EDPNA TERMS 4

Question 1

Social Security Disability Insurance SSDI Citation

Answer 1

CFR 20 Section 404

Question 2

If an appeal deadline is missed, and the claimant wants to appeal, he or she must show “good cause” for late filing.

Answer 2

Good Cause for Late Filing (Citations: 404.911, 416.1411)

Question 3

Examples of good cause are described in 404.911:

Answer 3

• You were seriously ill and were prevented from contacting us in person, by phone, in writing, or through a friend, relative, or other person;
• There was a death or serious illness in your immediate family;
• Important records were destroyed or damaged by fire or other accidental cause;
• You were making serious efforts to find necessary information to support the claim but had not been able to obtain it within the stated time periods;
• You requested additional information from us explaining this action within the time limit. Within 60 days of receiving the explanation you requested reconsideration or a hearing, or within 30 days of receiving the explanation you requested Appeals Council review or filed a civil suit;
• We gave you misleading, incorrect or incomplete information about when and how to request administrative review or to file a civil suit;
• You did not receive notice of the determination or decision;
• You sent the request to another government agency in good faith within the time limit and the request did not reach us until after the time period had expired; or
• Unusual or unavoidable circumstances exist, which show that you could not have known of the need to file timely, or which prevented you from filing timely.

Question 4

SSA will consider the following for deciding whether a claimant had good cause

Answer 4

• What circumstances kept the claimant from making the request on time;
• Whether SSA’s action mislead the claimant;
• Whether the claimant did not understand the requirements;
• Whether the claimant had any physical, mental, educational, or linguistic limitations which prevented them from making a timely request or from understanding or knowing about the need to file a timely request for review.

Question 5

Social Security Disability Insurance SSDI

Answer 5

Title XVI

Question 6

SSDI Eligibility

Answer 6

1. Is the applicant under full retirement age (66)?
2. Is the applicant fully insured?
3. Is the applicant insured for disability?

Question 7

Auxiliary Benefits

Answer 7

Benefits can be paid to the disabled worker’s family in some cases. Benefits can be paid to dependent children under the age of 18 or a spouse (or divorced spouse if married for 10 years) under the age of 62 who has joint care of the children.

Question 8

Supplemental Security Insurance SSI

Answer 8

Title II

Question 9

Supplemental Security Insurance SSI Citation

Answer 9

CFR 20 Section 416

Question 10

SSI

Answer 10

No work requirement
Children can qualify as disabled
No retroactive benefits earlier than filing date
Strict income and resource provisions

Question 11

Definition of Disability

Answer 11

Citations: 404.1505, 416.905
The inability to do any substantial gainful activity (SGA) by reason of any medically determinable physical or mental impairment(s) which can be expected to result in death, or which has lasted or can be expected to last for a continuous period of not less than 12 months.

Question 12

Insured Status

Answer 12

1. An individual must be fully insured
2. as a general rule they must meet to 20/40 requirement. (5 of last 10 years)

Quarters of Coverage at least 6 Quarters
One of Four For every year beginning with the year after attainment of age 21 up until the age you turn 62 or you die

Question 13

Rules of Disability Insured Status (SSDI Only)

Answer 13

Citations: 404.130, 404.131, and 404.140
Rule 1 - 20/40:You have to have 20 quarters of coverage in the 40-quarter period ending with the quarter that you became disabled. This is called the 20/40 rule. Or essentially, you have worked five years out of the last ten years, before you became disabled.
Rule 2 - Special Insured Status:
Rule 3: You had a period of disability before age 31.You are insured in a quarter for purposes of establishing a period of disability or becoming entitled to disability insurance benefits if in that quarter-
(1) You are disabled again at age 31 or later after having had a prior period of disability established which began before age 31 and for which you were only insured under paragraph (c) of this section; and
(2) You are fully insured and have QCs in at least one-half the calendar quarters in the period beginning with the quarter after the quarter you became age 21 and through the quarter in which the later period of disability begins, up to a maximum of 20 QCs out of 40 calendar quarters; however-
(i) If the number of quarters during this period is an odd number, we reduce the number by one;
(ii) If the period has less than 12 quarters, you must have at least 6 QCs in the 12-quarter period ending with that quarter; and
(iii) No monthly benefits may be paid or increased under Rule Ill before May 1983.

Rule 4: You are statutorily blind.
(1) You are disabled by blindness as defined in § 404.1581; and
(2) You are fully insured.

