97-25365. Administrative Review Process; Identification and Referral of Cases for Quality Review Under the Appeals Council's Authority To Review Cases on Its Own Motion  

  • [Federal Register Volume 62, Number 186 (Thursday, September 25, 1997)]
    [Proposed Rules]
    [Pages 50266-50270]
    From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
    [FR Doc No: 97-25365]
    
    
    =======================================================================
    -----------------------------------------------------------------------
    
    SOCIAL SECURITY ADMINISTRATION
    
    20 CFR Parts 404 and 416
    
    RIN 0960-AE53
    
    
    Administrative Review Process; Identification and Referral of 
    Cases for Quality Review Under the Appeals Council's Authority To 
    Review Cases on Its Own Motion
    
    AGENCY: Social Security Administration.
    
    ACTION: Proposed rules.
    
    -----------------------------------------------------------------------
    
    SUMMARY: We propose to amend our regulations to include the rules under 
    which a decision or order of dismissal that is issued after the filing 
    of a request for a hearing by an administrative law judge (ALJ) will be 
    referred to the Appeals Council for possible review under the Appeals 
    Council's existing authority to review cases on its own motion. The 
    proposed rules concern identification and referral procedures that we 
    currently follow to ensure the accuracy of decisions at the ALJ-hearing 
    step (hearing level) of the administrative review process, and new 
    quality assurance procedures that we are proposing under the Plan for a 
    New Disability Claim Process approved by the Commissioner of Social 
    Security in September 1994 (59 FR 47887). The procedures set forth in 
    the proposed rules apply to dispositions at the hearing level of the 
    administrative review process that are made by ALJs, and also to 
    dispositions at the hearing level that are not made by ALJs but are 
    subject to review under the Appeals Council's own-motion authority. The 
    latter type of dispositions currently consist of wholly favorable 
    decisions issued by attorney advisors and adjudication officers.
    
    DATES: To be sure that your comments are considered, we must receive 
    them no later than November 24, 1997.
    
    ADDRESSES: Comments should be submitted in writing to the Commissioner 
    of Social Security, P.O. Box 1585, Baltimore, MD 21235; sent by telefax 
    to (410) 966-2830; sent by E-mail to regulations@ssa.gov''; or, 
    delivered to the Division of Regulations and Rulings, Social Security 
    Administration, 3-B-1 Operations Building, 6401 Security Boulevard, 
    Baltimore, MD 21235, between 8:00 A.M. and 4:30 P.M. on regular 
    business days. Comments may be inspected during these same hours by 
    making arrangements with the contact person shown below.
    
    FOR FURTHER INFORMATION CONTACT: Harry J. Short, Legal Assistant, 
    Division of Regulations and Rulings, Social Security Administration, 
    6401 Security Boulevard, Baltimore, MD 21235, (410) 965-6243 for 
    information about these rules. For information on eligibility or 
    claiming benefits, call our national toll-free number, 1-800-772-1213.
    
    SUPPLEMENTARY INFORMATION:
    
    Background
    
        Under procedures set forth in Secs. 404.967 ff. and 416.1467 ff., 
    and pursuant to a direct delegation of authority from the Commissioner 
    of Social Security (see 61 FR 35844, 35852, July 8, 1996), the Appeals 
    Council, a component in our Office of Hearings and Appeals (OHA), 
    reviews hearing decisions and orders of dismissal issued by ALJs of the 
    Social Security Administration (SSA). The Appeals Council may review a 
    decision or dismissal action of an ALJ at the request of a party to the 
    action or, under authority provided in Secs. 404.969 and 416.1469, on 
    its own motion. Through the exercise of its authority to review cases, 
    the Appeals Council is responsible for ensuring that the final 
    decisions of the Commissioner of Social Security under titles II and 
    XVI of the Social Security Act (the Act), as amended, are proper and in 
    accordance with the law, regulations, and binding agency policy.
        The Appeals Council's authority to review cases on its own motion 
    also applies, at present, to two types of hearing-level cases that do 
    not result in decisions by ALJs. Under Secs. 404.942 and 416.1442, 
    attorney advisors of OHA are temporarily authorized to conduct certain 
    prehearing proceedings and to issue, where warranted by the documentary 
    evidence, wholly favorable decisions. Under the provisions of 
    Secs. 404.942 (e)(2) and (f)(3) and 416.1442 (e)(2) and (f)(3), such 
    decisions are subject to review under the own-motion authority of the 
    Appeals Council established in Secs. 404.969 and 416.1469. In addition, 
    under Secs. 404.943 and 416.1443, adjudication officers are authorized, 
    for test purposes, to conduct certain prehearing proceedings and to 
    issue, where warranted by the documentary evidence, wholly favorable 
    decisions. Under the provisions of Secs. 404.943(c)(2)(ii) and 
    416.1443(c)(2)(ii), such decisions are also subject to review on the 
    Appeals Council's own motion.
        Under our regulations on the Appeals Council's procedures, if the 
    Appeals Council decides to review a case in response to a request for 
    review or on its own motion, it may issue a decision or remand the case 
    to an ALJ. The Appeals Council may also dismiss a request for hearing 
    for any reason that the ALJ could have dismissed the request.
        A decision by the Appeals Council ``to review'' a hearing-level 
    decision means that the Appeals Council assumes jurisdiction to cause 
    that decision not to be the final decision of the Commissioner of 
    Social Security. A decision that the Appeals Council ``reviews'' will 
    be replaced by a new final action in the case, either by a decision or 
    dismissal order of the
    
