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Business Guide
Lesson Four Introduction: This lesson discusses several important techniques that will allow you to properly interact with the Social Security Administration during the processing of a disability claim.
There are several reasons for why you would need to interact with the Social Security Administration (SSA). At the beginning of a case, a representative might contact Social Security to inform them of his/her representational status. An advocate might also contact Social Security to begin the application process on behalf of a client or to request case documentation. These listed Social Security contact objectives may occur at anytime and on all adjudicative levels.
Interacting with the Social Security Administration can be frustrating. What you'll discover is that despite the fact that all Social Security offices are controlled by the same rules, there can be an enormous difference in how various processes are handled within a given office. To reduce frustration, approach your local Social Security District Office (DO) with the intent of learning how it functions. That is, try to learn how your local Social Security office handles such important functions as the distribution of client evidence to representatives, form distribution and other common functions. You will most often be in contact with either your local Social Security District Office or your state's Disability Determination Section (DDS). All cases are first developed at the claimant's local Social Security District Office (DO). The DO is responsible for requesting and acquiring copies of the claimant's initial forms and other essential documentation. Once the DO has received these basic case materials, the case is forwarded to the state Disability Determination Section (DDS). At the DDS, the case will be assigned to a disability Examiner. The Examiner will continue the case development started by the District Office. Once a case is transferred to the DDS, all case activities will be handled at that location. You will have the opportunity to create a relationship between yourself the DDS Examiner handling the case. Creating a positive relationship with a DDS Examiner can make your career as an advocate much easier. Although the DDS Examiner cannot make a case decision alone, these professional clerks do control access to the case materials.
Why would a DDS examiner want to create a cooperative relationship with a disability advocate? To understand what motivates the DDS examiner, you must understand how they acquire rank and pay within the Social Security system. In most states, the DDS examiner is a State, not Federal employee. However, his job is strictly Federal in nature. This means that the Feds can and do place standards of performance on the state examiner. The state administrator's job is to make sure that the DDS examiner continually performs at the required level determined by his rank. The performance standards are extremely high and it can be difficult for the average examiner to survive in this system. One of the most important standards placed upon the DDS examiner is called the case processing number. The size of this number is also set by examiner rank. The higher the rank, the more cases the examiner is expected to complete. If the examiner misses his designated number of completed cases for two consecutive six-month periods, he can be demoted or dismissed. If for example an examiner is ranked at the entry level, less than three years of experience, and he misses his case completion number, he will be fired. So, as you can see, the examiner can be influenced by anyone and anything that can help him make his stats. The single greatest reason for slow case processing is the case development phase as practiced by Social Security. Social Security is still using standard mail and other antiquated approaches to acquiring evidence. That is, evidence is delivered to the Social Security office in paper format instead of electronic format. This means that it can take weeks just to get a single document needed to adjudicate a case. Therefore, anything you can do to help the examiner to get his hands on the evidence sooner, will result in a happy examiner and a more rapid case decision. Faster case completion helps the examiner to keep his job, while simultaneously allowing you access to an insider. Make friends with examiners! Offer your assistance to every examiner in every case you represent. Let the examiner know that you’re willing to personally acquire whatever is needed to help him complete the case. One caveat! Do not ask the examiner for any special favors related to a case. To do so might make it appear that the examiner's actions are a conflict of interest.
Use our case guidance approach described in Lesson 3 under Initial Client Contact when reviewing cases that are at the pre-initial case level. Taking on a case at the initial level just before the claimant applies, does represent a powerful strategic weapon for the disability advocate who knows how to use it. This situation allows the advocate to covertly construct the case before Social Security reviews the case. Early entry into a case in the form of a Guidance Packet also allows for strong advocate input before the claimant has a chance to weaken the case with inappropriate statements or evidence. Using our case guidance approach at the initial level can also allow the advocate to acquire and review medical evidence before the Social Security Administration. The advocate can review the supporting evidence first, verifying the claimant's allegations, limitations and onset date. Non-supportive evidence can be set aside, while strong evidence is presented immediately to the Social Security Administration. Using the above approach can also save time! The evidence can be presented at the time of case application, reducing the DDS examiner's need for case development. This approach can cut months off the time it takes to process a disability claim. If early in a case, Social Security has the evidence it needs to make a decision, there may be a special District Office (DO) team that will make the decision on the spot. Not all states use these DO teams. If your Social Security office is not using a DO case expediting team, the case will be sent to the DDS as usual for case development and a decision. If the evidence sent is appropriate and is enough to make a decision, this will be done within a few weeks after the case arrives at the DDS. The case guidance approach can save at least a month or more in case processing time. The case guidance technique is usually only used at the initial level. In using this approach, you'll be doing the applicant, Social Security and yourself a tremendous service. Why, because the goal of the claimant is to get his benefits as fast as possible. The goal of the DDS examiner is to make a disability decision in as short a period as possible to make his stats. If the case is denied, you’re in a perfect position to take over the representational duties. Your input and assistance helps everybody involved in the case to achieve their prospective goals. By assisting the client in the pre-initial or first application phase, you're also helping Social Security to do its job. Using our guidance approach to dealing with client evidence and DDS employees will help remove a serious case processing bottleneck. This in turn will significantly improve your overall relationship with Social Security. Your use of this approach does require a little more work, but will ultimately serve the best interest of everyone involved in the case.
