Study Guide
 Lesson
One
Introduction to the
Social Security Disability Process
Notice:
At the end of each lesson, you'll find a lesson completion notice.
In order to earn your Certificate of Achievement, this notice must be
submitted to our training coordinator Dr. Jeff Scott for all sixteen lessons
of both the online Study and Business Guides. Do not submit a lesson notice
until you have completed the lesson in both the DA Pro and online.
Make sure that you pass the basic quiz inside of the DA Pro software.
If cannot pass a lesson quiz, you're not ready to move on to the next
lesson. If you need assistance, please do not hesitate to contact us.
Our business motto is simple. If we can help you succeed as a
disability advocate, we succeed!
The Social Security Process:
In this lesson one
reading, we're going to introduce you to the Social Security disability process.
The Disability Process:
To understand the Social Security disability process, you must first have a
general idea of what occurs when a claimant applies for disability benefits.
This lesson will provide a generalized overview of the Social Security
disability application process as it pertains to the disability applicant
and his or her representative.
Do not attempt to memorize this material. This lesson is best utilized as a
reference source. It's designed to familiarize you with common Social
Security disability practices and procedures as would occur in a standard
application for Social Security disability benefits.
What happens when a person applies?
A disability case begins when an individual decides he/she is no longer able
to perform work due to a severe impairment. A severe impairment is defined
by Social Security as any impairment that has lasted or is expected to last
for twelve continuous months. The severe impairment must also cause
physical or mental limitations that would interfere with a person’s ability
to perform or sustain work.
On application, the disabled individual contacts his local Social Security
District Office and begins the application process. A person may apply by
phone, mail or in person. At the Social Security District Office (DO), the
claimant fills out a number of forms giving Social Security information
about his condition, medical sources, income and other vital facts used to
determine the client's eligibility to apply for benefits.
If the claimant meets Social Security's income and resource requirements, he
is then allowed to continue the application process. Keep in mind that
there are two levels of eligibility that the claimant must meet. The
first is eligibility to apply, which is based on income and resources. The
second is eligibility to receive benefits which is based on the severity of
the applicant’s disorder.
If the applicant meets Social Security‘s income and resource requirements,
he must then meet Social Security‘s impairment severity requirement in order
to actually receive benefits. A disability advocate cannot help a claimant
meet Social Security's income and resource requirements. However, we can
help the applicant to meet Social Security's medical criteria. A disability
advocate assists an applicant in meeting Social Security’s medical criteria
by making sure that all aspects of the applicant’s disorder are considered
before a disability decision is made.
Case Types:
There are many different types of disability claims. However, for our
purposes, there are just two general categories. These categories are
Social Security Disability Insurance (SSDI) and Supplemental Security Income
(SSI). We'll define these case types later in the program.
The original application for disability usually occurs at the Social
Security District Office. Once Social Security has determined that a
claimant is eligible to apply for disability benefits under one or both of
these case types, the case is then forwarded to the state Disability
Determination Section (DDS).
Application Levels:
There are three common application levels. These applicant levels are the
Initial, Reconsideration and Administrative Law Judge (ALJ). We recommend that a
disability advocate restrict their representational services to these three
levels. However, we know of no law prohibiting an advocate from
representing on the Appeal Council level which occurs after the ALJ appeal.
The Appeal Council level appeal is much more formal than the ALJ appeal and
is best left to attorneys or advocates with years of experience.
Some states use hearings at both the Reconsideration and ALJ levels. A
hearing is simply a review of the claimant's application in a face-to-face
setting. A reconsideration face-to-face hearing is small and informal,
and is usually performed by a Hearings
Officer or Judge.
When the case arrives at the Disability Determination Section (DDS), it's
assigned to a claims examiner who is responsible for developing, evaluating
and making a final decision in the case. The examiner does not make this
decision alone. The decision is made in conjunction with a medical
professional, usually an MD.
All medical sources (evidence) provided by the claimant
are contacted by the examiner and asked to supply reports discussing the
claimant's impairment. The examiner may also contact the claimant to extract
additional information about his/her condition, daily activities or for details about
the claimant's past work history.
The Decision:
Once the medical and vocational information has been received by the
examiner, the case is evaluated to determine if it meets Social Security’s
criteria for a total disability as defined in SSA policy and the Code
Federal Regulations. The steps that are followed by the examiner in
determining disability are called the Sequential Analysis process.
