[Federal Register Volume 62, Number 153 (Friday, August 8, 1997)]
[Notices]
[Pages 42850-42851]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 97-20900]


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SOCIAL SECURITY ADMINISTRATION


Social Security Ruling, SSR 97-2p; Title II and Title XVI: 
Prehearing Case Review by Disability Determination Services

AGENCY: Social Security Administration.

ACTION: Notice of Social Security ruling.

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SUMMARY: In accordance with 20 CFR 402.35(b)(1), the Acting 
Commissioner of Social Security gives notice of Social Security Ruling 
(SSR) 97-2p. This Ruling states the Social Security Administration's 
(SSA) policy on returning claims pending at the hearing level from the 
Office of Hearings and Appeals to the Disability Determination Services 
for a prehearing case review when new medical evidence is submitted. 
This Ruling was developed as part of SSA's effort to further ensure 
consistency in the way disability claims are adjudicated at all levels 
of the administrative review process.

EFFECTIVE DATE: August 8, 1997.

FOR FURTHER INFORMATION CONTACT: Joanne K. Castello, Division of 
Regulations and Rulings, Social Security Administration, 6401 Security 
Boulevard, Baltimore, MD 21235, (410) 965-1711.

SUPPLEMENTARY INFORMATION: Although we are not required to do so 
pursuant to 5 U.S.C. 552 (a)(1) and (a)(2), we are publishing this 
Social Security Ruling in accordance with 20 CFR 402.35(b)(1).
    Social Security Rulings make available to the public precedential 
decisions relating to the Federal old-age, survivors, disability, 
supplemental security income, and black lung benefits programs. Social 
Security Rulings may be based on case decisions made at all 
administrative levels of adjudication, Federal court decisions, 
Commissioner's decisions, opinions of the Office of the General 
Counsel, and other interpretations of the law and regulations.
    Although Social Security Rulings do not have the same force and 
effect as the statute or regulations, they are binding on all 
components of the Social Security Administration, in accordance with 20 
CFR 402.35(b)(1), and are to be relied upon as precedents in 
adjudicating cases.
    If this Social Security Ruling is later superseded, modified, or 
rescinded, we will publish a notice in the Federal Register to that 
effect.

(Catalog of Federal Domestic Assistance, Programs 96.001 Social 
Security--Disability Insurance; 96.002 Social Security--Retirement 
Insurance; 96.004 Social Security--Survivors Insurance; 96.005 
Special Benefits for Disabled Coal Miners; 96.006 Supplemental 
Security Income.)

    Dated: July 31, 1997.
John J. Callahan,
Acting Commissioner of Social Security.

Policy Interpretation Ruling

Title II and Title XVI: Prehearing Case Review by Disability 
Determination Services

    Purpose: To state the Social Security Administration's (SSA) policy 
on returning claims pending a hearing before an Administrative Law 
Judge (ALJ) from SSA's Office of Hearings and Appeals (OHA) to the 
Disability Determination Services (DDS) for a prehearing case review 
when new medical evidence is submitted.
    Citations (Authority): Regulations No. 4, sections 404.941, 
404.944, and 404.1527(f); and Regulations No. 16, sections 416.1441, 
416.1444, and 416.927(f).
    Background: 20 CFR 404.941 and 416.1441 provide that after a 
hearing before an ALJ is requested but before it is held, SSA may, for 
the purposes of a prehearing case review, forward a case to the 
component of SSA (including a State agency) that issued the 
determination being reviewed. That component will decide whether the 
determination may be revised. These regulations provide that SSA may 
conduct a prehearing case review if:
    1. Additional evidence is submitted;
    2. There is an indication that additional evidence is available;
    3. There is a change in the law or regulation; or
    4. There is an error in the file or some other indication that the 
prior determination may be revised.
    Under these rules, SSA has the authority to conduct a prehearing 
case review in a wide range of circumstances. However, SSA has 
generally used its authority to conduct a prehearing case review in 
limited circumstances, keeping most cases in the hearing process even 
when a prehearing case review would be permissible under these rules. 
Now, under an initiative approved by the Commissioner of Social 
Security in July 1996 as part of SSA's overall goal of process 
unification, SSA has decided to use its existing regulatory authority 
to reexamine selected disability claims after a hearing is requested 
but before it is held. This Ruling explains the policy SSA will apply 
in these cases.
    The goal of process unification is to achieve correct, similar 
results in similar cases at all stages of the administrative review 
process. SSA's studies indicate that additional