Entering a case at the initial level may involve one of two possible
scenarios. Either the claimant has never applied for Social Security
disability benefits or he has applied but has not as yet received a
decision. If the claimant has never applied for disability benefits, follow
the instructions as outlined under the Business Guide Lesson 3, First Client
Contact. If the claimant has already made application at the initial level,
use our guidance approach. Becoming the Authorized Representative: To become a client's authorized representative, send a signed copy of the Social Security Request for Authorization to Represent form 1696. This form can be sent to the District Office, Disability Determination Section or Appeals Office. Where you send this notice depends upon what level the case is on and how long the case has been in play. The Social Security office closes to the applicant is usually the office that will process the case. When Social Security receives the completed form 1696, they will date stamp the form and incorporate it into the claimant's folder. Social Security is suppose to send the representative a stamped copy of the 1696, but this doesn’t always happen. You can optionally request a copy of the stamped 1696 for your records. You also have the option of going down to the Social Security office, with or without your client, to pick up a stamped copy of this form if you wish. This step is not required in most cases. If you and the claimant apply together by phone or at the District Office, these forms are completed by a Social Security staff person during your visit. In most case, Social Security will not allow you to have an original of any official case form. Be prepared to request copies of items you think you'll need. As you announce your representation to Social Security, you also have the option of simultaneously making application for the appeal on behalf of the client. We are of course assuming that the claimant has been denied on the initial case level. It's not always clear if the claimant has received a denial from the initial or reconsideration levels. You should be able to determine which level the case is on by your interview with the claimant. If the claimant interview doesn't expose the client's case level, then the client's records from Social Security will make this clear. Example: Asking the claimant the following questions can help you to determine case level:
These questions above will help you to determine at what case level the claimant is currently on. If the claimant has received notice of a denial within the last two months, chances are he is eligible for either a Reconsideration or an Administrative Law Judge appeal. You and/or the claimant must apply for an appeal at some point within the claimant's sixty-day appeal window. Later in this lesson, we'll discuss methods of extending the sixty-day time limit for requesting an appeal of a disability claim.
A representative transfer is the act of transferring a case from one representative to another. Only the claimant can initiate this action. Example: A claimant was represented by an attorney on the initial or reconsideration level. The claimant is dissatisfied with the attorney's work. The claimant want's you to take over the case. What do you do? 1. Instruct the claimant to contact both Social Security and the attorney in writing, requesting that the representative relationship be terminated. 2. Make sure that the claimant does not mention you or your firm in the request. You have nothing to do with the case until the contract between the parties has been terminated. 3. Before accepting the case, request a copy of the claimant's request letter and all correspondence from Social Security or the attorney concerning this issue. Make sure that the relationship has been terminated and request written proof of the termination. The best written proof is a letter from the attorney addressed to the claimant, indicating an end to their professional relationship. For additional discussion of this subject, see Representative Transfer article in the Executive website under special subjects.
Accepting a case at the Reconsideration appeal level involves many of the same interactions with Social Security as would occur at the initial case level. However, at the reconsideration level, case development is usually a lot easier. That's because in most cases, the majority of the claimant's available medical evidence has already been acquired. Although the appeal levels reduce case development, do not allow them to reduce your vigilance. If the case is new to you at reconsideration, perform a case assessment, an intensive client interview and a review of all evidence currently available in the case. You'll also have the opportunity to interact with Social Security at the reconsideration appeal level when you request the appeal on behalf of a client.