Question 14

Special Insured Status (SSDI Only)

Answer 14

Disable before the age of 31
20 CFR 404.130: You are insured in a quarter for purposes of establishing a period of disability or becoming entitled to disability insurance benefits if in that quarter-
(1) You have not become (or would not become) age 31;
(2) You are fully insured (next chapter); and
(3) You have Quarters of Coverage (QCs) in at least one-half of the quarters during the period ending with that quarter after the quarter you became age 21; however-
(i) If the number of quarters during this period is an odd number, we reduce the number by one; and
(ii) If the period has less than 12 quarters, you must have at least 6 QCs in the 12- quarter period ending with that quarter.

Question 15

Insured Status - Statutorily Blind

Answer 15

Citation: 404.130(e)
Statutorily blind individuals must only meet the fully disability insured status.

Question 16

Statutorily Blindness

Answer 16

Defined in the law as central visual acuity of 20/200 or less in the better eye with the use of correcting lens. An eye which has a limitation in the field of vision so that the widest diameter of the visual field subtends an angle no greater than 20 degrees is considered to have a central acuity of 20/200 or less. (404.1581)

Question 17

Fully Insured Status (SSDI Only)

Answer 17

404.110
You need at least one QC (Quarter of Coverage) for each calendar year after you turned 21 and the earliest of the following:
* The year before you attain age 62,
* The year before you die, or
* The year before you become disabled.
The minimum number of QCs needed is 6. The maximum number needed is 40. Any year (all or part of a year) that was included in a period of disability is not included in determining the number of QCs you need.

Question 18

Waiting Period (SSDI Only)

Answer 18

There is a 5-month period in which a claimant must have been disabled for 5 full consecutive months, beginning with the month that they were both insured and disabled, before cash benefits can begin. Your waiting period can begin no earlier than the 17th month before the month you apply-no matter how long you were disabled before then.

Question 19

Medicare Waiting Period

Answer 19

Test Tip: Include the 5-month waiting period in your calculation and count 29 months forward from established onset date to get the date the Medicare eligibility would begin.
To become eligible for Medicare a claimant has to have 24 months of disability eligibility, meaning they have been paid 24 months of cash benefits. 24 months after SSDI payments begin, the claimant will be automatically eligible for Medicare.

Question 20

Disabled Adult Child (DAC) (SSDI Only)

Answer 20

An adult who was disabled before age 22 may be eligible for child’s benefits if a parent is deceased, or receiving Social Security retirement, or receiving Social Security disability benefits. SSA considers this Disabled Adult Child claim a “child’s” benefit because it is paid on the parent’s earnings record. To meet requirements, the adult child – including an adopted child, or, in some cases, a stepchild, grandchild, or step grandchild - must
1. be unmarried;
2. be age 18 or older;
3. have a disability that started before age 22;
4. meet the SSA definition of disability for adults, and
5. not have substantial earnings to be insured for Title 2 on their own record.

Question 21

Disabled Widow Benefits (DWB)

Answer 21

Citation: 404.335
A widow or widower may be eligible for Disabled Widow(er)’s benefits if these requirements are met:
1. The widow(er) is between 50 and 60 years old;
2. The widow(er) meets the SSA definition of disability for adults;
3. The widow(er)’s disability began before or within seven years after the spouse’s death.
4. The deceased spouse must have been on Title 2 disability or had Title 2 insured status at death.

Question 22

Substitution Of Party (SSDI)

Answer 22

POMS DI 23510.035
Substitution of Party is limited to a surviving spouse who was living with the decedent at the time of death or within six months immediately preceding death, or to the parent or parents of a disabled or blind child who was living with the parent or parents at the time of death or within six months immediately preceding the month of death. Title XVI may also be pursued on a deceased claimant if Medicaid benefits had been paid on the claimant’s behalf.

Question 23

Substitution Of Party (SSI)

Answer 23

1. Surviving spouse living with claimant or entitled to benefits on the claimant’s account in the month of death;
2. Any child entitled to monthly benefits on the claimant’s SSN for the month in which the claimant died;
3. Parent(s) of the claimant entitled to monthly benefits on the claimant’s SSN for the month in which the claimant died;
4. Surviving spouse of the claimant;
5. Child(ren) of the claimant;
6. Parent(s) of the claimant;
7. Legal representative of the estate of the claimant.