    [[Page 50267]]
    
    Appeals Council or, if a hearing or other hearing-level proceedings are 
    required, by a decision or dismissal order issued following remand of 
    the case from the Council to an ALJ.
        A decision by the Appeals Council to review a case is made when, 
    following a preliminary consideration of all aspects of the case to 
    determine if review is appropriate, the Council issues a notice 
    announcing a decision to review. The Council's standard notice of 
    review advises the parties of the reasons for the review and (unless 
    the Council issues a wholly favorable decision upon taking review) the 
    issues to be considered in proceedings before the Council or before an 
    ALJ on remand. In instances in which the Council reviews a hearing 
    level decision that has been issued based on the documentary evidence 
    without the holding of an oral hearing by an ALJ, the parties have the 
    right to such a hearing, except where the parties waive that right in 
    writing.
        The existing provisions in Secs. 404.969 and 416.1469 on the 
    Appeals Council's authority to review cases on its own motion provide 
    that the Appeals Council itself may decide to review a case within 60 
    days after the date of the hearing decision or dismissal and that, if 
    the Council does review a case under this authority, it will provide 
    notice to the parties to the hearing decision or dismissal action. 
    Sections 404.969 and 416.1469 do not currently address the procedures 
    we use in identifying and referring cases to the Appeals Council for it 
    to consider for possible review on its own motion.
        The Appeals Council has broad authority to review any case on its 
    own motion pursuant to Secs. 404.969 and 416.1469. The conditions under 
    which the Appeals Council will review a case, on request for review or 
    on its own motion, are set forth in Secs. 404.970 and 416.1470. Those 
    sections provide that the Council will review a case if: (1) There 
    appears to be an abuse of discretion by the ALJ; (2) there is an error 
    of law; (3) the action, findings or conclusions of the ALJ are not 
    supported by substantial evidence; or (4) there is a broad policy or 
    procedural issue that may affect the general public interest. Sections 
    404.970 and 416.1470 further provide that the Council will also review 
    a case if new and material evidence is submitted that relates to the 
    period on or before the date of the ALJ's decision and the Council 
    finds, upon evaluating the evidence of record and the additional 
    evidence, that an action, a finding or a conclusion of the ALJ is 
    contrary to the weight of the evidence currently of record as a whole.
        In fiscal year 1996 (FY '96), the Appeals Council received 99,735 
    requests for review filed by parties to the actions of ALJs. Most of 
    the requests were for review of unfavorable decisions and dismissal 
    actions; some concerned partially favorable decisions. In FY '96, the 
    Council also considered 8,602 cases for possible review on its own 
    motion. Almost all of these cases involved favorable hearing-level 
    decisions that were referred to the Appeals Council under one of two 
    types of identification and referral procedures we currently use--
    random sample procedures, which generated the majority of this workload 
    in FY '96, and ``protest'' procedures.
    
