You’ll be interacting routinely with SSA personnel on your clients’ behalf.  Having been SSA employees ourselves, we at Disability Associates know how these folks want to be treated.  SSA’s huge bureaucracy can be hard to deal with, but remember it is not a machine, but a tangled network of people just like you.  As a result, although all SSA offices follow the same rules, there is an enormous difference in how things are actually handled from office to office.

To avoid frustration, learn how your local DO handles things such as distributing forms and client evidence to representatives.  The quickest way to learn is to represent a local case.  You will interact with the DO on a number of issues, allowing you to adapt to their methods.

You’ll contact SSA to become authorized at the beginning of every case.  After authorization, contact can go either way.  Usually you’ll communicate directly with your local DO or your state’s DDS.  Your client’s local DO is responsible for compiling initial application forms and supporting documents, after which they forward the case to the DDS.  A DDS Examiner handles it to the decision point. 

Create a positive relationship with the DDS Examiner and your career as an Advocate will be much smoother.  Although he/she cannot make a case decision alone, these professional clerks control all access to case materials. 

Motivating the DDS Examiner

As with anyone, you use the WIIFM principle to motivate DDS Examiners to cooperate with you.  So what’s in it for the Examiner?

In most states, the DDS Examiner is a State employee with a Federally regulated job.  The Feds impose performance standards and the State Administrator enforces them.  These standards are very high, making it tough for the average Examiner to survive the system.  Processing standards are critical to Examiner promotion and dictate expected caseload and completion goals, decision accuracy and allowable errors.  Standards rise with rank - the higher an Examiner’s rank, the higher the performance requirements.  If he/she misses any standard for two consecutive six-month periods, he/she can be demoted or dismissed.  This really puts the pressure on!   As a result, Examiners are easily influenced by anyone and anything that can help make the stats!

The main thing that slows an Examiner’s processing time is the fact that SSA still handles evidence using “snail mail” and other traditional methods.  Half the typical case time is time wasted waiting for SSA to receive a necessary document.  Anything you do to help the Examiner get evidence quickly results in both a happy Examiner and a more rapid case decision – a win/win situation! 

SSA is modernizing, so now you can get digitally formatted evidence on a CD that links to their document storage server.  Although this makes for faster access to data that SSA already has, getting information from the source is still done the old-fashioned way.  So if you can help the Examiner acquire evidence of record you’ll be a hero!

Once the Examiner has all case documentation, he/she goes through Sequential Analysis to reach a decision.  The faster he/she completes the case, the better the chances of keeping his/her job!   Make friends with the Examiner by offering to get any data that he/she may be missing.  Let him/her know that you’re willing to do whatever you appropriately can to move the case forward.  Do not ask the Examiner for any special favors, as this might appear to be a conflict of interest.  This is not a quid pro quo situation.  You are being a responsible citizen who is helping an overworked public servant do his/her job.  If you become a willing and honest assistant to the Examiner, he/she will love you for it and will cooperate with you in subtle but valuable ways.

Letting SSA Know That You are the Authorized Representative

To become the authorized representative, send a signed copy of the Request for Authorization to Represent Form 1696 to the client’s local DO, DDS or Appeals Office, depending on case level.  If you’re unsure where to send the form, the client’s local DO is your best bet, because the office closest to the applicant is usually the one that processes the case.  When SSA receives the form they’ll date stamp it and place it in the applicant's folder.  They are supposed to send you a date-stamped copy, but this doesn’t always happen.   If you don’t receive one, request a copy for your records by phone or in person at the DO.   If you and the claimant make application together, an SSA staff person will complete a Form 1696 during the visit or phone call.  SSA keeps all originals, so request copies of all pertinent official case forms. 

If the claimant applies online, there are built-in forms which are processed through a central location and distributed to the appropriate DO.  The DO then sends copies to the claimant, who signs and returns them to SSA, officially starting the formal disability process.

You can also request application forms when you send in Form 1696 announcing your authorization to represent, so you need to know which level the case is on right from the start.  It's not always obvious, but you can figure it out during the initial client interview by asking these questions:

• When did you apply for Social Security disability benefits? 
• Did you receive a letter indicating a decision in your case? 
• If so, can you provide a copy of the decision letter? 
• What was the reason for the denial decision?  
• Have you appealed a previous decision?

