POMS Reference

GN 03101: Appeals (Title II and Entitlement Under Title XVIII)

TN 14 (10-11)

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 lose the right to further review.

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.

  • For nonmedical issues, it is a case review.

  • 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, and for more information involving medical cessation and adverse reopening determinations, see DI 12026.001.

2. Hearing before an administrative law judge (ALJ)

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

3. Appeals council review

If the claimant or appointed representative disagrees with either the ALJ’s decision or the dismissal of a hearing request, they may ask the Appeals Council (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, but 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, he or she may challenge the constitutionality of the law, 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

It is possible for a case to have different issues at different steps of appeal.

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) for effectuation of 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, as the next level of appeal. The ALJ's notice provides the claimant or representative with the AC’s review, as the next step of 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, along with 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 determination or decision that has further administrative and judicial review. See GN 03101.120C., Procedure for New Application in Lieu 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 Lieu of Appeal.

G. References

  • GN 03101.010, Time Limit for Filing Administrative Appeals

  • GN 03102.000, Reconsideration (Title II and Entitlement Under Title XVII)

  • GN 03103.000, Hearings (Title II and Entitlement Under Title XVII)

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

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

  • DI 12005.000, Reconsiderations – Initial Claims – Table of Contents

  • DI 12010.000, Hearings Level Review – Initial Claims – Table of Contents

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