Question 24

Appeal Deadlines

Answer 24

Test Tip: 60 days +5 days for mailing= 65 days to appeal!

Question 25

Levels of Appeal

Answer 25

The three levels of appeal relevant to non-attorney representatives are:
· Reconsideration
· Administrative Hearing
· Appeals Council

Question 26

Timely Appeals

Answer 26

Important to file because administrative finality.
A determination or decision becomes final and binding if it is not appealed timely.

Question 27

Trial Work Period (SSDI Only)

Answer 27

Citation: 404.1592, (no equivalent in 416)
The worker does have a period of time during which they can work without risk of losing their benefits.

The trial work period is 9 months and it can be 9 different months so it doesn’t have to be consecutive. A beneficiary can work in January and then again in May and then again in September and that’s only three months of their trial work period (TWP) the trial work period cannot begin in a month that cannot be considered TWP month if the work occurred during the waiting period.

There are dollar amounts that Social Security applies to decide if you use one of your TWP months. In 2017 that was $840.00 in 2018 it is $850.00. If a person works and earns $500, they have not used one of their 9 trial work period months but if they work and earn $900 in a month then 1 of their 9 TWP months has been used.

Rules: 9 months within a 60 month rolling period

Question 28

Income (SSI Only)

Answer 28

test tip: Income does not have to be cash to be counted against a claimant.
Income is defined in the regulations at 20 CFR 416.1104. You will find that income is anything that you received during a calendar month, that can be used to meet your needs for food or shelter. It may be cash or non-cash. Non-cash items they consider “in-kind” income. “In-kind” income is an item of food or shelter or something that you can use to get food or shelter. Additionally, Social Security breaks all income down into two categories; either earned income or unearned income.

Question 29

Earned Income (SSI Only)

Answer 29

Earned Income (SSI Only)
Explain this

Citations: 416.1112 “Earned Income We Do Not Count”

In simple terms, when calculating Supplemental Security Income (SSI), not all the money you earn is counted as income. Here’s a breakdown of how it works:

General Rule: The first $20 of income you receive each month is not counted at all. This applies to any type of income.
Earned Income: If you have earned income (like wages or self-employment profits), there’s an additional amount that won’t count:
The first $65 of your earned income each month is not counted.
After the first $65, only half of the remaining earned income is counted.
How Wages are Counted: If you’re employed, your wages are counted when you actually get paid.
Self-Employment: If you’re self-employed, they look at your net profit for the year, divide it by 12, and count one-twelfth of that profit as income each month.
So, if you earn money, the Social Security Administration (SSA) will disregard a total of $85 ($20 general + $65 earned income) plus half of the remaining earned income when they calculate your SSI benefit amount. This is done to encourage work by allowing you to keep more of your SSI benefits even if you’re earning money.

Question 30

Unearned Income (SSI Only)

Answer 30

One important example is cash, Other examples of unearned income include, but are not limited to: annuities, pensions, SSDI benefits, or other periodic payments like alimony, support payments, dividends, interest, some royalties, rental income, prizes, awards, gifts, inheritances, etc. Support and maintenance in-kind, can also be considered unearned income

Question 31

In Kind Support (SSI Only)

Answer 31

Citations: 416.1102, 416.1130 -416.1148
anything that you received used to meet your needs for food or shelter. Almost always unearned income

There are special rules as to how the value of this food or shelter is treated and received in a month. You should really be familiar with 20 CFR 416.1130 through 1148 for the detailed information about those rules.

Question 32

One Third Reduction Rule (VTR)

Answer 32

Test Tip: If the claimant is not receiving both food AND shelter, the 1/3 reduction rule does not apply. Instead SSA uses the presumed value rule as described in 416.1140.
Applies when a claimant is living with someone else who is providing them with food and shelter.
Social Security reduces the SSI monthly amount in that situation by one third. There is also a provision where any other income in the household, or that the recipient receives, is additionally subtracted from that 113rd lower SSI payment amount.

Question 33

Presumed Max Value (SSI)

Answer 33

Citation: 416.1140
This is similar to the 1/3 reduction rule, but it is applied in a situation where claimant normally lives in their own home but still gets help in the form of food and shelter or from another individual. In that situation Social Security deducts the current market value of the item from the monthly benefit subject to a maximum 1/3 of the FBR.
The presumed maximum value rule is rebuttable and if the recipient feels that the help that they are getting is not worth 1/3 of $841 (for 2022), then they can submit evidence to establish that the help they receive is worth less.

