I-3-2-23.Appeals Council Actions When Case Contains an Unadjudicated Claim
Last Update: 2/12/21 (Transmittal I-3-177)
In evaluating an administrative law judge's (ALJ) decision or dismissal, the analyst must determine whether there is an unadjudicated claim. An unadjudicated claim is one that the ALJ's decision was required to address, or one that otherwise requires Social Security Administration (SSA) action. An unadjudicated claim may exist when:
The claimant submitted an application for a specific class of benefits, or the claimant's application covers that class of benefits under Program Operations Manual System (POMS) GN 00204.020. SSA has made an initial or reconsidered determination on those benefits, and the claimant filed a request for hearing or the ALJ accepted a request to escalate the claim for those benefits. However, the hearing decision does not address the claimant's entitlement or eligibility for those benefits.
EXAMPLE: The claimant filed concurrent applications for disability insurance benefits and supplemental security income (SSI) under titles II and XVI of the Social Security Act (Act). Both claims were denied at the initial and reconsideration levels, and the claimant requested a hearing. The ALJ issued a decision, but the decision covered the title II claim only and did not adjudicate the title XVI claim or the claimant's eligibility for SSI.
The claimant submitted an application for a specific class of benefits, or the claimant's application covers that class of benefits under POMS GN 00204.020. Neither SSA nor the Disability Determination Services (DDS) has issued a determination about the claimant's entitlement to or eligibility for that class of benefits. The hearing decision also does not address the claimant's entitlement or eligibility to those potential benefits.
EXAMPLE: The claimant filed an application for SSI under title XVI of the Act. At the time of the application, the claimant did not meet the insured status requirement for title II benefits. However, while the title XVI application was pending at the initial, reconsideration, or hearing level, the claimant was credited with additional quarters of coverage and gained insured status for title II benefits.
B. Procedure for Processing an Unadjudicated Claim
1. An Unadjudicated Claim Properly Before the ALJ
A claim is properly before the ALJ if the claim was subject to the request for hearing. This occurs when:
the claimant received a reconsidered determination on the claim (or an initial determination in a former prototype state) unadjudicated at the hearing level and filed a request for hearing before an ALJ related to that claim; or
the ALJ accepted the field office's (FO) request to escalate the unadjudicated claim.
Unless the claim was properly before the ALJ, the Appeals Council (AC) generally will take no action on the unadjudicated claim.
For unadjudicated claims properly before the ALJ, the AC may either remand the case to an ALJ or issue a decision on both the adjudicated and unadjudicated claims.
A claim is not properly before an ALJ if it could have been escalated at the hearing level but the ALJ did not agree to escalate that claim pursuant to the requirements of Hearings, Appeals and Litigation Law (HALLEX) manual I-2-2-22. Under that provision, a claim is not escalated if:
the ALJ does not agree that there is a common issue;
for other reasons, the ALJ does not find it appropriate to join the claims; or
the claimant objects to joining the claims.
Therefore, the AC will only grant review (and remand or issue a decision) for escalation if evidence in the claim(s) file indicates the ALJ agreed there was a common issue, the ALJ found no other reason that it was inappropriate to join the claims, and the claimant did not object to joining the claims.
2. An Unadjudicated Claim Not Properly Before the ALJ
If neither SSA nor the DDS has taken any action to evaluate the unadjudicated claim, and the claim has not been escalated per HALLEX I-2-2-22, then the unadjudicated claim was not properly before the ALJ, and the AC will not grant review to evaluate that claim. Neither will the AC grant review to remand for the ALJ to “escalate” the unadjudicated claim. A field office may initiate escalation when that office believes there may be a common issue that would benefit by esclation. However, the determination to escalate a new claim to the hearing level is at the discretion of the ALJ and subject to notice and the opportunity to object to that escalation by the claimant. See HALLEX I-2-2-22 B.
If the final AC action results in a partially or fully favorable decision on the adjudicated claim (e.g., AC denies review of a partially or fully favorable hearing decision or grants review to issue a partially or fully favorable corrective decision) and the analyst identifies a potentially unadjudicated claim, the FO may be required to process the unadjudicated claim or to take a new or supplemental application. In these circumstances, the analyst will take the following steps to notify the servicing FO of the claimant's potential entitlement or eligibility to another class of benefits or entitlement on another earnings record:
Check queries to confirm the FO has not already taken action on the unadjudicated claim, particularly in cases where the claimant receives a favorable decision based on his or her title XVI application and meets the insured status requirement for title II benefits (see POMS SI 00601.035).
If the FO has not taken an application for the unadjudicated claim or has not taken any action to explore the claimant's potential entitlement to another class of benefits covered by the scope of an existing application, the analyst will prepare and send a MISC 505 transmittal to alert the servicing FO to the claimant's potential entitlement, and ask the FO to take the appropriate action under POMS GN 00204.020.