Social Security Summary of Administrative Review Process

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Social Security Summary of Administrative Review Process 

 

Source: SSA.gov GN 03101.001 Effective Dates: 09/19/2023 TN 20 (09-23)

A. Administrative Review Process Defined

A claimant or appointed representative who disagrees with an initial determination or decision may request further review under the administrative review process, also known as the appeal process. The claimant or appointed representative must request a review within 60 days of the decision, or the right to further review will be lost.

B. Steps In The Administrative Review Process

1. Reconsideration

Reconsideration is the first step in the administrative review process for individuals who disagree with the initial determination unless a hearing is the first level of appeal.

We provide the opportunity for an Administrative Law Judge (ALJ) hearing, as the first step in the administrative review process, for revised initial determinations on non-medical issues and determinations involving a request for waiver of an adjustment or recovery of an overpayment. For information on reopenings and appeal rights, see GN 04001.090.

• Reconsideration for Title II consists of a case review and disability hearing. The method used depends on the issue involved.

• It is a case review for nonmedical issues. For medical issues, it is a case review for initial claims and a disability hearing, which is a face-to-face reconsideration for all medical cessation cases.

For more information on reconsideration, see GN 03102.000; for more information involving medical cessation and adverse reopening determinations, see DI 12026.001.

2. Hearing before an ALJ

After we make a reconsideration determination, the next step of the appeal is a hearing before an ALJ. See GN 03103.000, Hearings.

3. Appeals Council (AC) review

If the claimant or appointed representative disagrees with the ALJ’s decision or the dismissal of a hearing request, they may ask the AC to review the action. The AC may dismiss or deny the request for review, or the AC may grant the request and either issue a decision or remand the case to an ALJ. The AC may also review an ALJ’s decision (within 60 days of the hearing decision or dismissal) on its own motion. The AC has final review authority for SSA. See GN 03104.000, Appeals Council Review.

C. Alternative Appeals Process

1. Expedited appeals process (EAP)

The claimant or appointed representative may request an EAP only after appealing through the reconsideration step. The claimant or representative can use the EAP in cases where they do not dispute SSA's version of the facts in the claim. Rather, they may challenge the law's constitutionality, underlying the determination. See GN 03107.000, Expedited Appeals Process.

NOTE: SSA and all parties to the determination must agree to use EAP.

2. Federal court review

The AC review completes the administrative review process. If the claimant or appointed representative is still dissatisfied, they may request a judicial review by filing a civil action in a federal district court.

D. Considering Multiple Issues At Different Steps Of Appeal

A case can have different issues at different appeal steps.

1. Disposition of the ALJ’s decision

When the ALJ issues a decision and notifies the claimant or their appointed representative, the case goes to the program center (PC) to effectuate the ALJ’s decision. The PC then sends a notice on those issues not addressed by the ALJ. This notice provides the claimant or representative with reconsideration, which is the next level of appeal. The ALJ's notice provides the claimant or representative with the AC’s review, which is the next step of the appeal.

2. New issue before the ALJ

The ALJ may consider a new issue at the hearing, even though it arose after the hearing request and not considered in the initial or reconsidered determination. The ALJ notifies all parties to the hearing about the new issue.

E. How We Conduct The Administrative Review Process

Administrative reviews are informal and non-adversarial. At each step of the appeals process, the claimant can present any helpful information and ask SSA to look at the case again. The AC may notify the claimant and other parties of the issues for review. SSA considers all information supplied by the claimant and information already in SSA's files. The claimant may present information personally or be represented by an attorney or another qualified person.

F. Definitions Of Terms Used In Administrative Review Process

1. Administrative finality

Administrative finality refers to a determination or decision being final and binding when rendered unless it is timely appealed or later reopened and revised.

2. Decision

A decision is the finding issued by an ALJ or the AC after the claimant's hearing or AC review.

3. Merits determination or decision

When used in the context of appeals, merits determination or decision refers to a decision with further administrative and judicial review. See GN 03101.120C, Procedure for New Application in place of Appeal.

4. Res judicata

Res judicata is a rule in civil law and administrative policy. Res judicata protects SSA from repeatedly considering the same claim (a claim already issued a determination). For more information on res judicata, see GN 03101.160. Also, see GN 03101.120, Appeals – FO Interview with Dissatisfied Claimant.

5. Vacate

To vacate means to set aside the previous action. For example, an ALJ or the AC may vacate a dismissal of a request for review. The AC may also vacate a dismissal on its own motion. See GN 03101.120C, Procedures for New Application in place of Appeal.

G. References

• GN 03101.010 Time Limit for Filing Administrative Appeals

• GN 03102.000 Reconsideration (Title II and Entitlement Under Title XVIII)

• GN 03103.000 Hearings (Title II and Entitlement Under Title XVIII)

• GN 03104.000 Appeals Council Review (Title II and Entitlement Under Title XVIII)

• GN 03107.000 Expedited Appeals Process (EAP) (Title II)

• DI 12005.000 Reconsiderations – Initial Claims

• DI 12010.000 Hearings Level Review – Initial Claims

• DI 12026.000 Reconsideration – Disability Hearing for a Medical Cessation/Adverse Medical Reopening Determination – Title II and Title XVI

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