Most claims for Social Security Disability benefits are denied at first level, and end up traveling through the various steps of the disability process. At the first, or “Initial” level, a claim is assigned to an examiner at Social Security. Their job is to collect sufficient information about the claim so that a determination may be made. The examiner does this by requesting medical records, asking the claimant and a third party to fill out forms about the claimant’s impairments, and sometimes sending the claimant to a consultative evaluation.
These evaluations are performed at Social Security’s cost by a doctor of their choosing. Unfortunately, claimants often tell me that the exams are very brief and cursory, and the reports are frequently detrimental to the claim. It is very important for a claimant to know that if possible, Social Security must get the information they need from the claimant’s treating physician (for example, range of motion findings). If Social Security’s need for information can be fulfilled by the treating doctor, a consultative evaluation may be avoided.
Once the examiner has sufficient information for a decision to be made, the file is transferred to a “medical consultant” or a “single decision maker.” A medical consultant is a medical doctor of any number of specialties. (The specialty of the medical consultant who analyzes a particular claim can be found at the bottom of their “Medical Evaluation/Case Analysis” form in the claim file, with the corresponding codes found here: https://secure.ssa.gov/poms.nsf/lnx/0426510090.) The medical consultant will review the claimant’s medical records and make a determination regarding his or her medically documented physical and/or mental limitations. This information will be evaluated in terms of whether an individual with the determined limitations would still have the capacity to do any work.
A “single decision maker” may be an individual with no more than a bachelor’s degree. They are supposed to consult with medical doctors in coming to their conclusions regarding a claimant’s limitations; however, even ALJs often afford much less weight to their findings.
Very frequently, claims are denied at the initial level. At that point, a claimant has sixty days to file an appeal. If the claimant misses the appeal deadline and does not show good cause for doing so, the file will be closed and they will have to begin again with a new application if they still wish to pursue disability benefits. Some examples of good cause for late filing include serious illness preventing the claimant from contacting SSA; death or serious illness in the claimant’s immediate family; incorrect, incomplete, or misleading information from SSA which caused the missed deadline; lack of understanding regarding the requirement to file in a timely manner; or belief that a representative had filed an appeal when the representative did not. More examples can be found here: https://secure.ssa.gov/poms.nsf/lnx/0203101020.
If a claim is denied at the initial level (as most are) and appealed, the claim is then at the “reconsideration” level. The examiner again obtains updated records and forms from the claimant, and forwards the file to the medical consultant or single decision maker for a determination. Far fewer claims are awarded at the reconsideration level than are awarded at the initial level.
If a claim is denied at the reconsideration level, the same sixty day deadline applies for filing an appeal. This second appeal is a “request for hearing.” When SSA receives this appeal, it sends the claim from the lower determinations level to the hearing office, known as the Office of Disability Adjudication and Review, or “ODAR.” At this point, SSA will stop requesting updated records and the claim will wait in line for a hearing. The wait is approximately twelve to eighteen months, and it is important that a claimant or the claimant’s representative continue to provide updated medical records during this time.
At the hearing, an ALJ will hear the claimant’s testimony and will sometimes also take testimony from vocational or medical experts. The ALJs task is to review the medical records in the claimant’s file, take hearing testimony, and make a determination by using SSA’s five step process (discussed in another blog on this site). Oftentimes the judge will not provide a decision at the hearing, but will instead mail out their decision in writing.
This describes the path that a claim takes from the application through to the hearing level. There are additional appeal options if a claim is denied by an ALJ, including review by judges on the Appeals Council, and beyond that, a complaint filed against the Commissioner of the Social Security Administration in federal court.