The case is taken through the sequential analysis process and a decision is
made. An examiner may utilize the assistance of a staff physician to help in
determining the level of impairment, but the decision is ultimately the
responsibility of the examiner.
If the case is a denial, the examiner prepares a personalized denial notice
or PDN and a technical rationale (TR) explaining why the case was denied. The
case materials and decision notices are sent back to the claimant’s local
District Office. The DO then mails the decision letter to the claimant and his
representative. The case will remain at the local district office for
sixty-days or until the claimant or representative requests an appeal of the
previous denial decision.
The Initial Claim:
An initial claim is defined as the first claim submitted to the Social
Security administration on behalf of an applicant. Most disability
advocates do not accept many cases at the initial level. The reason for
this is because this level often requires more footwork on the part of the
representative in acquiring the needed evidence of record. However, there are
hidden advantages to accepting a case at the initial level.
An Important Change:
In the early days, Disability Associates recommended that the advocate not
enter a case until the Reconsideration or ALJ levels. This recommendation
is still basically true. However, with years of experience, not to
mention trial and error, we've discovered that an initial claim
could be a unique opportunity to create a stronger case for consideration at
an appeal level. This is only true if the advocate feels that he can
structure the case for a current or future win.
A case prepared at the initial level by an advocate usually results in both
a faster decision and more allowances at the appeal levels. A case
developed early by an advocate makes it easier to avoid many of the common
errors that result in a denial decision. Taking or guiding a case at the
initial level can also save time because you may be able to avoid the
appeal levels altogether.
You'll most often enter a case at the reconsideration level. This is due
to the fact that many applicants are still being told by Social Security
that a representative is not needed at the initial level. By the first
appeal or reconsideration level, the claimant will no longer be willing to
take Social Security at its word. It's at the reconsideration appeal level
that most applicants begin seeking serious representation. If the claimant is aware of a
disability advocate service, he/she will seek it out help.
Entering a case on the reconsideration level will still give you ample time
to acquire the evidence accumulated by Social Security and begin structuring
an appeal argument on behalf of your client. At the reconsideration appeal
level, you’ll also be given the opportunity to submit additional medical
evidence. The additional evidence may help the case by supporting added
limitations suffered by the claimant or by supporting the existence of
impairments not previously alleged or considered by Social Security.
Although new evidence or additional impairments may help to win a disability
case, these actions may also slow down the reconsideration process. This
fact should not stop you from acquiring new evidence or adding allegations
if these approaches can be substantiated by the medical evidence - and will
help to win your client's case. Your first obligation as a disability
advocate is to win your client’s case. Speed is secondary!
The Reconsideration
Appeal:
If the claimant decides to appeal the initial decision within sixty-days of
receiving their denial notice, he or the representative must notify the
Social Security district office and inform them of the intent to appeal.
This action on the part of you or the claimant will initiate a
reconsideration appeal.
Once notified of the reconsideration request, the Social Security district
office will send the case back to the DDS or allow you the option of a
face-to-face hearing in some states. If the case is returned to the DDS, it
will contain all medical reports from the initial application. The case is
then assigned to a different examiner for review. If the claimant has been
seen by a medical doctor since the last decision, you must get a copy of
that report. This is especially true if the evidence shows a worsening of
the claimant’s condition! The examiner will send for this new information
only if he/she is made aware of its existence by the claimant or
representative.
Once received at the DDS, the case is again evaluated and a decision is
made. If the decision is a denial, the notice process is repeated. The
claimant and representative will again be notified by mail of Social
Security's decision and the claimant or representative will be given
sixty-days to request an appeal to the Administrative Law Judge.
Administrative Law Judge (ALJ) Appeal:
The next appeal level the claimant may pursue after being denied at
reconsideration is the Administrative Law Judge or ALJ appeal level. At this
level the claimant definitely needs help from a professionally trained
representative. If you had taken the case on the reconsideration level and
received notice of a denial, you would automatically contact the Social
Security district office in writing to request an ALJ appeal for your
client. Request SSA forms HA-501 and HA-4608 from Social Security. To
access these and other SSA Forms, visit Social Security's web site.
These forms may also be found within our Forms Buddy web site.