    Existing Identification and Referral Procedures
    
        Section 304(g) of Public Law 96-265 (1980) required SSA to 
    implement a program for initiating review of ALJ decisions in 
    disability claims. Under section 304(g), the Appeals Council considers, 
    for possible review on its own motion, a national random sample of 
    favorable ALJ decisions that have not been implemented, and, as 
    resources permit, a random sample of unappealed denial decisions and 
    dismissals. (See Social Security Ruling 82-13.)
        The Appeals Council also considers, for possible review on its own 
    motion, a random sample of wholly favorable decisions issued by 
    attorney advisors under the time-limited provisions of Secs. 404.942 
    and 416.1442. Wholly favorable decisions issued by adjudication 
    officers under the testing provisions of Secs. 404.943 and 416.1443 are 
    also identified by random sampling for referral to the Appeals Council 
    for possible own-motion review. These procedures have been established 
    in accordance with commitments we made, in publishing the final rules 
    for the attorney advisor and adjudication officer provisions, to assess 
    carefully the quality of the decisions issued by the attorney advisors 
    and the adjudication officers (see 60 FR 34127 and 60 FR 47471, 
    respectively).
        Our existing identification and referral procedures also include 
    those under which the SSA components responsible for implementing 
    hearing-level decisions--SSA Processing Centers (PCs) and Field Offices 
    (FOs)--refer (``protest'') certain cases to the Appeals Council for 
    possible review under its own motion authority. The PCs, which include 
    our Program Service Centers and the Office of Disability and 
    International Operations, refer cases directly to the Appeals Council; 
    FOs forward cases to a PC or an SSA Regional Office, which decides if 
    the PC or the Regional Commissioner should make a referral to the 
    Council.
        The decisions of ALJs and the decisions currently issued by 
    attorney advisors and adjudication officers are subject to referral to 
    the Appeals Council under our protest procedures. Almost all protested 
    decisions are favorable decisions because almost all of the ALJ 
    decisions that require implementation are wholly or partially favorable 
    decisions under which benefit payments are to be effectuated (initiated 
    or continued), and because all decisions issued by attorney advisors 
    and adjudication officers are favorable. In protesting a decision, an 
    effectuating component may recommend that the decision be made more or 
    less favorable or unfavorable.
        Effectuating components refer a case if the need for referral is 
    believed to be clear (not dependent on a judgment factor) because of 
    one of the following circumstances: (1) The decision contains a 
    clerical error which affects the outcome of the claim; (2) the decision 
    is clearly contrary to the Act, regulations or rulings; or (3) the 
    decision cannot be effectuated because its intent is unclear as to an 
    issue affecting the claim's outcome.
        Effectuating components refer cases to the Appeals Council by 
    written memoranda. If the Council decides to review a referred case, it 
    provides the parties a copy of the effectuating component's referral 
    memorandum with the notice by which it advises the parties that it will 
    review the case.
        We are proposing to amend our regulations to include rules on the 
    existing random sample and protest procedures discussed above. We have 
    decided to propose rules setting forth these procedures in connection 
    with our decision to propose, in furtherance of the Plan for a New 
    Disability Claim Process, that the Appeals Council's own-motion 
    functions be strengthened by establishment of a new process for 
    identifying and referring cases for possible review under the Council's 
    existing own-motion authority.
    
    New Identification and Referral Procedures
    
        The Appeals Council currently considers only a small percentage of 
    all favorable decisions issued at the hearing level for possible review 
    under its own-motion authority. (In FY '96, the Council's workload in 
    this area represented fewer than 3 percent of such decisions in that 
    year.) In addition, the processes we currently use to select decisions 
    for possible review on the Appeals Council's own motion are generally 
    not designed to identify, in
    
    [[Page 50268]]
    
