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In Lesson One we introduce you to the Social Security disability process.  A process is a series of actions that lead to a desired result, and in this case the end result we desire is disability benefits for our client.  To do this, you must become the client’s authorized legal representative. 
 

To understand the Social Security disability process, you must have a general idea of what occurs when a claimant applies for benefits. This lesson overviews the process as it pertains to the applicant and his or her representative.

This lesson is a reference, not a memorization exercise.  It's designed to familiarize you with common Social Security disability practices and procedures that occur in a standard application for Social Security disability benefits.

What happens when a person applies?

A disability case begins when an individual finds he/she is no longer able to perform work due to a severe impairment.  “Severe impairment” is defined by Social Security as any impairment that has lasted or is expected to last for twelve continuous months.  The impairment must also cause physical or mental limitations that would interfere with a person’s ability to perform or sustain work. 

The disabled individual can contact his local Social Security District Office to begin the application process.  A person can apply for benefits by phone, mail, online or in person.  Most applications are now occuring online.  An applicant alone or with the assistance of his representative may apply online at any time.  The appropriate forms for the application level are completed using SSA's online application system.  This system will walk you through the process of completing the required forms. 

The form data is sent to a central processing center and a paper copy is generated for the client's signature.  When the signed forms are returned to SSA, the case is officially open.  An advocate can also complete the 1696 Authorization to Represent form during the online application process.  A signed copy of the 1696 will be required to make it official.  For your convenience, we have provided a link to SSA's online Application website in your Syllabus.  After completing your course, access this site and learn how the SSA application system works.  Now let's return to the general application process.

During the application process, a claimant fills out a number of forms giving information about his/her condition, medical sources, income, etc.  The Social Security Administration (SSA) will use this data to determine the client's eligibility to apply for benefits.  For your convenience, we have provided a link to SSA online Application website in your Syllabus.

If the claimant meets the SSA's income and resource requirements, he/she continues the application process.  There are two levels of eligibility that the claimant must meet:

1.  Eligibility to apply, which is based on income and resources

2.  Eligibility to receive benefits, which is based on the severity of the applicant’s disorder.

If the applicant meets SSA‘s income and resource requirements, he/she must then meet Social Security‘s impairment severity requirement in order to actually receive benefits.  A Disability Advocate cannot help a claimant meet SSA's eligibility to apply requirements.  You can help the applicant to meet Social Security's eligibility to receive benefits criteria.  A Disability Advocate assists the applicant in meeting SSA 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 only two general categories:  

1.   Social Security Disability Income (SSDI)

2.   Supplemental Security Income (SSI)

We'll define these case types later in the program. 

A person’s initial application usually occurs at the Social Security District Office (DO) or online.  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 basic application levels:

1.  Initial

2.  Reconsideration/Hearing

3.  Administrative Law Judge (ALJ)

We recommend that a Disability Advocate restrict representational services to these three levels.  We know of no law prohibiting an Advocate from representing on the Appeal Council level, which occurs after the ALJ appeal.  However, the Appeal Council level is much more formal than the ALJ appeal and is best left to attorneys or Advocates with years of experience. 

The Initial Level

At the Initial Level, the case is sent from the processing District Office to the Disability Determination Section (DDS).  SSA assigns a Claims Examiner.  This person is responsible for developing, evaluating and making a final decision in the case.  The examiner makes this decision in conjunction with a medical professional; usually an MD. 

The DDS Examiner contacts all medical sources listed in the claimant’s application, requesting reports discussing the claimant's impairment. The examiner may also contact the claimant for additional information about his/her condition, daily activities or for details about the claimant's past work history.  As the claimant’s authorized representative, you have both the right and the responsibility to review these records on your client’s behalf.

The DDS Examiner and in-house medical adviser will review the client’s medical records looking for ways to deny the case.  The Disability Advocate will review the same medical and vocational data looking for evidence that supports the claimant’s inability to perform work.   Among experienced Disability Advocates, this is sometimes referred to as the “The Game”. 