If you still aren’t sure, find out from SSA the first time you interact with them on the client’s behalf.  If he/she has been denied within the last two months, he/she is eligible for appeal.  You and/or the claimant must apply within sixty days of the denial decision.  Later we'll discuss ways to extend this deadline.

Representative Transfer:   Either the claimant or the representative of record can initiate an action to transfer a case to a different representative. 

Example:  James was represented by XYZ law firm on the Reconsideration Level, and is dissatisfied with their work.  He wants you to take over the case.  What do you do?

1.      Instruct James to contact both SSA and XYZ in writing, asking that the representative relationship be terminated.  Get a copy of the letters from James after it’s sent.

2.      Make sure James doesn’t mention you in the request.  You have nothing to do with the case until XYZ’s contract terminates.

3.      Get copies of all correspondence between James and SSA or XYZ regarding termination.  Be sure the relationship has officially ended and that you have written proof.  The best proof is a letter to James on XYZ letterhead clearly stating the professional relationship is over.

 
First Correspondence

Now let's turn our attention to SSA contact correspondence.  The usual materials sent to the DO or DDS at all case levels include:

·        A cover letter on your letterhead

·        A signed Form 1696 – original to DO, copies to other appropriate people

·        Multiple signed copies of the client’s Medical Release Form

·        Copies of any 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 summary of the key supportive evidence. 

Cover Letter:  Use your cover letter to:

1. Introduce yourself to SSA
2. Announce your appointment as the authorized representative
3. Inform SSA of any special case issues
4. Request copies of evidence from SSA
5. Summarize your Formal Argument, if you are submitting it

See the sample Cover Letter in Study Guide Lesson Seven.

Appeal Request Letter:  You can use Form 561: Request for Reconsideration or you can send a letter on your letterhead.  If you send a letter SSA will probably request a signed copy of Form 561 anyway, but it can buy time when the client’s appeal deadline is near.  In the body of your Reconsideration Request Form or letter ask for a copy of your client’s Personalized Denial Notice (PDN) or Technical Rationale.   Also ask for a copy of all available evidence of record.  If there’s any new or additional evidence since the last decision, you'll need to request it from the sources and provide it to SSA.   We'll discuss the appeal process in greater detail in Business Guide Lesson Five.

Common Social Security Forms

Forms are your primary interface with SSA.  Disability Associates provides a link to commonly used SSA forms in the Program Syllabus.  The following is a short list of forms you will use on various adjudicative levels:

• SSA-Form F16 - Initial Application Form:  Used to initiate an application at the initial case level.
   
• SSA-Form 1696 - Appointment of Representative:  Used to authorize a representative at all adjudicative levels

• SSA-Form 827 - Authorization to Disclose Information:  This is your generic release form

• SSA-Form 3288 - Consent to Release Information:  Allows you access to medical forms on all adjudicative levels

• SSA-Form 3441:  Used at the Reconsideration Appeal Level to request new or additional evidence and to document associated impairments 
• SSA-4268-U4:  This is the Personalized Decision Notice and/or Technical Rationale letter that the DDS Examiner prepares for Initial Level and Reconsideration Appeal decisions, specifying how and why a case was denied.  All cases that are denied will have this form on file.
• SSA-Form 561 – Request for Reconsideration:  Use this form to request a Reconsideration Appeal.

• SSA-Form 3368:  This is the adult disability report form that SSA uses at the Initial Level.  Completed by the claimant, it lists his/her medical allegations and medical sources. 

• SSA Form 3369:  The claimant fills out this vocational report/work history form as part of the initial application and it goes into his/her case file.  You'll need either a copy of this form or the information it contains to evaluate past work history.  
• SSA-Form 831-U5:  The 831 is a special form that DDS Examiners use to code case decisions at the time of adjudication.  These codes make it easier for SSA employees to process the case internally.  We sometimes request this form because it contains specific coded information that we can use.  Since few know how to read this form, SSA will consider your request for it to be puzzling, but this is actually a very sophisticated maneuver.  If you know how to read it, this form gives the case type, DLI date if applicable, primary diagnosis, reason for prior decision and the adjudicative case level at a single glance.