    any systematic way, hearing-level decisions that are likely to be 
    incorrect. The random sample processes bringing cases before the 
    Appeals Council do not identify cases other than by techniques designed 
    to assure randomness of selection within broadly identified categories 
    (i.e., allowances, unappealed denials, and dismissals). The 
    identification of ``protest'' cases that occurs in the effectuation 
    process is a secondary function of a process that is principally 
    focused on the prompt payment of benefits.
        Based on the above considerations, we are proposing to establish 
    procedures under which our Office of Program and Integrity Reviews 
    (OPIR), the SSA component that oversees the review of State agency 
    determinations made under section 221(c) of the Act, will examine 
    certain allowance decisions at the hearing level and refer to the 
    Appeals Council the decisions that may not be supported by the record. 
    Decisions that have been issued at the hearing level will be included 
    in the OPIR-conducted examination process by random sampling and, as we 
    develop the computer systems and other technical capacities needed to 
    support this function, selective sampling that will rely on case 
    profiling and other sampling techniques to identify cases that involve 
    problematic issues or fact patterns that increase the likelihood of 
    error.
        Under the proposed process, upon referral of a case by OPIR, the 
    Appeals Council would consider the case and OPIR's reasons for 
    believing the decision is not supported by the record and decide 
    whether to review the case in accordance with Secs. 404.969-404.970 
    and/or 416.1469-416.1470. If the Appeals Council decides to review an 
    OPIR-referred case, it would provide the parties a copy of OPIR's 
    referral with its notice of review. The 60-day time limit for the 
    Appeals Council to initiate review of a case under the authority and 
    standards provided in Secs. 404.969-404.970 and 416.1469-416.1470 would 
    apply to cases the Council considers for review in response to 
    referrals from OPIR.
        Section 304(g) of Public Law 96-265 (see above) does not specify 
    the kind of identification and referral procedures that SSA should use 
    in implementing a program for initiating review of ALJ decisions in 
    disability cases. We believe that use of the new procedures we are 
    proposing, in combination with the existing identification and referral 
    procedures that we are proposing to regulate, would be consistent with 
    the kind of review contemplated by section 304.
        An important purpose of the new procedures we are proposing is to 
    increase our ability to identify policy issues that should be clarified 
    through publication of regulations or rulings. We plan to monitor how 
    our policies are understood and implemented by post-adjudicative 
    evaluation of cases that are shown, as a result of their referral to 
    the Appeals Council, to pose significant policy or program issues.
    
    Proposed Regulations
    
        We propose to revise Secs. 404.969 and 416.1469, the regulations 
    that set forth the Appeals Council's authority to review cases on its 
    own motion, to state that we refer cases to the Appeals Council for it 
    to consider reviewing on its own motion. As proposed for revision, 
    Secs. 404.969 and 416.1469 describe the identification and referral 
    procedures we will follow and the action of the Appeals Council in 
    cases it considers for possible review on its own motion.
        Sections 404.969 and 416.1469 as proposed will apply to all cases 
    that our regulations make subject to review on the Appeals Council's 
    own motion. These currently include, in addition to cases involving ALJ 
    decisions and dismissals, cases involving wholly favorable decisions 
    issued by attorney advisors under the time-limited provisions of 
    Secs. 404.942 and 416.1442, and cases involving wholly favorable 
    decisions issued by adjudication officers under the test procedures set 
    out in Secs. 404.943 and 416.1443.
        Proposed Secs. 404.969(b) and 416.1469(b) specify that we will 
    identify a case for referral to the Appeals Council for possible review 
    under its own-motion authority before we effectuate a decision in the 
    case. These sections also provide that we will identify cases for 
    referral through random and selective sampling techniques, that we may 
    use these techniques in association with examination of the cases 
    identified by sampling, and that we will also identify cases for 
    referral through the evaluation of cases we conduct in order to 
    effectuate decisions.
        Under Secs. 404.969(b)(1) and 416.1469(b)(1) as proposed, we may 
    conduct random and selective sampling of cases involving all types of 
    actions that occur at the hearing level of the administrative review 
    process (i.e., wholly or partially favorable decisions, unfavorable 
    decisions, or dismissals) and any type of title II or title XVI 
    benefits (i.e., different types of benefits based on disability and 
    benefits not based on disability). Our decision to propose these rules 
    rests on our conclusion that we should increase the number of favorable 
    disability decisions the Appeals Council considers for possible review 
    on its own motion to better balance review of favorable and unfavorable 
    decisions. However, the Council's existing authority to review cases on 
    its own motion covers all types of title II and title XVI cases 
    adjudicated at the hearing level, and these proposed rules will allow 
    use of the identification and referral procedures being set forth with 
    respect to all such cases.
        Sections 404.969(b)(1) and 416.1469(b)(1) as proposed specify that 
    we will use selective sampling to identify cases that exhibit 
    problematic issues or fact patterns that increase the likelihood of 
    error. Under the provisions as proposed, the factors considered in 
    selective sampling will not include the identity of the decisionmaker 
    or the identity of the office issuing the decision.
        Proposed Secs. 404.969(b)(1) and 416.1469(b)(1) also authorize but 
    do not require that we examine cases that have been identified through 
    random or selective sampling. Cases may be identified for referral by 
    random or selective sampling. The purpose of the examination of cases 
    that we may conduct is to refine the identification of cases in which 
    the action that has been taken is not supported.
        Proposed Secs. 404.969(b)(2) and 416.1469(b)(2) provide that 
    effectuating components will identify cases for referral under criteria 
    presently used to identify clear error and circumstances preventing 
    effectuation of a decision. Any type of decision requiring effectuation 
    may be identified for referral under these provisions.
        Under Secs. 404.969(c) and 416.1469(c), as proposed, we will make 
    referrals that occur as the result of a case examination or the 
    effectuation process in writing. The written referral will state the 
    referring component's reasons for believing that the Appeals Council 
    should review the case on its own motion. Sections 404.969(c) and 
    416.1469(c) as proposed also provide that referrals resulting from 
    selective sampling without a case examination may be accompanied by a 
    written statement identifying the issue(s) or fact pattern that caused 
    the referral, and that referrals resulting from random sampling without 
    a case examination will only identify the case as a random sample case. 
    A statement of the issue(s) or fact pattern identified in selective 
    sampling may be computer generated.
        Proposed Secs. 404.969(d) and 416.1469(d) specify that the Appeals 
    Council's notice of review will include a copy of any written referral 
    provided
    