Question 34

Income Deeming

Answer 34

Citation: 416.1160
Income deeming is the process of considering another person’s income and/or resources to be available for meeting the basic needs of a disabled SSI claimant or recipient. Deemed income is a major class of income where the actual disabled individual is not receiving the income, but another person’s income is deemed to be used for the individual’s benefit. To understand deeming, you must first understand the term “ineligible individual” which is a person who is ineligible for SSI benefits due to income and/or resources.
Deeming relationship include:
* Parent-to-Child Deeming:
Parent-to-child deeming only applies to deeming of income and resources from ineligible parent(s) to an SSI eligible child under the age of 18. Once the child reaches age 18, deeming of income and resources from the parent(s) no longer applies. Generally, for parent-to-child deeming to apply, the child needs to be living with the parent(s). However, there are certain instances when a child who lives away from the parental home is still subject to parent to-child deeming. A common example of this would be when a child under age 18 is away at school, but is still under parental control. There are also several very limited situations in which SSA may waive deeming of parental income and/or resources.

• Spouse-to-Spouse Deeming:
  Spouse-to-spouse deeming only applies when an SSI eligible individual is married to an ineligible spouse. If both members of a married couple are SSI eligible, another set of rules will apply. Generally, spouse-to-spouse deeming applies only when the two spouses live together in the same household, but there are some exceptions. In addition, there are certain circumstances under which SSA may treat individuals who are not legally married as a married couple for the purposes of deeming.
• Sponsor-to-Alien Deeming:
  Sponsor-to-alien deeming only applies to deeming the income and/or resources of an ineligible individual (and the individual’s ineligible spouse if the individual is married) who sponsors an alien’s

Question 35

Resources

Answer 35

Citation: 416.1201 (Subpart L - Resources & Exclusions)
Part 2 of benefit eligibility
Resources are things you own such as:
* cash;
* bank accounts, stocks, U.S. savings bonds;
* land;
* life insurance;
* personal property;
* vehicles;
* anything else you own which could be changed to cash and used for food or shelter; and
* deemed resources.
The following things generally do not count toward the resource limit, no matter how much they are worth:
* the house you live in;
* one vehicle, if it is used for transportation for the claimant or a member of the claimant’s household (in practice, the most expensive vehicle in your name);
* life insurance policies the claimant owns with a face value of $1,500 or less per person;
* burial plots or spaces for the claimant or the claimant’s immediate family;
* a burial fund of up to $1,500 each for the claimant and the claimant’s spouse’s burial expenses;
* household goods and personal effects;
* property the claimant or the claimant’s spouse uses in a trade or business, or on their job if they work for someone else; and
* if the claimant is disabled or blind, money or property set aside under a Plan to Achieve Self-Support (PASS).

Question 36

Resources

Answer 36

Citation: 416.1201 (Subpart L - Resources & Exclusions)
divided into two categories:
* Liquid resources can be converted into cash within 20 days. The 20 days excludes certain non-workdays as described in 20 CFR 416.120(d);
* Non-liquid assets cannot be turned into cash within 20 days (ex. Loan agreements, vehicles, machinery, livestock, buildings, and land that the claimant does not live on). Non-liquid resources are evaluated according to their equity value except as otherwise provided. 20 CFR 416.1218
Remember: Income is anything that comes in during the month that you can use to
provide food or shelter. Resources anything that you already had before a month began
that you can use to provide food and shelter.

Question 37

Fee Approval

Answer 37

Citation: 404.1720, 404.1730**
A representative may not charge a fee for any work performed on behalf of a claimant for Social Security benefits unless the fee is specifically approved by the SSA.**

Question 38

Fee Agreement

Answer 38

Citation: 404.1720, 404.1730
Fees are limited to 25% of past-due benefits limited to a regulatory cap (not to exceed $7200 as of November 30, 2022). Past-due benefits has very specific definitions which are a little different for Title 2 and for Title XVI claims

Question 39

Fee Petition

Answer 39

Citation: 404.1720, 404.1730
Another way that you can request and be approved to receive a fee is by fee petition. Under fee petition you have to show exactly what you did and ask the adjudicator to approve an amount that you request based on the work and the amount of time you spent on the case. There is no technical limit to the amount Social Security could approve under a fee petition.

