An initial determination is a determination we make about your entitlement or continuing entitlement to benefits that is subject to administrative and judicial review.
Initial determinations include, but are not limited to, determinations about:
Entitlement or continuing entitlement to benefits;
Reentitlement to benefits;
The amount of benefits;
Recomputation of benefits;
Revisions of Social Security earnings records;
A deduction from benefits because of work;
Termination of benefits;
The establishment or termination of a period of disability;
Whether benefits should be paid to another person on behalf of the beneficiary (unless the beneficiary is under age 18 (see §1602 for exception) or legally incompetent);
Who will act as payee if we determined that representative payment will be made;
Any overpayment or underpayment of benefits;
How an underpayment of benefits due a deceased person will be paid;
An offset of benefits because of SSI previously received for the same period;
A deduction from disability benefits because of refusal to accept rehabilitation services;
Whether completion of or continuation for a specified period of time in an appropriate vocational rehabilitation program will significantly increase the likelihood that the person will not have to return to the disability benefit rolls and thus, whether benefits may be continued even though the person is not disabled;
Whether an overpayment of benefits must be repaid to us;
Reduction in disability benefits because the person also receives benefits under a workers' compensation law;
Penalty deductions imposed because of failure to report certain events;
Nonpayment of benefits because of claimant's confinement for more than 30 continuous days in a jail, prison, or other correctional institution for conviction of a criminal offense;
Whether or not the person has a disabling impairment(s) as defined in §507. Nonpayment of benefits because of claimant's confinement for more than 30 continuous days in a mental health institution or other medical facility because a court found the individual was not guilty for reason of insanity; a court found that he/she was incompetent to stand trial or was unable to stand trial for some other similar mental defect; or, a court found that he/she was sexually dangerous; and
Nonpayment of benefits because the person has not furnished us satisfactory proof of their Social Security number, or, if a Social Security number has not been assigned, a proper application has not been filed.
Nonpayment of benefits, unless good cause is found, for any month in which a beneficiary has an unsatisfied warrant for more than 30 continuous days for:
A crime, or attempted crime, that is a felony or, in jurisdictions that do not classify crimes as felonies, a crime that is punishable by death or imprisonment for more than one year (regardless of the actual sentence imposed); or
Violation of a condition of Federal or State probation/parole.
We will mail you a written notice of the initial determination, stating:
The reasons for the determination;
The effect of the determination; and
Information concerning the right to a reconsideration or to a hearing.
We will not mail a notice if the beneficiary's entitlement to benefits has ended because of his or her death.
If you are dissatisfied with any action taken affecting your right to monthly benefits, a lump-sum death payment, or entitlement to hospital or medical insurance protection, you may appeal. We will explain your appeal rights. We will also assist you in your appeal, your request for a hearing by an administrative law judge, or your request for review by the Appeals Council. (See Chapter 20.) If you are dissatisfied with any action taken regarding your request for extra help with Medicare prescription drug costs, see Chapter 26. If you want to appeal a determination regarding your Medicare Part B Income-Related Monthly Adjustment Amount see Chapter 26.
Last Revised: Aug. 8, 2011