Last Update: 9/08/05 (Transmittal I-3-36)
Citations:
The Appeals Council may reopen a determination or decision, which is otherwise final, for good cause as follows:
within 4 years from the date of the notice of the initial determination in a claim under Title II; or
within 2 years from the date of the notice of the initial determination in a claim under Title XVI.
Good Cause for reopening a determination or decision exists under the following circumstances:
new and material evidence is furnished;
a clerical error in the computation or recomputation of benefits was made; or
there is an error on the face of the evidence on which the determination or decision is based.
Good cause for reopening a determination or decision exists under the following circumstances:
new and material evidence is furnished;
a clerical error was made; or
there is an error on the face of the evidence on which the determination or decision is based.
See I-3-3-6 A. for definition and general discussion of new and material evidence
EXAMPLES:
New medical evidence shows that the claimant's impairment met an impairment listed in Appendix 1, Subpart P, during the previously adjudicated period and that an allowance based on the prior application is warranted.
New medical evidence shows that the original medical prognosis did not prove to be accurate and that an allowance based on a prior application is warranted; e.g., the prior adjudicator believed that the claimant's broken hip would be healed within 12 months, but later medical evidence shows that the broken hip had not healed sufficiently within 12 months to permit the claimant's return to substantial gainful activity.
It may not always warrant a different conclusion.
It may produce a significant change in a factor of entitlement which warrants a revision of a prior unfavorable determination or decision, but does not change the ultimate unfavorable determination or decision.
The Appeals Council found that the 30 year-old claimant for disability insurance benefits was illiterate, unskilled, could no longer perform his heavy labor job due to his back impairment but had the residual functional capacity to perform light work. The Council issued a decision finding that pursuant to Rule 202.16, the claimant was not disabled. The Appeals Council's decision became final and binding upon the claimant's failure to commence a civil action. Two years later, the claimant requests the Appeals Council to reopen its decision and submits new and material evidence which established that in fact the claimant was limited to sedentary work. Even though the claim will still be denied under Rule 201.23, if the time limit criteria are met, the Council must reopen its prior decision, issue a revised decision and provide the claimant with court rights.
If the claimant submits new and material evidence after the prescribed time for reopening has expired and the evidence warrants an allowance during the previously adjudicated period, the Appeals Council may establish the onset date as shown by the evidence, but can find entitlement to benefits or a period of disability on the basis of a current application only.
Change of Position: A “change of position” is a change of legal interpretation or administrative ruling on which a determination or decision was made.
A change of position is not “good cause” to reopen a determination or decision under the 2- or 4-year rules. Although a change of position may be a basis for reopening within 12 months of the date of the initial determination, such reopening is appropriate only if the result would be favorable to the claimant.
If a statute has been amended, any reopening depends on the provisions of the amendment itself. The amendment will provide the effective date of the change and, thus, indicate its effect on any prior determinations or decisions.
Clerical Error: A clerical error is a mathematical error or misapplication of benefit tables, etc., which resulted in an incorrect payment of a monthly benefit or an incorrect lump-sum death payment. It ordinarily occurs in the computation or recomputation of benefits.
Title II: To revise for clerical error, the Appeals Council may reopen a determination or decision which is otherwise final within 4 years from the date of the notice of the initial determination. However, if a determination or decision was fully or partially unfavorable to the claimant due to a clerical error, see I-3-9-6, Reopening at Any Time.
Title XVI: To revise for clerical error, the Appeals Council may reopen a determination or decision which is otherwise final within 2 years from the date of the notice of the initial determination.
Error on the face of the evidence: In general, it is the type of error which clearly caused an incorrect determination or decision to be made. The following are examples of “error on the face of the evidence”:
Another claimant's medical report was in the claim file and the adjudicator relied on that report in making an incorrect determination or decision.
In a Title II case, the adjudicator relied on another claimant's earnings record.
In a Title II case, onset of disability was found as of a date after the claimant last met the special earnings requirements.
Benefits in a cessation case were terminated as of the month disability ceased, rather than being terminated as of the close of the second month following the month in which disability ceased.
Evidence in the possession of the Social Security Administration at the time the determination or decision was made clearly shows that the determination or decision was incorrect.
While the claim was being processed, the claimant submitted to the Social Security field office a medical report which would have resulted in a different conclusion. However, the medical report was inadvertently misplaced and not associated with the claim file until after the determination or decision became final.
Within 4 years from the date of the notice of the initial determination, the Appeals Council may reopen an otherwise final determination or decision because of error on the face of the evidence on which the determination or decision is based. However, if the determination or decision was fully or partially unfavorable to the claimant, see I-3-9-6.)
The Appeals Council may reopen an otherwise final determination or decision because of error on the face of the evidence on which the determination or decision is based, within 2 years from the date of the notice of the initial determination.