Generally, initial determinations made on your claim are subject to your right to appeal, usually within 60 days. However, in certain instances, a decision which would otherwise be final and binding may be reopened or revised.
Social Security Administration may reopen a decision on its own initiative, or, a claimant may request that a previous determination be reopened. In either situation, if SSA decides to reopen a determination or decision, it may revise that determination or decision.
SSA regulations set forth the conditions under which a previous determination may be revisited. Although the regulations sound as if a party to a claim may simply request a reopening and it will be done, it is generally well established that whether or not to reopen a claim is left to the discretion of the Administration.
According to 20 C.F.R. §404.900, an Initial Determination is one made about your entitlement or your continuing entitlement to benefits or about any other matter that gives you a right to further review. Regulations differentiate between actions that are deemed initial determinations and those actions deemed not to be initial determinations.
Administrative actions that are not initial determinations may be reviewed by SSA, but are not subject to the administrative review process, and are not subject to judicial review. Denying a request to reopen a determination or a decision is considered such an action.
Therefore, denial of a request to reopen is not grounds for appeal. Nevertheless, regulations do provide for three conditions for reopening an otherwise closed case. The most generous provision allows for reopening a case for any reason within twelve months of the initial determination. Again, the refusal by SSA to reopen a case within twelve months for any reason is not subject to appeal.
The second listed condition listed is within four years (two years for SSI), for good cause. Good cause includes new and material evidence, clerical errors in computations of benefits, or evidence that, on its face, was clearly construed in error. A change in the law is not considered good cause.
Finally, a case may be reopened at any time if the determination was induced by fraud or similar fault. The regulation goes on to list what it means by similar fault, and includes instances related to death, convictions, and other clerical errors.
Most often, the request for reopening situation arises when a claimant has had a previous claim denied, but files a new claim that is subsequently approved. The question then becomes whether the previously denied claim can be reopened, effectively granting a claimant more back pay. Because of the huge backlog and the slow pace at which SSA adjudicates claims, it often happens that the request for reopening cannot be made for any reason under paragraph 1, and the good cause provisions of paragraph 2 come into play, ostensibly allowing for reopening within 4 years if the provisions can be met. As a matter of practice, the most common good cause would have to do with new and material evidence that relates back to the period of the initially denied claim.
In the end though, a claimant may not demand reopening under any of these provisions. It may only be requested. And, if denied, the decision may not be appealed.