[[Page 42851]]

evidence is submitted to SSA's OHA by claimants or their 
representatives in at least 40 percent of claims pending at the hearing 
level. (SSA requests or develops for additional evidence in 
approximately another 20 percent of cases.) Given this volume of cases 
involving additional evidence at the hearing level, evaluation of these 
cases by DDS medical and/or psychological consultants could either 
result in a revised favorable determination without a hearing, or at 
least present a clearer picture of the medical record for purposes of a 
hearing before an ALJ in a significant number of cases. For these 
purposes, the ALJ would accept the DDS medical and/or psychological 
consultant's analysis as evidence material to the issues, pursuant to 
20 CFR 404.944 and 416.1444.
    Including the DDS medical and/or psychological consultant's 
analysis of additional evidence in the record is consistent with 
considering DDS medical and psychological consultant opinion in 
adjudication at the OHA level (SSR 96-6p, 7/2/96). The analysis is 
expected to help ensure uniform decision making at all levels of 
administrative review within SSA by providing expert consideration of, 
and opinion on, the medical issues presented by the additional 
evidence, including, but not limited to, the existence and severity of 
the claimant's impairment(s), the existence and severity of the 
claimant's symptoms, whether the impairment meets or equals the 
requirements for any impairment listed in 20 CFR Part 404, Subpart P, 
Appendix 1, and the claimant's residual functional capacity. The 
analysis is also expected to help OHA focus any additional development 
it may consider necessary by indicating what issues raised in the 
additional evidence, if any, could be clarified by such development.
    Policy Interpretation: Under 20 CFR 404.941 and 416.1441, OHA may 
return selected cases to the DDS for a prehearing case review when new 
medical evidence is received at the hearing level.
    OHA may return a case to the DDS if all of the following criteria 
are met:
    <bullet> The claimant requested a hearing regarding his or her 
entitlement to disability insurance benefits under title II of the 
Social Security Act (the Act), eligibility for supplemental security 
income based on disability under title XVI of the Act, or both;
    <bullet> A hearing has not been held in the case;
    <bullet> SSA received additional evidence in the case after the 
date of the reconsideration determination;
    <bullet> The additional evidence is not duplicative and was not a 
result of SSA development; and
    <bullet> SSA has not previously returned the case to the DDS for a 
prehearing case review.
    The DDS will decide whether its determination may be revised based 
on the additional evidence when considered with the entire record. A 
revised determination may be wholly or partially favorable to the 
claimant.
    If the DDS revises the determination, SSA will mail written notice 
of the revised determination to all parties to the hearing at their 
last known address. The notice will state the basis for the revised 
determination, and will advise all parties of their right to request a 
hearing on the revised determination within 60 days after the date of 
receiving the notice.
    If the DDS revises its determination to a wholly favorable 
determination, the notice will also state that:
    <bullet> The ALJ will dismiss the request for hearing unless the 
claimant or another party requests that the hearing proceed; and
    <bullet> The request to proceed with the hearing must be made in 
writing within 30 days after the date the notice of the revised 
determination was mailed.
    If the DDS revises its determination to a partially favorable 
determination, the notice will also state:
    <bullet> What was not favorable in the revised determination; and
    <bullet> That the hearing requested by the claimant will be held 
unless the claimant and all other parties inform SSA that they agree to 
dismiss the hearing request.
    If the DDS does not revise its determination based on the 
additional evidence, the DDS will return the case to the ALJ with a 
medical and/or psychological consultant's analysis of the entire 
medical record, including the additional evidence, in a format 
appropriate for inclusion into the record. This analysis will be 
considered opinion evidence from a nonexamining source or sources, 
under the provisions of the regulations at 20 CFR 404.1527(f) and 
416.927(f), and the guidelines in SSR 96-6p. The ALJ must consider the 
medical and/or psychological consultant's analysis by applying the 
rules in paragraphs (a) through (e) of those sections of the 
regulations, and must explain in the decision the weight given to the 
analysis.
    Returning a case for a prehearing case review will not delay the 
scheduling of a hearing unless the claimant agrees to continue the 
review and delay the hearing. If the prehearing case review is not 
completed before the date of the hearing, the case will be sent to the 
ALJ unless a favorable revised determination is in process, or the 
claimant and the other parties to the hearing agree in writing to delay 
the hearing until the review is completed.

EFFECTIVE DATE: This Ruling is effective on August 8, 1997.
    Cross-Reference: SSR 96-6p, ``Titles II and XVI: Consideration of 
Administrative Findings of Fact by State Agency Medical and 
Psychological Consultants and Other Program Physicians and 
Psychologists at the Administrative Law Judge and Appeals Council 
Levels of Administrative Review; Medical Equivalence.''

[FR Doc. 97-20900 Filed 8-7-97; 8:45 am]
BILLING CODE 4190-29-P