It's not unusual for a claimant to have already applied for an appeal before seeking advocacy services. If the claimant has applied for reconsideration, but has not gotten a decision notice, you should send Social Security the SSA-1696 form as usual. If you enter a case during the reconsideration process, the claimant's case folder may have already left the Social Security District Office, headed back to the Disability Determination Section (DDS). If this is the case, contact the DDS and find out which examiner has been assigned the case. Write a brief letter informing the examiner that you are the authorized representative. Be sure to attach a copy of the signed 1696 representative authorization form. Note: Social Security regulation directs that a case on reconsideration cannot be handled by the same examiner who performed the initial review.
The first reconsideration contact with Social Security can be made in-person or by mail. If you use mail, include a rebuttal letter indicating your disagreement with the previous denial decision. This Social Security contact is also an opportunity for you to inform Social Security of any new impairments, medical sources or evidence that may need to be considered. This reconsideration appeal is also an opportunity to submit a questionnaire, allege a new impairment or submit an Activities of Daily Living (ADLs) report. Use an ADL report only if this information is not already in the claimant's folder. Remember, a claimant's activities of daily living report can be used to support the claimant's alleged physical or mental limitations. Any evidence that supports a claimant's alleged limitations can be used to reduce that claimant's Residual Functional Capacity (RFC). After you have submitted and received all requested medical evidence from the SSA District Office or Disability Determination Section, allow the case to be processed as usual. Interfere as little as possible unless your actions will enhance the claimant’s chances for an allowance or speed up the decision process. Be sure to bring up any additional impairments, new evidence, allegations, physical or mental restrictions suffered by the claimant that might not have been considered in the previously decision. Adding additional impairments and/or physical limitations at recon could result in a reversal of the initial denial decision. Don't be shy about adding additional evidence or allegations if they are supported by the medical evidence. Your actions at reconsideration could help Social Security to avoid making another erroneous denial decision.
Now let's turn our attentions to the contact correspondence itself. The usual materials sent to the Social Security District Office (DO) or the Disability Determination Section (DDS) at any case level include: a. An introductory cover letter b. A signed 1696 c. Signed copy of a client’s medical release form. d. All medical or vocational evidence in your possession. If you have copies of all the evidence and can immediately create an argument, include your formal argument with a summation of the key supportive issues in the case. This usually does not occur at the initial case level, but it's possible. Even if the claimant has already applied, you'll still need to send a cover letter, a copy of the Rep form 1696 and a list of any new or additional evidence supporting your position.
A Cover letter can be used by an advocate to:
Se sample Cover Letter in the online Study Guide lesson seven.
A request for a Reconsideration Appeal or an ALJ appeal is based on the contents of one form or letter. You can use the Request for Reconsideration form SSA 561 or you can send a letter requesting same. SSA will probably request a signed copy of the SSA Form 561 if only a letter is sent. However, the letter can act as a safety preserving the client’s right to appeal period to the end of the appeal deadline. You should also send a request to review the client's record and as for a copy of all available evidence of record. If there is any new or additional evidence since the last decision, you'll need to provide it to SSA or request it for the source. In the body of your Reconsideration Request form or letter, you should also request a copy of the previous case decision notice. You do this by asking for a copy of the claimant's Personalized Denial Notice (PDN) or Technical Rationale. You may also wish to request a copy of any forms, questionnaires, etc, in the claimant's SSA file. We'll discuss appeal cases in greater detail in upcoming lessons.
Reference source: Book 20 CFR Regulation 416.1411) If, as a newly appointed representative, you find that the claimant has run out of time to request a reconsideration or ALJ appeal, you can request a good cause extension. SSA has a number of circumstances they consider to be good cause to extend the sixty-day appeal deadline. These good cause circumstances are outline in the online version of this lesson.
When you request medical evidence of record at any adjudicative level, be careful of what and how you ask. Regardless of source, requesting non-specific evidence could result in your receiving a ton of useless paperwork. In the wording of a request letter, ask for the specific medical items you need. For example, instead of requesting all medical evidence from date-to-date, request a copy of a report with a specific date that addresses a specific impairment if possible. No matter the adjudicative level, learn to request specific types of evidence over specific time periods. Here is a short list of various types of medical evidence:
If you know the onset date of a claimant's impairment, it’s common practice to request medical evidence from the onset date to the most currently available evidence date. Do not request evidence that occurred more than a few months before the claimant's onset date or AOD. Evidence created outside of the impairment period would be useless to the case. For more information about medical evidence in a disability claim, visit Lesson Four of the online Study Guide. In our approach to disability advocacy, the Merck Manual, the SSA Guide and the Systems Explorer play an important role in helping you to sort out what types of medical evidence will be required in a case. To use the online Merck Manual, open your Advocate Client Manager Pro software and click on the red Med Info button.
