What is a Claims Representative (CR) in a Social Security Disability Claim?

A Claims Representative (CR) works in the District Office and assists individuals in establishing entitlement to disability under the Social Security SSDI and SSI programs of benefits. The CR has contact with the public either in face-to-face interviews or by telephone. These contacts allow the Claims Representative to obtain, clarify and verify information which will be used to analyze disability claims and make decisions regarding entitlement to benefits.

The Initial Interview/Application

A Social Security claims rep conducts initial interviews with Social Security disability claimants. As stated above, the CR may do these interviews in person or by phone. In the initial interview, the Social Security Claims Representative will collect information on your medical sources, work history, and education background. Once the CR has completed the interview, the claims representative continues the initial processing on your claim.

Preliminary Eligibility Check

The claims representative will perform a preliminary eligibility check to verify your eligibility for either Social Security Disability Insurance (SSDI) or SSI.  Your eligibility for SSDI depends on the number of years you’ve worked at a job and payed your FICA taxes. Your SSI eligibility does not depend on your work history, but it does depend on the amount of income and assets your household has.

Substantial Work Test

The CR will also check to see whether you have been working. If you have been working, the claims rep will review whether you have been working at the substantial gainful activity (SGA) level. If you have consistently been working at SGA, you may be disqualified from disability benefits. Social Security considers income over $1,040 per month (in 2013) to be SGA.

Submission to Disability Determination Services (DDS)

If you pass all of the above tests, the claims representative will send your disability claim to your state disability agency, or Disability Determination Services, for a medical disability determination. At this point, the claims representative may expedite your claim under certain limited circumstances.

Expedited Claims

If you have a medical condition that is specifically listed on the Compassionate Allowances List (CAL), you have a terminal illness (TERI), or your case otherwise qualifies for a quick disability determination (QDD), the claims representative should identify your application to Disability Determination Services (DDS) in a way that alerts DDS that your claim qualifies as a CAL, TERI, or QDD case, to expedite your claim. For more information, see our section on expedited disability benefits.

Advance Disability Payments

If you have applied for Supplemental Security Income (SSI) and the claims representative sees from your application (or from personal observation) that you have a serious medical condition that qualifies for advance payment of disability, the CR can grant you “presumptive” disability payments. For example, if you have multiple herniated discs with nerve room impingement, a double leg amputation, total blindness or deafness, or are confined to a wheelchair, you may be eligible for presumptive disability payments. See our article on presumptive disability (which is only available to SSI applicants) for more information .

Status Checks

While your Social Security disability claim is being reviewed and processed, you may contact your claims representative to supplement your claim with additional information or to check the status of your disability claim.

Final Eligibility Check

Once DDS has made a medical decision on your claim, the claim will be returned to your local Social Security district office. If your claim has been determined to be medically eligible for disability, the claims representative will again check to see whether you have worked and performed SGA since you filed your application for disability benefits and whether you still qualify financially for SSI. This is because it can take several months for you receive a decision after you’ve filed for benefits.

If your claim is denied because you were found not medically disabled, you will be sent a denial letter, and you can appeal the decision.