In “The Game”, the Disability Advocate is pitting his/her argument against that of the SSA employee.  This is a tricky situation for the Advocate, so a properly trained Disability Advocate must possess a number of strategies to use in his/her client’s best interest.

The Initial Decision

Once the DDS Examiner receives the medical and vocational information, the case is evaluated to determine if it meets SSA’s criteria for a total disability as defined in SSA policy and the Code of Federal Regulations.  The steps the Examiner follows in determining disability are called the Sequential Analysis process.

Using the Sequential Analysis process, the Examiner makes a decision.  He or she may get a staff physician’s assistance to determine the level of impairment, but the decision is ultimately the Examiner’s responsibility.

If the case is denied, the DDS Examiner prepares a Personalized Denial Notice (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 Social Security District Office (DO).  The DO then mails the decision letter to the claimant and his/her authorized representative. The case will remain at the local DO for sixty days or until the claimant or representative requests an appeal. 

Many Disability Advocates don’t accept cases at the Initial claim level because acquiring the necessary evidence of record can take a lot of footwork.  However, there are subtle but extremely important advantages to accepting a case at the Initial Level.

In the early days, Disability Associates recommended that the Advocate not enter a case until the Reconsideration or ALJ levels.   After years of experience (not to mention trial and error!), we've discovered that assisting in the initial claim can provide a unique opportunity to create a stronger case for the appeal level.  Of course, this only holds true if the case can be structured for a 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.  This occurs because representation at the initial level can help to avoid many of the common errors that result in a denial decision.  Guiding a case at the Initial Level can also save time because you may be able to win early and avoid the appeal levels altogether. 

The Reconsideration Appeal

You'll most often enter a case at the Reconsideration level, due to the fact that the SSA usually tells applicants that they don’t need a representative at the Initial Level.  By the Reconsideration Level, the claimant will no longer be willing to take the SSA at its word, and will seek serious representation.  If the claimant is aware of a Disability Advocate service at this point, he/she will seek it out.

Entering a case at the Reconsideration Level will still give you ample time to review the evidence accumulated by the SSA and begin structuring an appeal argument.  You can submit additional medical evidence to strengthen the case by supporting added limitations suffered by the claimant or by supporting the existence of impairments not previously alleged or considered by the SSA.

Although new evidence or additional impairments may help to win a disability case, they may also slow down the Reconsideration process.  This fact should not stop you from acquiring new evidence or adding allegations if they are substantiated by medical evidence and will help to win your client's case.  Your primary obligation as a Disability Advocate is to win your client’s case.  Speed is secondary!

The Reconsideration Process

If the claimant chooses to appeal the initial decision, either the claimant or the representative must inform the DO of the intent to appeal within sixty days of receiving the denial notice. This action initiates a Reconsideration Appeal.

Once notified of the Reconsideration request, the Social Security DO will send the case back to the Disability Determination Section (DDS) or, in some states, will allow you the option of a face-to-face hearing.  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 DDS Examiner for review.  If the claimant has seen 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.

The case is again evaluated and a decision made.  If the decision is a denial, the notice process is repeated. The claimant and representative will again be notified by mail of the SSA's decision and the claimant or representative will be given sixty days to request an appeal to the Administrative Law Judge (ALJ).

Some states use hearings at both the Reconsideration and ALJ levels.  A hearing is simply a face-to-face review of the claimant's application.  A Reconsideration face-to-face hearing is small, informal and is usually conducted by a Hearings Officer or Judge.

Administrative Law Judge Appeal:

The next appeal level the claimant may pursue after being denied at the Reconsideration level is the Administrative Law Judge or ALJ appeal level. At this level the claimant definitely needs help from a professionally trained representative.  

