Who Makes The Decision in My Social Security Disability or SSI Claim?

Disability Determination Process

The Initial Application

Most Social Security disability claims are initially processed through your local Social Security Administration (SSA) field office (FO) and State agencies (usually called Disability Determination Services or DDSs).

An initial application for disability begins with a local claims representative. Social Security representatives in SSA field offices usually obtain applications for disability benefits in person, by telephone, by mail, or by filing online. The application and related forms ask for a description of the claimant’s impairments, treatment sources, and other information that relates to the alleged disability. (The “claimant” is the person who is requesting disability benefits.)

The field office representative is responsible for verifying “non-medical” eligibility requirements, which may include age, employment, marital status, or Social Security coverage information. The field office then sends the case to DDS for evaluation of disability.

The DDS, which is fully funded by the Federal Government, is the State agency responsible for developing medical evidence and making the initial determination on whether or not a claimant is disabled or blind under the law.

Usually, DDS tries to obtain evidence from the claimant’s own doctors and medical sources first. If that evidence is unavailable or insufficient to make a determination, DDS will arrange for a consultative examination (CE) to obtain the additional information required. The claimant’s own treating source is the preferred source for the CE, but DDS may obtain the CE from an independent source. After completing its development of the evidence, trained staff at the DDS makes the initial disability determination.

Then, DDS returns the case to the field office for appropriate action. If the DDS found that the claimant is disabled, SSA completes any outstanding non-disability development, computes the benefit amount, and begins paying benefits. If the claimant was found not to be disabled, the file is kept in the field office in case the claimant decides to appeal the determination.

Reconsideration

In most cases, the reconsideration is the first step in the administrative review process for individuals who disagree with the initial determination.

A reconsideration is a complete review of the claim by someone other than the person who made the original decision. Social Security will reevaluate all evidence, plus any additional evidence submitted and render a new decision. If you disagree with the reconsidered decision, you choose to go to the next level of the appeals process. Use the Request for Reconsideration (Form SSA-561-U2) for a reconsideration request.

ALJ Hearing

In general, a hearing before an Administrative Law Judge (“ALJ”) is the next level of appeal after Social Security has made an unfavorable reconsideration determination. The ALJ will conduct a hearing. You and your attorney or representative go to the hearing and present your case in person. The ALJ will evaluate all the evidence on record, including any additional evidence brought to the hearing, and will issue a decision. Use the Request for Review of Decision/Order of Administrative Law Judge (Form HA-520-U5) to appeal an ALJ’s decision.

Appeals Council

If the claimant disagrees with either the ALJ decision or the dismissal of a hearing request, he or she may ask the Appeals Council (AC) to review the action. The AC may dismiss or deny the request for review, or it may grant the request and either issue a decision or remand the case to an ALJ. The AC may also review an ALJ decision (within 60 days of the hearing decision or dismissal) on its own motion. The AC has final review authority for SSA.

Expedited Appeals Process (EAP)

An individual may request an Expedited Appeals Process (EAP), but only after appealing at least through the reconsideration step. EAP may be used in those cases in which the individual does not dispute SSA’s version of the facts in his or her claim. Rather, the claimant challenges the constitutionality of the law underlying the determination. SSA, and all parties to the determination, must agree to using EAP.

Federal Court Review

The AC review completes the administrative review process. If an individual is still dissatisfied, he may request judicial review which is done by filing a civil action in a Federal district court.