I-3-9-1.Reopening and Revising Determinations and Decisions
Last Update: 5/1/17 (Transmittal I-3-151)
Under 20 CFR 404.987 and 416.1487, a determination or decision becomes final if the claimant does not request review within the time period for appeal or the Social Security Administration (SSA) does not notify the claimant of its intent to revise the determination or decision before it becomes final and binding. In most situations, the established time period for requesting review of a determination or decision is 60 days. See 20 CFR 404.909, 404.933, 404.968, 416.1409, 416.1433, and 416.1468. (If the claimant files exceptions to an administrative law judge decision in a case remanded by a Federal court, see 20 CFR 404.984(b) and 416.1484(b), as well as Hearings, Appeals and Litigation Law (HALLEX) manual I-4-8-25). For more information about administrative finality at the hearing level, see generally HALLEX I-2-8-5.
However, under the same authority and under certain conditions, SSA may reopen and revise a determination or decision after it is final and binding, either on SSA's own initiative or at the request of a party to the determination or decision. Generally stated, under 20 CFR 404.988 and 416.1488, an adjudicator may reopen a determination or decision:
Within 12 months of the date of the notice of the initial determination, for any reason (see HALLEX I-3-9-30);
Within four years (title II) or two years (title XVI) of the date of the notice of the initial determination if SSA finds good cause (see HALLEX I-3-9-40); and
At any time if the determination or decision was obtained by fraud or similar fault (see HALLEX I-3-10-7); and
While the regulations are written in permissive terms, as a general practice, if both the conditions and timeframes for reopening are met, the SSA component with jurisdiction will usually reopen a determination or decision.
Information about computing the time period for reopening is found in HALLEX I-3-9-20.
B. Reopening by the Appeals Council (AC)
When a case is properly before the AC and the conditions for reopening exist, the AC has the authority to consider the issue of reopening and revising. See generally HALLEX I-3-9-5.
A claimant may expressly request reopening or may submit information that implies a request for reopening. See HALLEX I-3-9-10.
The AC may also consider reopening an otherwise final action on its own initiative. For example, if the AC is unable to review a protest case (see HALLEX I-3-6-20) using its own motion authority under 20 CFR 404.969 and 416.1469, it may consider whether the conditions for reopening a case exist under 20 CFR 404.987 and 416.1487.
Additionally, the AC may consider reopening and revising a prior favorable determination or decision when the AC reaches a conclusion on a subsequent application that conflicts with or adversely affects a claimant's entitlement, earnings record, insured status, etc. For example, the AC may find that the claimant does not have earnings from self-employment for deduction purposes, and that the earnings are not earnings for entitlement purposes. In this event, the AC must reopen and revise the prior award to disallow the claim or to reduce the amount of monthly benefits, whichever is appropriate. (For more information, see HALLEX I-1-10, Subsequent Applications.)
When the AC declines to reopen a prior determination or decision, it is a threshold inquiry only, meaning the AC does not adjudicate the merits of the prior claim.