    [[Page 50269]]
    
    to the Appeals Council. These provisions also include language to state 
    clearly our long-standing policy that issuance of the notice of review 
    establishes when a decision to conduct a review occurs.
        We are also proposing to include in Secs. 404.969(d) and 
    416.1469(d) a statement specifying our policy that, when the Appeals 
    Council is unable to decide whether to review a case on its own motion 
    within the 60-day period in which it may do so, it may consider whether 
    the decision should be reopened under the provisions of Secs. 404.987 
    and/or 416.1487, which authorize the Council to reopen a final decision 
    on its own initiative or at the request of a party to the decision, if 
    a condition for reopening stated in Secs. 404.988 and/or 416.1488 is 
    present. We are including this statement in the regulations to clarify 
    our long-standing policy that the Appeals Council may also reopen final 
    decisions in accordance with Secs. 404.987 and 416.1487 after the 60 
    days for initiating review under Secs. 404.969 and 416.1469 have 
    expired.
    
    Electronic Version
    
        The electronic file of this document is available on the Federal 
    Bulletin Board (FBB) at 9:00 a.m. on the date of publication in the 
    Federal Register. To download the file, modem dial (202) 512-1387. The 
    FBB instructions will explain how to download the file and the fee. 
    This file is in WordPerfect and will remain on the FBB during the 
    comment period.
    
    Regulatory Procedures
    
    Executive Order 12866
    
        We have consulted with the Office of Management and Budget (OMB) 
    and determined that these rules do meet the criteria for a significant 
    regulatory action under Executive Order 12866. They were therefore 
    submitted to OMB for review.
    
    Regulatory Flexibility Act
    
        We certify that these regulations will not have a significant 
    economic impact on a substantial number of small entities because these 
    rules affect only individuals. Therefore, a regulatory flexibility 
    analysis as provided in the Regulatory Flexibility Act, as amended, is 
    not required.
    
    Paperwork Reduction Act
    
        These regulations impose no new reporting or record keeping 
    requirements requiring OMB clearance.
    
    (Catalog of Federal Domestic Assistance Program Nos. 96.001, Social 
    Security-Disability Insurance; 96.002, Social Security-Retirement 
    Insurance; 96.003, Social Security-Special Benefits for Persons Aged 
    72 and Over; 96.004, Social Security-Survivors Insurance; 96.006, 
    Supplemental Security Income)
    
    List of Subjects
    
    20 CFR Part 404
    
        Administrative practice and procedure, Death benefits, Disability 
    benefits, Old-Age, Survivors and Disability Insurance, Reporting and 
    recordkeeping requirements, Social Security.
    
    20 CFR Part 416
    
        Administrative practice and procedure, Aged, Blind, Disability 
    benefits, Public assistance programs, Supplemental Security Income 
    (SSI), Reporting and recordkeeping requirements.
    
