Aspects of Disability Decision Making: Data and Materials

B. Steps in the Social Security Disability Application and Appeals ProcessesInitial ApplicationField Office RoleA claimant files an application for SocialSecurity Disability Insurance (DI) andSupplemental Security Income (SSI) disabilitybenefits in one of SSA’s 1,300 field offices. Theapplication asks for information that will enableSSA staff to determine whether the claimantmeets the non-disability requirements for entitlement.For DI cases, these requirements includesuch factors as whether the claimant is insured fordisability benefits. In SSI cases, individuals mustprovide proof of citizenship status and documentationof their income and resources.The field office is also responsible for obtaininginformation from the claimant about his orher impairment and how it limits the ability todo work. Information about the claimant’s medicalsources, tests, and medications is collected, aswell as information about the individual’s pastwork, education and training. The accuracy andcompleteness of the information on this “disabilityreport” can influence whether the claimant’sapplication is approved or denied and affects thespeed in which the decision is made.Claimants generally rely on field office staffto advise them and their representatives on whattypes of evidence to submit to support their claims.SSA developed a “disability claim starter kit” thatis sent out in advance of the interview and providesthe claimant with preparatory materials forthe interview. The claimant or the representativecan complete the forms and worksheets and takethem or mail them to the field office, or use theInternet to transmit the information. Telephoneinterviews and disability reports filed over theInternet now comprise a growing number of theapplications filed. As a result, fewer applicants areactually being seen in the field offices.DDS RoleAfter securing the disability report, the SSAfield office sends it to a Disability DeterminationServices (DDS), a State-run agency that makes disabilitydeterminations using SSA’s regulations andprocedures. There, a team consisting of a disabilityevaluation specialist and a physician (or psychologist)considers the facts in the case and determineswhether the claimant is disabled under the SocialSecurity rules. While the State agencies are notunder SSA’s direct administrative control, SSAfully funds their costs and provides oversight.DDSs follow the SSA-established program standardsand their decisions are subject to qualityassurance review.The claimant is required to establish that he orshe is disabled by providing medical and other evidenceof a disabling condition. The DDS, however,is responsible for making every reasonable effortto help the claimant get medical reports from theclaimant’s physicians and hospitals, clinics, orinstitutions where the person has been treated.The DDS pays a fee for any medical reports that itneeds and requests.If additional medical information is neededbefore a case can be decided, the claimant may beasked to attend a “consultative examination,” paidfor by the DDS. (SSA pays the DDS for the cost ofthese examinations, and for the cost of obtainingmedical reports.) This examination is importantfor those applicants who may not have a currentmedical provider or where the necessary informationis not readily available. SSA requires thatevery reasonable effort be made to obtain the evidencefrom the claimant’s treating sources before aconsultative examination is scheduled.In making a decision on a claim, the DDS conductsthe process in an informal, non-adversarialmanner. Claimants are not seen in person by theState agency adjudicators, but telephone contactsare not unusual. The claimant may present informationhe or she feels is helpful. The informationthat the claimant provides and all the evidence thatSSA and the State agency obtain from medical andother sources will be considered. The individualmay submit the information him or herself, or itmay be provided by the claimant’s representative.Once a decision is rendered, the claimantreceives a written notice. The reasons for the allowanceor the denial determination are stated in thenotice. The claimant is also informed of the rightto appeal. When a claim is approved, the awardletter shows the amount of the benefit and whenpayments start.Administrative AppealsIndividuals who receive an unfavorable initialdisability decision have the right to appeal. Thereare four levels of appeal: (1) reconsideration by theState agency; (2) hearing by an administrative lawjudge (ALJ); (3) review by the Appeals Council; and(4) Federal court review. At each level of appeal,Aspects of Disability Decision Making: Data and Materials 87