Please note that form numbers do change, but the purpose for the form will
not. Ask for forms by function instead of by number. Example: Request an
“Adult Disability Report or Initial Application Form” rather than form
3368. Requesting forms by function will save you a lot of frustration when
dealing with Social Security.
| In the above two paragraphs, we mentioned
several forms that are commonly used in the Social Security
disability process. You do not need to memorize these
forms or their numbers. We provide a pdf copy of many of
the most commonly used forms within our online Forms Buddy
program. These forms can be filled out online and then
printed. We provide access to these forms to all student
levels. |
If a Social Security employee is unaware of a
particular form number, explain the reason for the form and they should be
able to figure out what form you need. Also note that all Social Security forms
are in the public domain and on that basis alone, gives you the right to any
form you need to process a case.
As the client's authorized representative, you should state your
disagreement with the previous decision and offer your formal written
argument on behalf of the client at whatever level the case is on. If you wish, you can
submit a formal argument at any adjudicative level if you feel that this
action might
better explain your position on the issues. In fact, it is your
obligation to do whatever is required to win a client's case. That's
what we call great representation! I almost always write a formal
argument regardless of adjudicative level. Some arguments are shorter
than others, but all should attempts to clarify your client's issues.
Formal arguments actually help me to stay focused on the
key issues in the case.
You should also request that your argument be considered on-the-record if
you do not wish to appear in person before the ALJ. This on-the-record
request will remove the need for you to present your argument in person
before the ALJ. Keep in mind that an ALJ has both the right and the power
to request your presence despite your on-the-record request. If the ALJ
requests your appearance, go! This ALJ hearing process is informal
and can in many instances help you to win the case. The process of preparing
for an ALJ hearing is discussed in the Business Guide lesson 5 segment of
this course.
The case, with all medical and vocational information, along with your
formal argument, will then be forwarded to the ALJ for a decision. This is
essentially the disability process as experienced by the majority of
claimants applying for Social Security disability benefits. Now how
hard was that?
Now I'm going to take you
through the disability process again. Only this time, I'll present the
process from the standpoint of an advocate and I'll add a little more
detail. This repetitive approach to teaching this complex subject has
proven over the pass fifteen years to be the most effective way to teach a
person to be a disability advocate.
Overview of
Representational Process:
Now let's review the disability process from the standpoint of the
disability advocate. The first step in representing a disability claim is
called a Case Assessment. This process allows you to determine the
approximate percent chance of winning the case before you accept it for
representation. This process is a critically important to your success as a
disability advocate because it helps to improve the likelihood that the case
will be won. Keep in mind that as an advocate you are only paid for
cases that are won.
This fact makes assessing cases one of the key steps in helping you to
succeed in this business.
Case Assessment:
There are two ways to perform a case assessment. These are manual and
digital. The manual case assessment requires that you perform extensive
interviews with the client and possibly review some of his/her medical
documentation. These actions help to determine if the case should be
accepted. Unfortunately, it can take years of experience and up to six hours
of unpaid work to perform a proper
manual case assessment. For this reason, Disability
Associates created the Case Assessment Navigator software.
The Navigator software
allows you to perform a complete case assessment within ten minutes without much
effort at all. If you're an Executive member, you'll find a copy of
the Case Assessment Navigator inside of the Office Suite software.
This software is no longer sold separately. You can acquire this
software by updating your program to our Executive package.
There are several other important considerations when assessing a case.
These important issues are:
1. Case type: Make sure that the case is a SSDI, SSI or Concurrent case
type. You’ll rarely see Black Lung and other more obscure case types. These
obscure case types require a slight different approach to the case
assessment process. If you get a case like this, contact your Executive
mentor for assistance. These two common case types (SSI and SSDI) are the
most profitable for most disability advocates.
How do you tell the case types?
Rule-of-thumb:
If the claimant has worked at SGA, full or
part-time work for at least five of the last seven years, he is probably an
SSDI case. If he has not worked in the last seven to ten years or has never
worked, it is probably an SSI claim.
A concurrent case is seen when a person worked sporadically, yet managed to
earn enough quarters to be eligible for SSDI. The SSI case comes into play
because this same client may have no current income or assets that would
prevent his eligibility to apply for SSI benefits. Remember that only SSA
can make a final decision on financial eligibility to apply and case type.
2.