Medical Evidence of Record

When you request medical evidence of record be careful what you ask for and how you ask.  Regardless of source, if you are careless about your request you could be inundated with useless paperwork.  Be very specific in your request letter about which items you need.  Wherever possible, instead of requesting all medical evidence from x-date to y-date, request a copy of the report dated zz/zz/zzzz that addresses a specific impairment.

Here is a short list of common medical evidence that you’ll want to consider:

• Doctors' reports
• Nurses’ notes
• Psychological examination reports
• Consultative examination reports 
• Hospital admission and discharge summary reports
• Surgical summary reports
• X-ray reports
• Diagnostic test reports

Ask for medical evidence from the onset date to the most currently available evidence date.  Don’t request evidence dated more than a few months prior to the onset date unless it definitively proves the impairment’s existence. 

Example:   Alice has cancer, so you request the pathology report dated 8/8/2007 that first diagnosed this disease.  Alice didn’t become too disabled to work until 9/11/2008, but this report is the one that first documented her condition.

With exceptions such as the above, evidence collected outside of the impairment period is generally useless.  Evidence unrelated to the limiting diagnoses is definitely irrelevant.   For more information about recognizing appropriate medical evidence in a disability claim, revisit Study Guide Lesson Four.   Recall that the Merck Manual, the SSA Guide and the Systems Explorer play an important role in helping sort out which types of medical evidence to request.  Use these resources to better understand how SSA views impairments.

The Pre-Initial Technique

As we have mentioned, we used to discourage our students from taking cases at the Initial Level, but have changed our position. 

Taking a case prior to application is a good strategic move for the Disability Advocate who knows how to use it.  It allows you to design a strategy before the naive applicant has a chance to put inappropriate statements or evidence into the official SSA record.  You also get to review the medical evidence before SSA gets it, verifying allegations, limitations and onset date while screening out extraneous data.   Send only the definitive evidence to SSA, making the DDS Examiner’s job easier and cutting months off decision time.

 In states which have a special DO case expediting team, your careful screening can reduce processing time to a few weeks.  If your DO doesn’t have an expediting team, they will send the case on to the DDS for Case Development and a decision.  If you have done your job well, the decision can come within a few weeks after the DDS receives the case.  We’ve processed cases in six weeks using these Pre-Initial techniques. 

Our Pre-Initial Technique does you, the applicant and SSA a tremendous service.  It speeds up the process and your payment and helps the DDS Examiner meet performance expectations.  And, if the case is denied, you’re in position to take over the appeal.  In short, your professional knowledge, input and assistance helps everybody reach their goals!

Assisting at the Initial Level helps SSA fulfill its purpose for existence by removing a major case processing bottleneck.  It takes a little more work, but benefits you by creating positive relationships with both the client and SSA. 

Of course, the Pre-Initial Technique is only for cases that you have screened and elected to take prior to application submittal.   

Initial Level Adjudication

The typical sequence of events in an Initial Level case adjudication is:

1.      SSA requests all medical evidence, reviews it and makes a decision.  As the representative, you have several interactions with the Examiner during this process.  Again, if you can help him/her expedite the case, do so! 

2.      The Examiner makes a decision with the aid of a medical and vocational staff professional.  Regardless of outcome, the case returns to the local DO which sends a decision notice to both you and the applicant.

3.      If the case is allowed, submit your Fee Petition Form and Attachment to SSA and bill the client.  You can generate a Fee Petition Attachment and Client Invoice automatically from the Olivia© software.  If the case is denied, begin the appeal process.  

The Reconsideration Appeal

Accepting a case at the Reconsideration Appeal Level involves many of the same interactions with SSA as at the Initial Level.  However, Case Development is typically a lot easier because SSA has collected most of the available medical evidence.  Don’t let this fact make you lazy!  If the case is new to you at the Reconsideration Level, perform the same interview, assessment, and review as you would in an Initial Level case. 