Question 40

Administrative Finality

Answer 40

Citation 404.987 and 416.1487
Once the Commissioner (DDS/ALJ/AC) decides about whether or not the claimant is disabled, and the claimant does not request review within the time period (usually 60 days +5 for mailing) or SSA does not notify the claimant of its intent to revise the determination or decision, it becomes final and the claimant loses his or her right for further review.

Question 41

Reopening

Answer 41

Citations 404.988 and 416.1488
A final determination or decision can be reopened under the following conditions:
* Within 12 months of the date of the initial determination for any reason.
* In SSI claims, within 2 years of the date of the initial determination if SSA finds there is good cause.
* In SSDI claims, within 4 years of the date of the initial determination if SSA finds there is good cause.
Once a decision is final, it cannot be changed unless SSA reopens it. Either SSA or the claimant can request reopening. When a claimant requests that a prior claim be reopened, the decision as to reopen is at the discretion of SSA/DDS and there are very specific conditions

Question 42

“good cause” for reopening

Answer 42

Citations 404.988 and 416.1488
* New and material evidence is furnished.
* A clerical error in benefit computation was made.
* The evidence that was considered clearly shows on its face that an error was made.

Question 43

Res Judicata

Answer 43

SSA has previously decided based on the same facts, same issues, same parties and same adjudicative period. If a claim is filed for the same facts and issues as a previous denied claim and if for the same time period as the previous claim, it will be dismissed.
For SSDI cases, applies when both of the following factors occur:
* A subsequent claim has been filed.
* The last determination has become final and the claimant has a DLI in the past.

Question 44

Collateral Estoppel

Answer 44

Citations 404.950(f) and 416.1450(f)
“issue already decided”
when a subsequent claim is filed alleging the same issues as a previous claim that was decided under a different program. Unlike Res Judicata, the concept of Collateral Estoppel can be the basis of an allowance or denial.
Receiving SSI and also filing for DAC

Question 45

Common Law Marriage

Answer 45

Citation: 404.726
SSA does recognize common-law marriage if the state (note - there are only a few states that still recognize it) where the couple lived does, but needs the following “preferred evidence” as proof:
1. If both spouses are alive, their signed statements and those of two blood relatives;
2. If either spouse is dead, the signed statement of the one who is alive and those of two blood relatives of the deceased person; or
3. If both the spouses are dead, the signed statements of one blood relative of each;
in addition:
* A deed listing both spouses
* Any legal document showing one spouse has assumed the married surname
* Employment records listing the common-law spouse as a immediate family member
* Insurance policies naming the other party as a beneficiary
* Bank statements showing joint ownership of an account

Question 46

Unsuccessful Work Attempt (UWA)

Answer 46

Citation 404.1574c
An effort to do work in employment or self-employment that discontinues or reduces to the non-Substantial Gainful Activity (SGA) level after a short time (no more than 6 months) because of the impairment or the removal of special conditions related to the impairment that are essential to the further performance of work.

Question 47

Income Exclusions

Answer 47

416.1112
Certain earned or unearned income situations include Impairment Related Work Expenses (IRWE) and earnings under a Plan to Achieve Self Support (PASS)

Question 48

Impairment-Related Work Expenses (IRWE)

Answer 48

Income Exclusion: items and services needed or used to enable the claimant to work such as attendant care expenses; medical devices such as wheelchairs, canes, crutches; pacemakers; residential modifications; necessary medications; medical services; special transportation needs. It does not matter if the claimant also uses these items and services for non-work activities.
IRWE will be deducted for SGA purposes when:

• The item(s) or service(s) enables the claimant to work;
• The claimant needs the item(s) or service(s) because of a physical or mental impairment;
• The claimant pays for the item(s) or service(s) and are not reimbursed by another source such as Medicare, Medicaid, or a private insurance carrier; and
• The cost is “reasonable”, that is, it represents the standard charge for the item or service in the claimant’s community.

Question 49

Plan to Achieve Self Support (PASS)

Answer 49

Allows claimants to set aside income and/or resources for a specified period of time so that they can pursue a work goal that will reduce or eliminate the SSI or Social Security Disability Insurance benefits they are currently receiving. Income and resources set aside under PASS are not counted as income or resources for SSI eligibility. The criteria for PASS are very specific and experts are available to help claimants with setting up a pass account. Can include supplies to start a business, school expenses, equipment and tools, transportation, uniforms and other items or services you need to reach your employment goal.