If you took the case at the Reconsideration Level and received a denial notice, you would automatically contact the DO in writing to request an ALJ Appeal for your client.   Request SSA forms HA-501 and HA-4608, or access these and other SSA Forms at the SSA website.   

Please note that the numbers of many supplemental forms change, but their functions do not.  Thus, it is better to request forms by function instead of by number.  For example, request an “Adult Disability Report” or “Initial Application Form” rather than Form 3368.  This will save you a lot of frustration! 

If an SSA 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.  All Social Security forms are in the public domain, which gives you the right to access any form you need to process a case.

At any appeal level, state your disagreement with the decision.  Submit a formal written argument if you feel it will better explain your position on the issues.   We at Disability Associates almost always write a formal argument, regardless of adjudicative level.  Some arguments will be shorter than others, but all should attempt to clarify the issues in the client’s favor.  Composing a formal argument can also help you to stay focused on the case’s key issues.

As the client's authorized representative, it is your obligation to do whatever is required to win the case, as long as it is legal.  That's what we call great representation! 

Review On-The-Record

If you’re uncomfortable with an ALJ face-to-face hearing you can request that your argument be considered on-the-record, which removes the need to present your argument in person.  Keep in mind that an ALJ has both the right and the power to request your presence despite an on-the-record request.  If the ALJ requests your appearance, GO!  The hearing process is informal and in many instances will help you win the case.  We discuss the preparation for an ALJ hearing in Business Guide Lesson 5 of this course.

Let’s Do It Again – Some Added Details

The three levels outlined above represent the disability process as experienced by the majority of claimants applying for Social Security disability benefits.  Now I'm going to take you through the disability process again.  This time, we present the process from the standpoint of an Advocate and add a little more detail.  A repetitive approach to teaching this complex subject has proven over the pass twenty years to be the most effective way to teach you how to be an effective Disability Advocate.

Review of the Process - Advocate’s Point of View

Client Interview

The Client Interview is the first step for an Advocate in representing a disability claim.  During this interview, the Advocate collects contact data and basic information about the client’s impairment.  If the Advocate believes there is a defensible case, he/she moves to the next step in the representation process.

Case Assessment

The Case Assessment is the second step in representing a disability claim.  This process allows you to approximate your percent chance of winning the case before you accept it.   Since you’re only paid for cases you win, this process is critically important to your success as a Disability Advocate. 

There are three assessment techniques:

1.   Manual - Performed and analyzed manually by advocate with no assistive devices.

2.   Digital - Performed by advocate, but analyzed by the Olivia Case Assessment algorithm.

3.   Client-generated - Client performs assessment on the Olivia web tool.

All case assessments require that you perform a question-and-answer interview with the client, based on specific issues of the case. The answers allow you determine if you should accept, guide or reject the case.  It takes years of field experience and up to six hours of unpaid work per case to correctly assess a case manually.  For this reason, Disability Associates created an automated case assessment system which is located in your Olivia© account.  The Olivia© software allows you to perform a complete case assessment using all three techniques in ten or fifteen minutes.  The Olivia case assessment tool enable you to quickly determine the approximate percent chance of winning enabling you to win more case.  The Olivia case assessment tool can also be used to generate additional income beyond case representation.  This additional income approach is discussed in the Executive training website.

There are several important considerations when assessing a case:

1.  Case type:  Make sure that the case is an SSDI, SSI or Concurrent (SSDI concurrent with SSI) case type. There are other more obscure and specialized case types, such as Black Lung cases, which require a slightly different approach to the assessment process.  If you get a case like this, contact your Mentor for assistance.  The SSDI and SSI case types are the most profitable for most Disability Advocates. 

How do you differentiate case types?  The general rule of thumb is:  If the claimant has worked full or part-time for at least five of the last seven years, he/she is probably an SSDI case.  If he/she has not worked in the last seven to ten years or has never worked, he/she will probably file an SSI claim.

