What Is A Claims Representative 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 that 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.

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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 paid 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. In 2026, Social Security considers income over $1,690 per month to be SGA for non-blind individuals.

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.

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When Can Your Claim Be Expedited?

Under certain circumstances, Social Security can move your disability claim to the front of the line—meaning DDS will process your claim faster than normal. The claims representative may expedite your claim if any of the following apply:

• You have a medical condition on the Compassionate Allowances List (CAL): These are serious conditions like ALS, certain cancers, or rare disorders that clearly meet Social Security’s disability standards.
• You have a terminal illness (TERI): If your condition is expected to result in death, your case will be given priority handling.
• Your case qualifies for Quick Disability Determination (QDD): If your application contains medical evidence that strongly indicates disability, the QDD process uses a computer-based screening to identify and fast-track your claim.

When your situation matches one of these scenarios, the claims representative will ensure your application is routed to DDS in a way that signals your eligibility for expedited review. This helps you get a faster decision, reducing the typical wait time for a medical determination.

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.

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. You can also check the status of your claim online.

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.

RELATED POST: What It Means When the SSA Starts a Final Non-Medical Review

What Should You Do If Your Claim Is Denied?

If you receive a denial letter from Social Security, it’s completely normal to feel discouraged—but remember, a denial isn’t the end of your journey. Many applicants are denied at first, but you still have the right to appeal the decision.

Here’s what you can do:

• Review Your Denial Letter: The letter will outline the specific reasons for the denial and explain how you can file an appeal. It’s important to pay close attention to the instructions and, most importantly, the deadline for filing—generally, you have 60 days to request an appeal.
• Contact Your Claims Representative: They can clarify why your claim was denied and answer your questions about the appeals process.
• Gather Additional Evidence: If possible, collect any new or updated medical records, statements from your doctors, or other documentation that might strengthen your case.
• Consider Legal Representation: Many applicants find success in the appeals process with the help of an experienced Social Security disability attorney. A qualified lawyer can help you navigate the appeals process, prepare the necessary paperwork, and present your case more effectively.

For most people, persistence during the appeal process can make all the difference. If your initial claim is denied, stay proactive and informed about your next steps.

Is It Common for Social Security Disability Claims to Be Denied at First?

It is, unfortunately, very common for initial Social Security disability applications to be denied. In fact, the majority of first-time claims receive a denial letter from the Social Security Administration. However, a denial at this stage doesn’t mean your claim can’t ultimately be approved. Many applicants who are initially denied go on to successfully secure benefits through the appeals process.

If you do receive a denial, remember that you have the right to appeal the decision. Having experienced legal representation during the appeals process has also been shown to improve your chances of a favorable outcome.

Does Hiring a Disability Lawyer Improve My Chances of Winning an Appeal?

Absolutely—having an experienced disability attorney on your side can make a significant difference if your claim is denied and you wish to appeal. Most initial Social Security disability applications are denied, but many individuals ultimately receive benefits after pursuing the appeals process. With a skilled lawyer guiding you, your odds can improve considerably.

A disability attorney can:

• Help Gather and Present Medical Evidence: They know what documentation and expert statements the Social Security Administration looks for and can ensure your records are thorough and persuasive.
• Handle Deadlines and Filings: Navigating appeals can be confusing and time-sensitive, but your lawyer will manage all paperwork and submissions to keep your claim on track.
• Represent You at Hearings: If your appeal requires a hearing before an administrative law judge, your attorney will prepare you, question witnesses, and argue your case.
• Spot Technical Issues: They’re experienced in identifying and overcoming the types of legal or procedural issues that may stand in your way.

In short, while you have the right to appeal on your own, working with a Social Security disability lawyer often increases your chances of success. If you’re facing a denial, don’t go it alone—reach out for legal help to give your appeal the best chance possible.

Schedule a Free Case Evaluation with a Social Security Disability Lawyer

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. If you would like an attorney to represent you in the appeal process, call the Ortiz Law Firm at (888) 321-8131.