Question 50

SVP 1-2

Answer 50

unskilled work

“SVP” stands for Specific Vocational Preparation, which is a rating system used to determine the skill level required for different jobs. Jobs with an SVP rating of 1 or 2 are considered unskilled work. This means they require little or no judgment to perform simple tasks and can usually be learned in less than a month. Unskilled work doesn’t typically help a person gain work skills and often involves physical strength. In contrast, jobs with higher SVP ratings require more training and are considered semi-skilled or skilled work.

Question 51

SVP 3-4

Answer 51

Semi-Skilled Work

“SVP” stands for Specific Vocational Preparation, and it’s a measure of how long it typically takes to learn the skills needed for a job. Jobs with an SVP rating of 3-4 are considered semi-skilled work. This means they require some skills but are not as complex as skilled work. Here’s what you need to know about semi-skilled work:

Learning Time: It usually takes between three to six months to learn a semi-skilled job.
Skills Required: These jobs may require you to stay alert, pay attention to detail, and sometimes protect against risks. They might also require coordination and dexterity, like moving your hands and feet quickly to do a repetitive task.
Complexity: The tasks involved are less complex than those in skilled work but more complex than unskilled work.
Education can sometimes substitute for job training. For example, a four-year college degree is equivalent to two years of SVP, and each year of graduate school adds another year of SVP

Question 52

SVP 5-10

Answer 52

Skilled work
“SVP” stands for Specific Vocational Preparation, which is a measure of the time needed to learn the skills required for a job. Jobs with an SVP rating of 5-10 are considered skilled work. Here’s what that means:

SVP 5: Over 6 months up to and including 1 year to learn the job.
SVP 6: Over 1 year up to and including 2 years to learn the job.
SVP 7: Over 2 years up to and including 4 years to learn the job.
SVP 8: Over 4 years up to and including 10 years to learn the job.
SVP 9: Over 10 years to learn the job.
Skilled work involves jobs that require specific qualifications, the use of judgment, and the ability to perform complex tasks to create a product, material, or provide a service. This type of work often requires extensive training, which may be acquired through vocational education, apprenticeship, on-the-job training, or significant experience in other jobs

Question 53

non-transferable skills

Answer 53

unskilled worker SVP 1-2

Non-transferable skills refer to abilities or knowledge that are specific to a particular job and cannot be easily applied to different work settings or occupations. For unskilled workers with an SVP (Specific Vocational Preparation) rating of 1-2, this concept is particularly relevant because their jobs typically require little to no specialized skills that could be transferred to other roles. Unskilled jobs are characterized by simple tasks that can be learned quickly and do not provide the worker with skills that would be useful in a different job. Therefore, if an unskilled worker seeks new employment, they would likely need to start from scratch in learning new job-specific skills, as their previous experience would not give them a significant advantage in the job market.

Question 54

Ocassional

Answer 54

At least once and up to 1/3 of an 8 hr workday or 2.67 hours or less in an 8 hr workday

Question 55

Frequently

Answer 55

1/3 to 2/3 of an 8 hr day or 2.67 to 5.33 hr of a workday

Question 56

Constantly

Answer 56

2/3 or more of an 8hr work day or 5.33 or more hours of a workday

The term “constantly” in a work context typically refers to an action or condition that occurs without interruption or variation, maintaining a consistent frequency or intensity throughout the specified period. When it is said that something happens “constantly” for 2/3 or more of an 8-hour workday, it means that the action or condition is present for at least 5.33 hours or more during the day. This implies a continuous and unchanging occurrence for the majority of the workday.

Question 57

illiteracy

Answer 57

404.1564
The inability to read or write. We consider someone illiterate if the person cannot read or write a simple message such as instructions or inventory lists even though the person can sign his or her name. Generally, an illiterate person has had little or no formal schooling.

Question 58

Marginal

Answer 58

404.1564
Ability in reasoning, arithmetic, and language skills which are needed to do simple, unskilled types of jobs. We generally consider that formal schooling at a 6th grade level or less is a marginal education.

Question 59

Limited

Answer 59

404.1564
Ability in reasoning, arithmetic, and language skills, but not enough to allow a person with these educational qualifications to do most of the more complex job duties needed in semi-skilled or skilled jobs. We generally consider that a 7th grade through the 11th grade level of formal education is a limited education.