Disability Associates has an online program called the Forms Buddy. The Forms Buddy contains a pdf version of the most commonly used Social Security forms. The Forms Buddy allows you to complete and print these forms right from your desktop. Otherwise, you will need to input information by hand when you complete these forms. The following is a short list of Social Security forms commonly used on various adjudicative levels:
This form is used to appoint a representative on all adjudicative levels.
This form is used on all adjudicative levels to acquire access to a claimant's medical records.
This form is used at reconsideration to request new or additional evidence and to document new or additional impairments.
The SSA 4268 is a personalized and/or technical rationale letter prepared by the disability examiner makes the initial and reconsideration decisions. This letter provides specific information about how and why a claimant's case was denied. All cases that are denied will have this form in file.
This is the adult disability report form used by Social Security at the initial case level. This form is usually completed by the claimant at the beginning of an initial claim. It allows the claimant to list his medical allegations and medical sources.
This is a vocational report or work history form that is filled out by the claimant at the initial application level. This form is also included in the claimant's permanent case folder. You'll need either a copy of this form or the information it contains in order to evaluate the claimant's past work history. Vocational information allows you to perform the vocational analysis process. For more information about the vocational analysis process, visit Lesson Five of the online Study Guide.
The 831 is a special form that is used by a disability examiner to code his case decisions. These codes make it easier for Social Security employees to do internal processing of the case. The 831 form is filled out at the time the case is adjudicated by the disability examiner. You and the claimant will never need to complete this form. We sometimes request this form because it contains specific coded information that we can use. Since no one knows how to read this form, Social Security will consider your request to be puzzling. In fact, this is a highly sophisticated maneuver. This form is important because with a single glance, you can learn the case type, DLI date if applicable, primary diagnosis, reason for prior decision and the adjudicative level the case is on. This form is not required to process a case.
On the Reconsideration or Administrative Law Judge (ALJ) appeal levels, there is often a period of weeks before a claimant will again approach Social Security on appeal. During this period the claimant's condition could change for the worse. Most often, the claimant continues to see his doctor who monitors the claimant's condition. If his condition worsens or if a test or procedure shows a new serious disorder or limitation, this is called additional supportive evidence. This evidence could change the case decision and must be brought to the attention of Social Security. An advocate will use this new evidence or new allegation to argue for a reversal of the previous denial decision. If there is new or additional evidence to consider on the Reconsideration or Administrative Law Judge (ALJ) appeals, take the initiative and acquire your own copy of this new evidence. You can then send a copy of the new evidence to Social Security, cutting weeks off the appeal case processing time. If claimant's doctor visits prior to reapplying for benefits were for medication refills or simple checkups, you might want to ignore this material to speed up the reconsideration process. However, if the doctor's visits were as a result of a worsening of the claimant's condition, or a new serious allegation is found, be sure this information is included in the claimant's Social Security file before the reconsideration or ALJ decision is made. You'll be able to determine the importance of new or additional evidence from your client phone interview prior to accepting the case. Your best chance to win a disability case at the appeal level occurs when additional evidence or a new serious condition, not previously considered by Social Security is incorporated into the case argument.
When a case is adjudicated at the initial level of a Social Security disability claim, here is a common scenario that may occur: Social Security receives all of the documentation needed to make a decision. You may have had to contact the examiner on a couple of previous occasions to offer your assistance in helping him complete the case. If you can help the examiner make the decision faster, do so! The case decision is made by the DDS examiner with the help of a medical and vocational staff professional. Regardless of the decision outcome, the case is then returned to the local Social Security District Office. The decision notice is sent to the claimant and his representative from the District Office. If the case is an allowance, you would submit your fee petition attachment form to Social Security and bill the claimant. Our Advocate Client Manager software automatically generates the fee petition attachment as you process the case. If the case is a denial, you begin the appeal process. The appeal process you start depends upon the previous level of the case. Note: Regardless of the appeal level, Social Security allows just sixty-days to request an appeal. If you wait longer than sixty-days, Social Security will not accept the appeal unless you can provide good cause.
Lesson five will discuss in greater detail, the Social Security disability appeal process at the Reconsideration and Administrative Law Judge levels. ********************
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