        Dated: September 12, 1997.
    John J. Callahan,
    Acting Commissioner of Social Security.
    
        For the reasons set out in the preamble, subpart J of part 404 and 
    subpart N of part 416 of chapter III of title 20 of the Code of Federal 
    Regulations are proposed to be amended as set forth below.
    
    PART 404--FEDERAL OLD-AGE, SURVIVORS AND DISABILITY INSURANCE 
    (1950-    )
    
        20 CFR part 404, subpart J, is amended as follows:
        1. The authority citation for subpart J of part 404 is revised to 
    read as follows:
    
        Authority: Secs. 201(j), 205 (a), (b), (d)-(h), and (j), 221, 
    225, and 702(a)(5) of the Social Security Act (42 U.S.C. 401(j), 405 
    (a), (b), (d)-(h), and (j), 421, 425, and 902(a)(5)); 31 U.S.C. 
    3720A; sec. 304(g), Pub. L. 96-265, 94 Stat. 456 (42 U.S.C. 421 
    note); sec. 5, Pub. L. 97-455, 96 Stat. 2500 (42 U.S.C. 405 note); 
    secs. 5, 6 (c)-(e), and 15, Pub. L. 98-460, 98 Stat. 1802 (42 U.S.C. 
    421 note).
    
        2. Section 404.969 is revised to read as follows:
    
    
    Sec. 404.969  Appeals Council initiates review.
    
        (a) General. Anytime within 60 days after the date of a decision or 
    dismissal that is subject to review under this section, the Appeals 
    Council may decide on its own motion to review the action that was 
    taken in your case. We may refer your case to the Appeals Council for 
    it to consider reviewing under this authority.
        (b) Identification of cases. We will identify a case for referral 
    to the Appeals Council for possible review under its own-motion 
    authority before we effectuate a decision in the case. We will identify 
    cases for referral to the Appeals Council through random and selective 
    sampling techniques, which we may use in association with examination 
    of the cases identified by sampling. We will also identify cases for 
    referral to the Appeals Council through the evaluation of cases we 
    conduct in order to effectuate decisions.
        (1) Random and selective sampling and case examinations. We may use 
    random and selective sampling to identify cases involving any type of 
    action (i.e., wholly or partially favorable decisions, unfavorable 
    decisions, or dismissals) and any type of benefits (i.e., benefits 
    based on disability and benefits not based on disability). We will use 
    selective sampling to identify cases that exhibit problematic issues or 
    fact patterns that increase the likelihood of error. Our selective 
    sampling procedures will not identify cases based on the identity of 
    the decisionmaker or the identity of the office issuing the decision. 
    We may examine cases that have been identified through random or 
    selective sampling to refine the identification of cases in which the 
    action taken may not be supported by the record.
        (2) Identification as a result of the effectuation process. We may 
    refer a case requiring effectuation to the Appeals Council if the 
    decision cannot be effectuated because it contains a clerical error 
    affecting the outcome of the claim; the decision is clearly 
    inconsistent with the Social Security Act, the regulations, or a 
    published ruling; or the decision is unclear regarding a matter that 
    affects the claim's outcome.
        (c) Referral of cases. We will make referrals that occur as the 
    result of a case examination or the effectuation process in writing. 
    The written referral based on the results of such a case examination or 
    the effectuation process will state the referring component's reasons 
    for believing that the Appeals Council should review the case on its 
    own motion. Referrals that result from selective sampling without a 
    case examination may be accompanied by a written statement identifying 
    the issue(s) or fact pattern that caused the referral. Referrals that 
    result from random sampling without a case examination will only 
    identify the case as a random sample case.
        (d) Appeals Council's action. If the Appeals Council decides to 
    review a decision or dismissal on its own motion, it will mail a notice 
    of review to all the parties as provided in Sec. 404.973. The Appeals 
    Council will include with that notice a copy of any written referral it 
    has received under paragraph (c) of this section. The Appeals Council's 
    decision
    
    [[Page 50270]]
    
    to review a case is established by its issuance of the notice of 
    review. If it is unable to decide within the applicable 60-day period 
    whether to review a decision or a dismissal, the Appeals Council may 
    consider the case to determine if the decision or dismissal should be 
    reopened pursuant to Sec. 404.987.
    
