TN 13 (06-09)

4159 Lead-In – Allowance to Denial – Title II

We are writing to you about your Social Security benefits. We recently looked at (1) disability claim again to make sure our decision was correct. After reviewing all of the information carefully, we are changing our decision.

Based on our rules, we now find that (2) not disabled. Therefore, (3) claim is denied. You will get another letter soon about when (4) payments (5) will stop.

Fill-ins:

(1) your/claimant’s name (possessive)

(2) you are/he is/she is

(3) your/his/her

(4) your/his/her

(5) and Medicare/null

Enter the Personalized Disability Explanation (PDE) language per DI 26530.020 and DI 26530.055, including a list of the evidence, an explanation of what the evidence shows, and the detailed, personalized reasons for the determination. For additional guidance, see Reopening of Prior Determination DI 27536.015. If merged text is not used, use paragraph 4041 “We have enclosed a page that gives you more details about how we made the decision on your case.” (NL 00708.100).

If concurrent claims are involved, include paragraph 842:

This decision refers only to (1) Social Security Disability Insurance benefits. You will get a separate letter about (2) Supplemental Security Income payments.

Fill-ins:

(1) your/claimant’s name (possessive)

(2) your/his/her

4054

Who Decided (1) Case

Fill-in:

(1) Your/His/Her

If DDS disability determination:

Doctors and other trained staff looked at this case and made this decision. They work for the State but used our rules.

If Federal disability determination:

Our doctors and other trained staff looked at this case and made this decision.

ALS023 – modified to show the SSA-789 instead of the SSA-561

NOTE: If the revision is due to a non-medical reason, such as work, show “SSA-561, called “Request for Reconsideration”” instead of the SSA-789. Do not include the language for the DHO hearing or statutory benefit continuation.

If You Disagree With The Decision

If you disagree with this decision, you have the right to appeal. We will review (1) case and consider any new facts you have. A person who did not make the first decision will decide (2) case. We will review those parts of the decision that you believe are wrong and will look at any new facts you have. We may also review those parts that you believe are correct and may make them unfavorable or less favorable to (3).

• You have 60 days to ask for an appeal in writing.

• The 60 days start the day after you get this letter. We assume you got this letter 5 days after the date on it unless you show us that you did not get it within the 5-day period.

• You must have a good reason for waiting more than 60 days to ask for an appeal.

• You have to ask for an appeal in writing. We will ask you to complete a Form SSA-789-U4, called “Request for Reconsideration – Disability Cessation – Right to Appear.” Please contact one of our offices if you want help.

Fill-ins:

(1) your/claimant’s name (possessive)

(2) your/his/her

(3) you/him/her

If a determination of fraud or similar fault (FSF) is not involved, use:

Please read the enclosed pamphlet, “Your Right To Question the Decision To Stop Your Disability Benefits.” It contains more information about the appeal.

If there is a determination of FSF, or if the revision is due to a non-medical reason, such as work, use:

Please read the enclosed pamphlet, “Your Right to Question the Decision Made on Your Claim.” It contains more information about the appeal.

Do not send the following caption and paragraph 4059 if there is a determination of fraud or similar fault since FSF precludes the payment of statutory benefit continuation (SBC).

Do not send the following caption and paragraph if the revision is due to a non-medical reason, such as work or other reason that precludes payment of SBC (see DI 27540.025). However, a predetermination due process notice is needed.

If there is no Medicare, delete the mention of Medicare in the caption and the text.

If there is no auxiliary, delete “and your family”.

4059 modified to add fill-ins.

Appeal In 10 Days To Keep Getting Your Payment (1)

Fill-in:

(1) And Medicare/null

Please let us know if you would like us to continue your benefits during your appeal. You have only 10 days to ask us, in writing, to continue your benefits.

• The 10 days start the day after you get this letter.

• You can ask us to keep paying you (1) (2).

• If you lose your appeal, you might have to pay back some or all of this money (3).

Fill-ins:

(1) and your family/null

(2) and/or continue your Medicare/null

(3) , but you will not have to pay back Medicare/null

4066 Do not send the following caption and paragraph if the revision is due to a non-medical reason, such as work.

How An Appeal Works

A Disability Hearing Officer (DHO) will decide your appeal. We will call this person a DHO in the rest of our letter. The DHO will meet with you before making the decision on your appeal. The meeting works like this:

• The DHO will write you about the time and place for the meeting.

• You can look at your file before the meeting.

• You can tell the DHO why you think you are still disabled. You can give the DHO more facts and you can bring people to say why you are disabled.

• You can have the DHO ask people to come to the meeting and bring important papers. You can question these people at the meeting.

• You do not have to go to the meeting in person. If you do not want to go, you can give the DHO more facts you may have. The DHO will decide your case using these facts and what is now in your file. But if you go to the meeting, it may help the DHO decide your case.

4069A

If You Want Help With Your Appeal

You can have a friend, representative, or someone else help you. There are groups that can help you find a representative or give you free legal services if you qualify. There also are representatives who do not charge unless you win your appeal. Your local Social Security office has a list of groups that can help you with your appeal.

If you get someone to help you, please let us know. If you hire someone, we must approve the fee before he or she can collect it. If you hire a representative who is eligible for direct pay, we will withhold up to 25 percent of any past-due benefits to pay toward the fee.

4070

If Your Health Gets Worse

If (1) health gets worse and you feel that (2) disabled again, please get in touch with us. (3) may be able to get benefits again

Fill-ins:

(1) your/claimant’s name (possessive)

(2) you are/he is/she is

(3) You/claimant’s name

4078

If You Have Any Questions

If you have any questions, please call us toll free at 1-800-772-1213, or call your local Social Security office at [FO phone number from DOORS]. We can answer most questions over the phone. You can also write or visit any Social Security office. The office that serves your area is located at:

Fill-in:

                                  [Field Office Address

                                   City, State, ZIP] per DOORS

If you do call or visit an office, please have this letter with you. It will help us answer your questions. Also, if you plan to visit an office, you may call ahead to make an appointment. This will help us serve you more quickly.

If a determination of FSF is not involved, use:

Enclosure:

SSA Pub. No. 05-10090

If there is a determination of FSF, or if the revision is due to a non-medical reason, use:

Enclosure:

SSA Pub. No. 05-10058