Question 60

High School and above

Answer 60

404.1564
Abilities in reasoning, arithmetic, and language skills acquired through formal schooling at a 12th grade level or above. We generally consider that someone with these educational abilities can do semi-skilled through skilled work.

Question 61

External Limitations

Answer 61

Strength demands of a job are affected such as sitting,standing,walking,lifting, carrying, push and pull

Question 62

Non-External Limitations (edit)

Answer 62

side effects of some medications may reduce your general alertness, concentration, or physical stamina, affecting your residual functional capacity for non-exertional or exertional work activities.

Question 63

basic work activities

Answer 63

Citation: 404.1522, 416.922
(1) Physical functions such as walking, standing, sitting, lifting, pushing, pulling, reaching, carrying, or handling;
(2) Capacities for seeing, hearing, and speaking;
(3) Understanding, carrying out, and remembering simple instructions;
(4) Use of judgment;
(5) Responding appropriately to supervision, co-workers and usual work situations; and
(6) Dealing with changes in a routine work setting.

Question 64

non-severe impairment

Answer 64

Citation: 404.1522, 416.922
An impairment is considered not severe if the impairment or combination of impairments doesn’t significantly limit your physical or mental ability to do basic work activities

Question 65

Multiple Impairments: Unrelated Severe Impairments

Answer 65

Citation: 404.1523, 416.923
SSA cannot combine two or more unrelated severe impairments to meet the 12-month duration test. If you have a severe impairment(s) and then develop another unrelated severe impairment(s) but neither one is expected to last for 12 months, we cannot find you disabled, even though the two impairments in combination last for 12 months.

Question 66

Multiple Impairments: Concurrent Impairments:

Answer 66

Citation: 404.1523, 416.923
If you have two or more concurrent impairments that, when considered in combination, are severe, we must determine whether the combined effect of your impairments can be expected to continue to be severe for 12 months. If one or more of your impairments improves or is expected to improve within 12 months, so that the combined effect of your remaining impairments is no longer severe, SSA will find that you do not meet the 12-month duration test.

Question 67

Multiple Impairments: Combined Effect:

Answer 67

Citation: 404.1523, 416.923
In determining whether your physical or mental impairment or impairments are of a sufficient medical severity that such impairment or impairments could be the basis of eligibility under the law, we will consider the combined effect of all of your impairments without regard to whether any such impairment, if considered separately, would be of sufficient severity. If we do find a medically severe combination of impairments, we will consider the combined impact of the impairments throughout the disability determination process. If we do not find that you have a medically severe combination of impairments, we will determine that you are not disabled

Question 68

Who Makes Disability Determinations

Answer 68

Citation: 404.1503, 416.903

-Commissioner of Social Security
-Disability Determination Services
-Bureau of Disability Determination
-Disability Determination Divison

not a claimant’s doctor

Question 69

Evidence

Answer 69

Citation: 404.1512, 406.1512

It must allow SSA to determine:
* The nature and severity of the impairment(s) for any period in question;
* Whether the duration requirement described in § 404.1509 is met; and
* The claimant’s residual functional capacity (RFC) to do work-related physical and mental activities, when the evaluation steps described in 404.1545-416.920g1 and 404.1520a4-416.920a4

Citation: 404.1512, 406.1512
The claimant must inform SSA about:
* medical source(s);
* age;
* education and training;
* work experience;
* daily activities both before and after the alleged onset date;
* efforts to work; and
* Any other factors showing how the impairment(s) affects the claimant’s ability to work. Read 404.1560 through 404.1569 to learn more about the evidence SSA needs to consider vocational factors.

Question 70

Objective medical evidence

Answer 70

Citations: 404.1502, 404.1513, 416.902, 416.913
medical signs that can be observed through acceptable clinical diagnostic techniques, laboratory findings or both.

Question 71

Categories Of Evidence: Acceptable medical sources

Answer 71

Citations: 404.1502, 404.1513, 416.902, 416.913
* physicians who are licensed, typically designated by M.D. or D.O.
* licensed or certified psychologists including school psychologists
* licensed optometrists
* licensed podiatrists
* licensed or certified speech-language pathologists
* licensed audiologists
- occupational therapist

Question 72

Consultative Examinations (CEs)

Answer 72

Citiation: 404.1503a, 404.1512b2 404.1519
416.903a, 416.912b2, 416.919, 416.919 g-i,
A physical or mental examination or test purchased by DDS or SSA to help the agency or judge have a complete record in making the determination. CEs are ordered when necessary information is not in the file, the file contains inconsistencies that need to be resolved. The claimant or the representative can object to the doctor for many reasons including language barriers and no interpreter, lack of accessibility to the exam location, prior knowledge of the claimant.

