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DI 27536: Simplified Reopening Rationale Procedures

Effective Dates: 03/24/2017 - Present

BASIC (01-12)

There is no need to duplicate information documented elsewhere in the file. Use the tables below to locate the information required to reopen initial determinations; and, what actions are necessary if the information is not already contained in the file.

Required information for reopening an initial determination includes:

  • Allegations

  • Assessment of functional abilities

  • Basis for determination

  • Citation of jobs and incidence

  • Duration of impairment

  • Evidence of substantial gainful activity (SGA) findings

  • Evidence Sources

  • Interpretation of medical findings

  • Medical facts

  • Pain-related issues

  • Resolution of conflicting medical opinions

  • Resolution of inconsistencies material to the determination

  • Vocational rule used for medical-vocational determinations

See Also:

DI 27536.001 Reopening Rationale Preparation

A. Location of required information

Use the table below to locate required information.

 Information Determination Where Usually Documented In File

Allegations

Allowance

  • Personalized determination notice (PDN)

  • SSA-3368-BK Disability Report Adult

  • SSA-5002 Report of Contact

  • SSA-795 Statement of Claimant or Other Person
 

Denial

  • PDN

  • SSA-3368-BK

  • SSA-5002

  • SSA-795

Assessment of functional abilities

Allowance

  • Medical evidence

  • SSA- 4734-F4- SUP Mental Residual Functional Capacity Assessment (MRFC)

  • SSA-4734-BK Physical Residual Functional Capacity Assessment (RFC)
 

Denial

  • Medical evidence

  • SSA- 4734-F4- SUP Mental Residual Functional Capacity Assessment (MRFC)

  • SSA-4734-BK Physical Residual Functional Capacity Assessment (RFC)

Basis for Determination

Allowance

SSA-831 Item 22 (Regulation basis code)
 

Denial

  • PDN

  • Regulation basis code

Citation of jobs and incidence

Allowance

Not applicable
 

Denial

Report by a Vocational specialist

Duration of impairment

Allowance

Favorable determination indicates duration met
 

Denial

  • MRFC

  • PDN

  • RFC

Evidence of substantial gainful activity (SGA) findings

Allowance

  • SSA-820-F4 Work Activity Report (Self-Employed Person)

  • SSA-821-BK Work Activity Report

  • SSA-5002
 

Denial

  • SSA-553 Special Determination

  • SSA-820-F4

  • SSA-821-BK

  • SSA-5002

Evidence Sources

Allowance

  • Medical evidence

  • PDN
 

Denial

  • Medical evidence

  • PDN

Interpretation of medical findings

Allowance

  • MRFC

  • PDN

  • Regulation basis code

  • RFC

  • SSA- 2506-BK Psychiatric Review Technique (PRTF)
 

Denial

  • MRFC

  • PDN

  • PRTF

  • Regulation basis code

  • RFC

Medical Facts

Allowance

  • Medical evidence

  • SSA-5002
 

Denial

  • Medical evidence

  • SSA-5002

Pain Related Issues

Allowance

  • Any medical listing which specifically mentions pain

  • MRFC

  • PRTF

  • RFC
 

Denial

  • MRFC

  • PRTF

  • RFC

Resolution of conflicting medical opinions

Allowance

Resolved by the determination of an allowance (SSA-831)
 

Denial

  • MRFC

  • PRTF

  • RFC

Resolution of inconsistencies material to the determination

Allowance

  • PDN

  • Resolved by the determination of an allowance (SSA-831)
 

Denial

  • MRFC

  • PRTF

  • RFC

Vocational rule used for medical-vocational determination

Allowance

Item 27 on the SSA-831
 

Denial

Item 27 on the SSA-831

B. Rationale documentation required

A rationale must address specific information not already documented in the case file.

Use the table below to determine how you need to document the missing information.

 Information Where Usually Documented In File Required Action

Citation of jobs and incidence

(denial determination)

Report by a Vocational specialist

See DI 27536.001B.6.

Interpretation of medical findings

(allowance determination)

SSA-831 Item 22 (Regulation basis code)

See DI 27536.001B.5. (closed period only)

Interpretation of medical findings


(denial determination)

SSA-831 Item 22 (Regulation basis code)

See specific instructions for:

  • Pain-related issues

  • Resolution of conflicting medical opinions

  • Resolution of inconsistencies material to the decision

Pain-related issues

(denial determination)

SSA-4734-BK Physical Residual Functional Capacity Assessment

See DI 27536.001B.2.

Resolution of conflicting medical opinions

(denial determination)

  • SSA- 2506-BK Psychiatric Review Technique

  • SSA-4734-BK Physical Residual Functional Capacity Assessment

  • SSA- 4734-F4- SUP Mental Residual Functional Capacity Assessment

See DI 27536.001B.1.

Resolution of inconsistencies material to the determination

(denial determination)

  • SSA- 2506-BK Psychiatric Review Technique

  • SSA-4734-BK Physical Residual Functional Capacity Assessment

  • SSA- 4734-F4- SUP Mental Residual Functional Capacity Assessment

See DI 27536.001B.3.

Vocational rule used for medical-vocational determinations

(allowance or denial determination)

Item 27 on the SSA-831

See DI 27536.001B.4.
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DI 27530: Reopenings - Completion of Form SSA-831-U5
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DI 275: Reopenings, Res Judicata, and Collateral Estoppel
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DI 27540: Reopening Notice Instructions
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