    PART 416--SUPPLEMENTAL SECURITY INCOME FOR THE AGED, BLIND, AND 
    DISABLED
    
        20 CFR part 416, subpart N, is amended as follows:
        1. The authority citation for subpart N is revised to read as 
    follows:
    
        Authority: Sec. 702(a)(5), 1631, and 1633 of the Social Security 
    Act (42 U.S.C. 902(a)(5), 1383, and 1383b); sec. 304(g), Pub. L. 96-
    265, 94 Stat. 456 (42 U.S.C. 421 note).
    
        2. Section 416.1469 is revised to read as follows:
    
    
    Sec. 416.1469  Appeals Council initiates review.
    
        (a) General. Anytime within 60 days after the date of a decision or 
    dismissal that is subject to review under this section, the Appeals 
    Council may decide on its own motion to review the action that was 
    taken in your case. We may refer your case to the Appeals Council for 
    it to consider reviewing under this authority.
        (b) Identification of cases. We will identify a case for referral 
    to the Appeals Council for possible review under its own-motion 
    authority before we effectuate a decision in the case. We will identify 
    cases for referral to the Appeals Council through random and selective 
    sampling techniques, which we may use in association with examination 
    of the cases identified by sampling. We will also identify cases for 
    referral to the Appeals Council through the evaluation of cases we 
    conduct in order to effectuate decisions.
        (1) Random and selective sampling and case examinations. We may use 
    random and selective sampling to identify cases involving any type of 
    action (i.e., wholly or partially favorable decisions, unfavorable 
    decisions, or dismissals) and any type of benefits (i.e., benefits 
    based on disability and benefits not based on disability). We will use 
    selective sampling to identify cases that exhibit problematic issues or 
    fact patterns that increase the likelihood of error. Our selective 
    sampling procedures will not identify cases based on the identity of 
    the decisionmaker or the identity of the office issuing the decision. 
    We may examine cases that have been identified through random or 
    selective sampling to refine the identification of cases in which the 
    action taken may not be supported by the record.
        (2) Identification as a result of the effectuation process. We may 
    refer a case requiring effectuation to the Appeals Council if the 
    decision cannot be effectuated because it contains a clerical error 
    affecting the outcome of the claim; the decision is clearly 
    inconsistent with the Social Security Act, the regulations, or a 
    published ruling; or the decision is unclear regarding a matter that 
    affects the claim's outcome.
        (c) Referral of cases. We will make referrals that occur as the 
    result of a case examination or the effectuation process in writing. 
    The written referral based on the results of such a case examination or 
    the effectuation process will state the referring component's reasons 
    for believing that the Appeals Council should review the case on its 
    own motion. Referrals that result from selective sampling without a 
    case examination may be accompanied by a written statement identifying 
    the issue(s) or fact pattern that caused the referral. Referrals that 
    result from random sampling without a case examination will only 
    identify the case as a random sample case.
        (d) Appeals Council's action. If the Appeals Council decides to 
    review a decision or dismissal on its own motion, it will mail a notice 
    of review to all the parties as provided in Sec. 416.1473. The Appeals 
    Council will include with that notice a copy of any written referral it 
    has received under paragraph (c) of this section. The Appeals Council's 
    decision to review a case is established by its issuance of the notice 
    of review. If it is unable to decide within the applicable 60-day 
    period whether to review a decision or dismissal, the Appeals Council 
    may consider the case to determine if the decision or dismissal should 
    be reopened pursuant to Sec. 416.1487.
    
    [FR Doc. 97-25365 Filed 9-24-97; 8:45 am]
    BILLING CODE 4190-29-U
    
    
    

Document Information

Published:
09/25/1997
Department:
Social Security Administration
Entry Type:
Proposed Rule
Action:
Proposed rules.
Document Number:
97-25365
Dates:
To be sure that your comments are considered, we must receive them no later than November 24, 1997.
Pages:
50266-50270 (5 pages)
RINs:
0960-AE53: Identification and Referral of Cases for Quality Review Under the Appeals Council's Authority To Review Cases on Its Own Motion (623F)
RIN Links:
https://www.federalregister.gov/regulations/0960-AE53/identification-and-referral-of-cases-for-quality-review-under-the-appeals-council-s-authority-to-rev
PDF File:
97-25365.pdf
CFR: (2)
20 CFR 404.969
20 CFR 416.1469