we only reopen and revise incorrect determinations or decisions.

For the criteria and instructions for reopening and revising a claim, see:

• DI 27501.001 Reopenings and Revisions: Pertinent Definitions and Related Policy

• DI 27501.005 Reopening and Revising a Determination or Decision

• DI 27505.000 Rules for Reopening Table of Contents

• DI 27510.001 Period Covered by a Final Determination or Decision: “Period Adjudicated”

3. How to identify the existence of prior determinations or decisions

A prior determination or decision exists if:

• the Electronic Disability Collect System (EDCS) and Form SSA-3367 (Disability Report – Field Office) show prior claims activity (DI 81010.025A.2.),

• eView shows prior claims (see DI 81005.025C), or

• The SSID, MBR, NDDSS, DIBWiz, or other SSA Systems or queries show prior claims activity.

A prior claim may exist if:

• the claimant alleges a prior filing, or

• medical evidence of record (MER) or other evidence in file indicates there may have been a prior filing.

If you are not able to reopen and revise the prior determination(s), you cannot establish the EOD earlier than the day after the last determination or decision.

4. Documentation needed to reopen prior folders

The DDS must attempt to obtain the prior folder to determine if the current claim meets the conditions necessary to reopen the final determination. If we lost or destroyed the prior folder, see DI 27510.005H.

5. When the EOD may be set within a previously adjudicated period

You may establish the EOD within a period previously adjudicated, without reopening the prior file, when supported by the evidence of record on file, if:

• more than 12 months elapsed since the date of the notice of the initial determination on the prior claim (thereby precluding reopening for any reason) and the disability criteria changed since the prior determination or decision. See DI 27505.020B.3. Change of Ruling or Legal Precedent (Change of Position) ; or

• more than four years elapsed since the date of the notice of the initial determination on the previous claim (thereby precluding reopening for “good cause”) and new and material evidence establishes an EOD within the period previously adjudicated in the determination or decision on the prior claim. For Processing Cases When Reopening Does or Does Not Apply in, see additional policy reminders in DI 27501.005C.2.; or

• the prior determination was a FO (not DDS) denial for “insufficient evidence furnished” (regulation basis codes M5/M6), when a claimant fails to submit essential evidence. See DI 11018.005, Field Office Responsibilities When a Claimant Fails to Cooperate (FTC).

B. Component roles for establishing the EOD within a previously adjudicated period

1. Field office (FO)

The FO determines whether the claimant previously filed for any type of benefit and documents prior claims activity in the EDCS 3367 (or on a paper SSA-3367-F5 (Disability Report- Field Office) in exclusion claims). See DI 11005.085, Prior Claims Activity.

The FO will annotate the basis for the prior denial.

2. Disability Determination Services (DDS)

The DDS follows the rules on reopening when processing a new claim in which the claimant alleges an onset date of a period of disability in a previously adjudicated period or when there is a possibility of establishing an onset date of a period of disability in a previously adjudicated period.

C. Component instructions for establishing the EOD within a previously adjudicated period

1. Field office (FO)

The FO will follow the instructions found in DI 11005.085. The FO annotates the regulation basis code in the remarks section of the SSA-3367-F5.

2. Disability Determination Services (DDS)

If there is evidence of a prior determination, review the rules for reopening the prior determination found in the following POMS references:

• DI 27501.001 Reopenings and Revisions: Pertinent Definitions and Related Policy

• DI 27501.005 Reopening and Revising a Determination or Decision

• DI 27505.001 Conditions for Reopening a Final Determination or Decision

• DI 27510.001 Period Covered by a Final Determination or Decision: “Period Adjudicated”

If you are able to reopen the prior determination, reopen and revise the prior denial and establish the EOD as of the date disability began. If the EOD is not fully favorable, prepare a personalized disability explanation (PDE) and send it with an interim allowance notice. (See DI 25501.280 Notifying Claimants of Partially Favorable Allowances, NL 00705.226: Reopening 6 - Denial to Partially Favorable Onset (Not AOD) Title II, and NL 00705.231: Reopening 7 - Denial to Partially Favorable Onset (Not AOD) Title XVI.)

If you are not able to reopen the prior determination and, if an exception to establishing the EOD within a previously adjudicated period does not apply, generally the EOD can be no earlier than the day after the final disposition date stamped or printed on the denial notice for the prior claim. Do not use the date we prepared the prior SSA-831 (Disability Determination and Transmittal) when establishing the EOD.

See DI 81020.130D Electronic Case Closure to determine the correct date of the prior personalized denial notice (PDN) in electronically prepared cases.

See DI 27510.005D.2. Subsequent Claim Filed to determine if an exception to establishing the onset date of disability within the previously adjudicated period applies.

If you are not able to reopen the prior determination or decision but an exception to establishing the EOD within the prior adjudicated period applies, establish onset as of the date the disability began. If the EOD is not fully favorable, prepare a personalized disability explanation (PDE) and send it with an interim allowance notice. (See DI 25501.280 Notifying Claimants of Partially Favorable Allowances.) To determine if an exception to establishing the EOD within the previously adjudicated period applies, see DI 27510.005D.2.

If reopening a prior claim, prepare a detailed rationale using the format outlined in DI 27536.005.

NOTE: Always attempt to obtain the prior folder(s) before reopening (see DI 20505.010C Determining Need for Prior Folder). There are circumstances that permit reopening without the prior folder, such as lost or destroyed folders (see DI 27510.005H, Subsequent Claim Filed).

D. References

• DI 20505.010 Determining Need for Prior Folder

• DI 20505.015 DDS Actions in Obtaining Prior Folder

• DI 81010.143 Processing Medical Reactivations

• DI 27505.010 Good Cause for Reopening

• DI 27515.000 Collateral Estoppel Table of Contents

• DI 27516.000 Refilings for the Same Period (Res Judicata Cases) Table of Contents

• DI 20101.025 Subsequent Claim Filed or Reconsideration on a Subsequent Claim is Requested While Hearing, Appeals Council (AC) Review, or Court Action Pending on Prior Claim

• DI 27516.005 Disability Determination Services (DDS) Res Judicata Development and Processing

• DI 27516.001 Field Office (FO) Res Judicata Development and Processing

• DI 27540.005 Reopening Notices Reference Chart