Citations:

Regulations 20 C.F.R. 404.904, 416.1404, 410.620, 42 C.F.R. 405.702, 405.804

TN 4 (05-95)

A. Introduction

This section contains the general policy common to title II and title XVI disability notices sent on initial, reconsideration and continuing disability review (CDR) cases. The information applies to notices of favorable and unfavorable determinations.

For specific information on personalized explanations, which are required for wholly or partially unfavorable disability determinations, refer to C. for references.

Notice instructions for disability adverse reopening cases will appear in another subchapter.

B. Policy

1. When a notice is required

SSA must send a written notice to individuals, including auxiliary claimants, notifying them of any:

• determination or decision about their entitlement to benefits; and

• planned action which will adversely affect their current/future entitlement to benefits.

2. Elements of a disability determination notice

The determination notice must:

• Contain the date (month/day/year);

• Contain the Social Security Number (SSN) the claim was filed on;

• Be agency approved language that is clear and simple, as defined in SSA's Notice Standards;

• State the action being taken (e.g., denial, cessation, revision or suspension);

• Provide a personalized explanation for totally or partially unfavorable determinations (See DI 26530.001 for additional instructions about the personalized explanation);

• Include appeal rights; and

• Include res judicata language, on all denials; and

• Include the claimant right to representation paragraph on domestic notices that contain appeals language; and

• Include a closeout paragraph which closes out all other classes of benefits covered by the scope of the application (See C.1. below which explains when close-out language should not be sent.);

• Refer the individual to a field office (FO) for assistance.

(See NL 00603.015 for sequencing information.)

NOTE: The personalized explanation will be omitted if it is provided in an advance (predetermination) notice.

3. Elements of advance (predetermination) notice

The advance notice must:

• Inform the individual of the planned action to be taken (e.g., substantial gainful activity (SGA) cessation);

• Summarize the evidence in file which supports the proposed determination;

• Advise the individual how to present evidence that may change the planned action; and

• Specify the allowable time frame for responding to the notice.

EXCEPTION: A predetermination notice does not apply to title XVI cases.

4. Concurrent Title II/Title XVI claims

In concurrent Title II and Title XVI denials, a single notice (SSA-L442-U3 Retirement, Survivors, and Disability Insurance/Supplemental Security Income Notice of Disapproved Claims) may be used if the basis for the denials is the same. In this situation, one personalized explanation is prepared. If the basis for the denials is different, separate Title II (SSA-L443-U3 Retirement, Survivors, and Disability Insurance Notice of Disapproved Claim) and Title XVI (SSA-L444-U3 Supplemental Security Income Notice of Disapproved Claim) notices are necessary.

The SSA-L442-U3 and the personalized explanation must be placed in the title II folder. If possible, a copy of the SSA-L442-U3 and the personalized explanation should be placed in the title XVI folder. If both notices will fit in one envelope, the DDS can mail them in a title II envelope.

5. Multiple notices

There are situations requiring separate notices and personalized explanations. These include:

• concurrent reconsideration title II/title XVI denials;

• initial disability insurance benefit (DIB)/disabled widow(er) beneficiary (DWB), DIB/childhood disability beneficiary (CDB), DWB/Supplemental Security Income (SSI), or CDB/SSI denials.

C. Process

1. Title II claim pending

The FO will indicate on the SSA-831-U3 when there is a title II claim pending. (See DI 11055.130B.3. for FO instructions for completion of the SSA-831-U3.)

When a remark is on the SSA-831-U3, the DDS should contact the FO to verify the title II claim is still pending.

If a claim is still pending, the DDS should not include closeout language in the denial notice.

2. No Title II pending

The DDS must include closeout language in the denial notice if there are no title II claims pending.

D. References

• Detailed instructions on due process and predetermination notices, DI 13010.000, DI 27525.000, DI 28080.000.

• Detailed instructions on personalized explanations, DI 26530.0051, DI 27025.001, and DI 28095.040B.