It's not unusual for a claimant to have already applied for appeal before seeking your services.  If he/she has applied but has not gotten a decision notice, send SSA the signed Form 1696 immediately.    The case folder may have already left the DO headed back to the DDS.  Contact the DDS and find out which Examiner has been assigned the case.  Write a brief letter informing him/her that you’re the newly authorized representative and attach a copy of the signed Form 1696.  Also alert him/her if there is additional evidence on the way that could affect the final decision.  If there’s no new evidence, simply request copies of all current evidence-of-record.  Ideally, the Examiner will forward this evidence to you prior to making a decision, giving you the opportunity to provide input - But don’t count on it!  He/she wants to adjudicate the case as fast as possible, not get involved in more discussion and review.  So what do you do?

If there’s no new evidence on the Reconsideration Level, request the evidence-of-record and ask the Examiner to hold off on making a decision until you’ve had time to review the case, providing a date by which you will submit comments.  It won’t happen but at least you documented your attempt.  Follow up every five days until you get the records.  This way, even if a decision is made you have the records and plenty of time to prepare for an ALJ Appeal.

Note:  Social Security regulations prohibit the Examiner who performed the Initial Level review from handling the Reconsideration Appeal. 

If, as a newly appointed representative, you find that the claimant has run out of time to request a Reconsideration Appeal, ask for a “good cause extension”. Based on Book 20 CFR Regulation 416.1411, certain circumstances justify extending the sixty-day appeal deadline:

1.      Claimant did not receive prior decision notice

2.       Claimant is incompetent and unable to understand decision notice

3.      Claimant is medically unable to respond to the notice

4.      SSA’s actions misled or confused claimant regarding the right to appeal

5.      Claimant is hospitalized and unable to respond to notice

6.      Representative never responded to decision notice

7.       Claimant is out of state and unable to apply

8.      There was a death in the family of the claimant or representative

9.      Important records were damaged or destroyed and have to be replaced

There are hundreds of good reasons why a person may miss the appeal deadline.  SSA is usually not particular about the excuses it accepts.

Social Security Contact at the Reconsideration Level

The first Reconsideration Level contact you’ll have with SSA may be online, in person or by mail.  If you use the mail, include a rebuttal letter indicating your disagreement with the previous denial decision.  This is also an opportunity for you to inform SSA of any new impairments, medical sources or other evidence that may warrant reconsideration.  You can also submit a questionnaire or ADL report.  Use an ADL report to support alleged limitations only if this information is not already in the claimant's folder. 

Once you have all necessary information and have submitted your argument, let SSA process the case without interference unless you can enhance your client’s chances for an allowance or speed up the decision process.  Be sure you have brought up any impairments, evidence, allegations, or physical or mental restrictions that were not previously considered.

Adding additional impairments and/or physical limitations at the Reconsideration Level may cause the denial decision to be reversed, so don't be shy about adding evidence or allegations that are supported by medical evidence.  Your responsible actions may help SSA avoid another erroneous denial decision.
 

Additional Evidence of Record

The discouraged claimant often won’t approach SSA again for weeks after receiving a denial decision.  Meanwhile he/she continues to see the doctor who is monitoring his/her condition.  If the condition worsens or if a test or procedure shows a new serious disorder or limitation, this becomes additional supportive evidence.  It might change the case decision and must be brought to SSA’s attention ASAP.  Use the new developments to argue for reversal of the previous denial.  Take the initiative and get copies of the new evidence.  Send them directly to SSA to cut weeks off processing time.

Don’t bog the system down with prescription refill visits or routine checkup reports. But before SSA makes a new decision, get doctor visits documenting a condition’s worsening or a new serious allegation into the record.

Determine the importance of new or additional evidence in your client interview prior to accepting the case. Your best chance to win at the appeal level is to incorporate additional evidence or a new serious condition into the case argument.  This is especially true when the prior denial was based on the claimant’s presumed ability to adjust to other less demanding work.

Note:  SSA allows a sixty-day window for appeal request regardless of case level.  If you wait longer than sixty days, SSA will refuse the appeal request unless you provide good cause as discussed above.
 

Summary

In Lesson Four, we have given you some tips for creating good working relationships with SSA personnel.  We also focused on navigating SSA paperwork at the Initial and Reconsideration, Levels. 
 

Preview of Lesson Five

Lesson Five details the all-important Administrative Law Judge Appeal process in which the preponderance of cases are won.