A concurrent case is when a person has worked sporadically, yet managed to earn enough quarters to be eligible for SSDI.  SSI comes into play because this same client may have no current income or assets that would prevent his/her 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 ago.  SSDI cases have a six-month waiting period, which means that the claimant will not be paid benefits for the first six months from the 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 onset date is at least six months in the past.

3.  Duration:  Make sure that the impairment is expected to prevent work for at least one year.  This requirement, part of SSA’s definition of a total disability, is frequently overlooked by new Advocates.  It is an important step in the Sequential Analysis process. 

4.  Work Activity:  Make sure that the claimant has stopped working.  If not, you can still consider the case if the claimant is working under special circumstances or is earning less than the current Substantial Gainful Activity (SGA) level.   If the claimant is currently working full time at SGA or above, he/she is automatically disqualified for SSDI and SSI benefits.  We will explain SGA in Lesson Two.


Client Intake

Accepting a Case – Intake Phase One

If you have interviewed a client, assessed the case and consider it viable, you can now officially accept the claimant as your client.  The intake or case acceptance process has two phases.  Phase One involves sending the claimant an "Information Packet" using templates which will be discussed and provided later in this course.   The packet includes instructions and forms needed to legitimize the representation relationship.  The claimant signs the intake forms and returns them to you.  

Accepting a Case – Intake Phase Two

Once the client has signed and returned the forms to you, begin Phase Two of the Intake Process.  First, send the SSA:

·        a copy of the “Authorization to Represent”

·        form a copy of your fee agreement or contract (optional)

·        a “Request for Evidence”

·        copies of any evidence that you have but that SSA doesn’t

·        an informal “Letter of Introduction”

The introduction letter establishes your client/advocate relationship.  It should also provide SSA with your contact information and the claimant’s primary diagnosis.  Use it to request any medical or vocational evidence the SSA might already have on file. 

The SSA will notify you that you have been assigned as the client’s representative.  This process can take up to three weeks.

The intake process accomplishes three important things for the Advocate:

1.      Reinforces your identify as the claimant’s representative

2.      Allows access to all case materials

3.      Provides access to materials necessary to create an argument

Once you have accepted a case, you must begin to develop it by collecting evidence, including medical evidence, descriptions of past work, client's Activities of Daily Living, etc.  We'll cover this subject in depth later in the course.  The Olivia© system is designed to help you keep control of all evidence of record. 

Case development also proceeds in phases.  You cannot complete the development phase until you have all of the claimant’s available medical and vocational evidence in your possession.  These are the materials you will evaluate to find key supporting evidence used in your argument for a total disability claim.

 
Case Evaluation:   Development Phase One

Once you have received all appropriate and available 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 is sufficient to create a written argument on behalf of the client.   The evaluation phase is also the advocate's opportunity to bring together vocational, client generated and other assorted evidence that is to be used to argue the case.


Argument Creation:  Development Phase Two

Our Disability Associates CEO was part of the original SSA team that developed the current argument structure; so needless to say, we understand the mechanics of this process!  To make the argument process easier for you, too, we've created a training program within the Olivia© system:  MemoWrite Composer©.  This software enables you to automatically construct an argument using our custom template. 

A formal argument is usually three to six pages in length and contains references to the medical evidence used to create and support it.  As you learn our unique policy approach to case evaluation, you’ll also learn how to effectively argue a case using this approach. 

When your argument is complete, you will mail it to the SSA.  Regulations require that the SSA accept and consider your argument before making a final decision.

The Decision

Allowance Decision:  If the decision is allowed, you have been successful on the first go-around.  You then bill the client per SSA instructions.  Our online Program Syllabus contains billing instructions within the fee information section.

Denial Decision:   If the case is denied, determine if your client wants to appeal.  We have already discussed the appeal levels:  Reconsideration first, followed by the Administrative Law Judge Level.   Our experience is 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 introduce you to a number of important Social Security terms and definitions.  This will help you to better understand the Social Security disability process.