TN 1 (07-99)

A. Policy — Initial Determination - Defined

An initial determination:

• is SSA's formal disposition of any legal or factual issue affecting an individual's right to benefit payments or any other right (e.g., period of disability) provided by the Social Security Act. Claimants only have a right to appeal actions taken by SSA that are initial determinations;

• can be made by any employee in SSA who is delegated authority to make determinations; and

• is subject to administrative and judicial review and is final and binding unless the claimant requests an appeal within 60 days or SSA revises the initial determination.

B. Policy — Actions that are Initial Determinations

Initial determinations are those determinations that are subject to administrative and judicial review. Examples of initial determinations include, but are not limited to, determinations about:

• eligibility for, or the amount of, supplemental security income (SSI) benefits or special SSI cash benefits, except actions solely involving transitions to eligibility between these types of benefits;

• suspension, reduction, or termination of SSI benefits or special SSI cash benefits or suspension or termination of special SSI eligibility status;

• the fact, amount, and cause of an overpayment or underpayment;

• whether an overpayment of benefits must be repaid to us;

• determinations as to the need to pay benefits through a representative payee because of a beneficiary's incapability to manage his/her own benefits are initial determinations. These determinations can be appealed only by adult beneficiaries who are directly affected by the determination and who have not been adjudged legally incompetent by a court of competent jurisdiction. (See GN 00503.110);

• determinations about who is selected or continued as a representative payee are initial determinations that can be appealed only by an adult beneficiary who is directly affected by the determination and who has not been adjudged legally incompetent by a court of competent jurisdiction. In the case of a beneficiary adjudged to be legally incompetent, who is selected or continued as his/her payee can be appealed only by his/her legal guardian. For a minor (person under age 18), the determination as to who is selected or continued as the payee can be appealed only by the beneficiary's guardian, parent, or person standing in place of the parent. (See GN 00503.110);

• representative payee misuse cases regarding the negligence (or good acquittance) determination. (See GN 00604.055);

• imposing penalties for failing to report important information;

• whether a claimant's drug addiction or alcoholism is a contributing factor material to the determination of disability;

• eligibility for special SSI eligibility status;

• a claimant's disability;

• whether a claimant's completion of or continuation for a specified period of time in an appropriate vocational rehabilitation program will significantly increase the likelihood that the claimant will not have to return to the disability benefit rolls and thus, whether benefits may be continued even though the claimant is not disabled;

• whether or not the claimant has a disabling impairment;

• a determination of whether an underpayment due a deceased person, the amount of the underpayment, and the party to whom the underpayment will be paid on behalf of the deceased individual;

• a claim for benefits based on alleged misinformation. (See GN 00204.008 for more information on what is appealable);

• our calculation of the amount of change in your federally administered State supplementary payment amount (i.e., a reduction, suspension, or termination) which results from a mass change. (See SI 04020.030B.1.);

• whether funds from a dedicated account can or cannot be used for a certain expenditure(s);

• a determination about increasing an installment payment for certain debts or expenses;

• misapplication of funds in a dedicated account;

• a decision to recover an overpayment, including through 10 percent check adjustment;

• a denial of a request for an adjustment rate of less than 10 percent;

• eligibility as an aged, blind, or disabled individual;

• eligibility for and the amount of SSA administered State supplementary payment;

• eligibility for and the amount of payment to an eligible recipient who has an essential person living in the home;

• residency, citizenship, or alien status;

• amount of income, what constitutes income, and exclusions from income for a period;

• amount of resources, what constitutes resources for a period, allocation of resources, tests of ownership, determination of value, exclusion from resources, and disposition of resources;

• marital relationship of an individual and spouse for SSI purposes;

• living arrangements for SSI purposes;

• failure to file for and/or pursue benefits under other programs;

• status as a child;

• status as an inmate of a public institution;

• status as a patient, throughout any month, in a medical facility receiving payments under title XIX of the Act;

• ineligibility for benefits because of refusal, without good cause, to accept available vocational rehabilitation services for the blind and disabled;

• reinstatement of payments, as well as denial of reinstatement, when the individual has requested reinstatement in writing;

• a determination of ineligibility for failure to submit evidence;

• a denial of a request for withdrawal of an application, or the denial of a request for cancellation of a withdrawal request; and

• deemed determinations; i.e., the determination of eligibility when the monthly payment is issued which is deemed to have taken place on the first day of any month for which eligibility and payment amount do not change (see SI 04070.015 through SI 04070.030).

C. Policy — Administrative Actions that are not Initial Determinations

Administrative actions that are not initial determinations may be reviewed by us, but they are not subject to administrative or judicial review. These include, but are not limited to:

• determinations of presumptive disability or presumptive blindness;

• an emergency advance payment;

• determinations to pay benefits through a representative payee for individuals adjudged legally incompetent, or for minors; i.e., persons under age 18 and not legally emancipated;

• determinations as to who is selected as a payee, or the denial of an application to be selected as a payee, are not initial determinations, except with respect to legally competent adult beneficiaries who are directly affected by the determination, legal guardians of legally incompetent beneficiaries, and the parent or person standing in place of the parent for minors;

• a finding that a representative payee misused benefits or payments paid on behalf of a beneficiary or recipient;

• disqualifying or suspending a person from representing a claimant before SSA;

• denial of a request to use the expedited appeals process;

• denial of a request to reopen a determination or a decision;

• denial of a request to be included as a class member eligible for relief in a court case.

• the fee that may be charged or received by a person who has represented a claimant in connection with a proceeding before us;

• denying a request to extend the time period for requesting review of a determination or a decision;

• determining whether (and the amount of) travel expenses incurred are reimbursable in connection with proceedings before us;

• denying a request to readjudicate a claim and apply an Acquiescence Ruling;

• denying a request to be included as a class member eligible for relief in a court case;

• determining whether an organization may collect a fee from an individual for expenses it incurs in serving as representative payee;

• declining under 20 CFR § 416.351(f) to make a determination on a claim for benefits based on alleged misinformation because one or more of the conditions specified in § 416.351(f) are not met;

• transition to eligibility for special SSI cash benefits in a month immediately following a month for which an individual was eligible for regular SSI benefits;

• transition to eligibility for regular SSI benefits in a month immediately following a month for which you were eligible for special SSI cash benefits;

• a determination to reduce, suspend, or terminate federally administered State supplementary payments due to a State-initiated mass change; see SI 04020.030B;

• termination of Federal administration of State supplementary payments;

• findings on whether we can collect an overpayment by using the Federal income tax refund offset procedure;

• method of recovering an overpayment; e.g., by withholding part of a regular monthly payment, netting against an underpayment, etc.;

• compromise settlement for an overpayment;

• timing and frequency of payment; and

• termination of eligibility after 12 continuous months of suspension.