Alleged Onset Date (AOD). Make sure that the alleged impairment began at
least six months in the past. This will allow you to comfortably use the
contingency fee approach. Social Security has a six month waiting period in
SSDI cases. This means that the claimant will not be paid benefits for the
first six months since his onset date. Using the contingency fee structure,
you’re paid according to the amount of the claimant’s back benefit.
Therefore, it is to your advantage to wait until the case (AOD) is at least
six months in the past.
3. Duration: Make sure that the impairment is expected to prevent work for a period
of at least one year. This requirement is frequently overlooked by new
advocates. This requirement is part of Social Security’s definition of a
total disability and it is also an important step in the Sequential Analysis
process.
4. Work Activity: Make sure that the claimant has stopped working. This doesn’t mean that
if the claimant is still working that the case is no good. You can still
consider the case if the claimant is working under special circumstances or
he is earning less than the current Substantial Gainful Activity (SGA)
level.
Example:
If the claimant is working at less than SGA or under special circumstances
that are not available to other employees within the same environment, the
case may still be viable. If the claimant is currently working full-time at
SGA or above, he is automatically disqualified for SSDI and SSI benefits.
Accepting a Case:
Once you have assessed a case, you must then
officially accept the claimant as your client. This is done by sending the
claimant an "Information Packet" which will be discussed later in this
course. An information packet contains the appropriate instructions and
forms needed to begin the process of representation. The claimant signs the
materials within the Information Packet and returns it to the
representative. With this material, the representative can begin the case
acceptance process.
Case Development:
Once you have accepted a case, you must begin developing the case. Case
development is the process of collecting evidence in a disability case.
Evidence includes but is not limited to medical evidence, a description of
past work, ADL description, etc. We'll cover this subject more
carefully later in the course. The ACM portion of the Office Suite is
designed to help you keep control of all evidence of record.
The
case development process accomplishes three important things for the
representative. These are:
1. Reinforces your identify as the claimant’s representative
2. Allows you to create a client folder with evidence.
3. Provides the materials need to create an argument.
With the information acquired from the returned information packet, the
representative can begin his representational duties. He begins by sending
Social Security a copy of the authorization to represent form, a copy of his
fee agreement or contract, any available medical evidence and an informal
letter of introduction, also called a notice of representation.
The notice letter is used primarily as a means to identify the
representative and the client. It also provides Social Security with contact
information, a primary diagnosis and allows the advocate to request any
medical or vocational evidence Social Security might already have on file.
If you’re using our Advocate Client Manager Pro software, you can perform
and track most case development activities within the software itself. The
ACM Pro also enables you to store all relevant data about a case within a
single location, simplifying and speeding up the case development process.
Case Evaluation:
Once you have received all appropriate evidence for a case, you’re ready to
perform a case evaluation. In the case evaluation process, the representative
reviews the available medical evidence and determines if it's sufficient and
strong enough to create a written argument on behalf of the client.
Gabriel Scott, CEO of Disability Associates was part of the Social Security
team that developed the current argument structure. To make the
argument process easier, we've created a training tool with template. This tool is called the MemoWrite
training program. This product is no longer sold separately.
If you're an Executive member, you'll be given
access to the MemoWrite as you progress through the course. If you're
a Basic Member, you can use our sample arguments located within the online
Syllabus as a guide in creating an arguments.
A formal
argument is usually four to six pages in length and contains references to
the medical evidence used to create and support the argument. As you learn
our unique policy approach to case evaluation, you’ll also learn how to
effectively argument a case using this approach. For details about the case
evaluation process, review Study Guide lesson four.
Submitting an Argument:
When your argument is complete, you will mail it to Social Security and wait
for a decision. SSA regulations require that Social Security accept and
consider your argument before making a final decision
Allowance Decision:
If the decision is an allowance, you then bill the
client per Social Security instructions. See online syllabus for billing
instructions under fee information.
Denial Decision:
If the case is denied, you then determine if you and your client will
continue to the next appeal level. This course teaches you how to
represent a case on the Initial, Reconsideration and Administrative Law Judge (ALJ) appeal
levels. Experience has shown that if a case isn't won by the ALJ
level, it will probably never be won.
Lesson Two Preview:
In lesson two of our training course, we will introduce you to a number of
important Social Security terms and definitions. These terms will help you
to better understand the Social Security disability process.
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