Question 73

Evaluating Opinion Evidence

Answer 73

Citations: For claims filed before March 27, 2017 see 404.1527C
For claims filed after March 27, 2017 see 404.1520C
After March 27, 2017, treating source opinions are evaluated under the same criteria as all medical opinion evidence and are no longer automatically given controlling weight.

Question 74

Evaluating Symptoms Including Pain

Answer 74

Citations: 404.1529
What SSA considers when evaluating symptoms:
* Statements about symptoms, including pain - these are usually found on the application, disability report and function report, but can also be found within medical records when claimants are describing symptoms to their providers.
* Any description medical sources or nonmedical sources may provide about how the symptoms affect ADLs and ability to do work.

If a claimant is alleging disabling symptoms, those symptoms must be supported by objective evidence in order for SSA to consider them.

Question 75

Sequential Evaluation Step 3 Meeting A Listing

Answer 75

Citations: 404.1525, 404.1526, 416.925, 416.926, Appendix 1 of Subpart P
Test Tip 1: If a claimant meets the criteria for a medical listing, their age, education, and work experience do not matter! SSA can approve the claim at Step 3 of the Sequential Evaluation Process without evaluating Steps 4 and 5.
Test Tip 2:Know where to find the Listings in the CFR!!! (Appendix 1 of Subpart P)
Test Tip 3: When evaluating a particular listing criteria, pay attention to words like AND & OR!

Question 76

Meeting A Listing

Answer 76

Citations: 404.1525, 404.1526, 416.925, 416.926, Appendix 1 of Subpart P
Part A applies to individuals under 18
Part B applies to individuals over 18

SSA can find medical equivalence when the claimant comes close to meeting the listing criteria, but the symptoms, findings or other findings are not the same as what is listed. For cases at Initial or Reconsideration, a finding of medical equivalence must be made by a State agency medical or psychological consultant or other designee of the Commissioner. For cases at the ALJ or AC level, the responsibility for deciding medical equivalence rests with the administrative law judge or Appeals Council.

Question 77

Following Prescribed Treatment

Answer 77

Citations: 404.1530, 416.930

In order for a claimant to receive benefits, they must follow treatment prescribed by their medical source(s) if the treatment is expected to restore the ability to work.
Unless:
* The specific medical treatment is contrary to the established teaching and tenets of the claimant’s religion.
* Surgery was previously performed with unsuccessful results and the same surgery is again being recommended for the same impairment.
* The treatment is very risky (open heart surgery, organ transplant)
* The treatment involves amputation of an extremity, or a major part of an extremity.

Question 78

Drugs Addiction And Alcoholism (DAA)

Answer 78

1. Would the claimant still be disabled if he or she stopped using drugs or alcohol? SSA evaluates which of the claimant’s current physical and mental limitations, upon which the disability determination is based, would remain if there were no substance abuse, and then whether any or all limitations would be disabling.
2. If SSA determines that the remaining limitations would not be disabling, the DA&A will be considered a contributing factor material to the determination, likely resulting in a denial.
3. If SSA determines that the remaining limitations are disabling, the claimant is considered disabled independent of the substance abuse and SSA will find that the DA&A is not a contributing factor material to the determination of disability, likely resulting in an allowance.

Question 79

Substantial Gainful Activity SGA

Answer 79

Citations: 404.1572, 416.2210
Claimant cannot make over national average wage if considering eligibility.
Substantial work activity requires significant physical or mental involvement.
Gainful work activity is for pay or profitable

Question 80

Not Substantial Gainful Activity

Answer 80

Generally, SSA does not consider activities like taking care of oneself, household tasks, hobbies, therapy, school attendance, club activities, or social programs to be substantial gainful activity.

Question 81

5 Step Sequential Evaluation Process

Answer 81

5 Step Sequential Evaluation Process
Explain this

404.1520(a)4, 416.920(a)4
Step 1: Is the individual working above SGA level?
Step 2: Is the individual’s physical and/or mental condition severe?
Step 3: Does the individual’s medical condition meet or equal the severity of a Listing?
Step 4: Can the individual do any of his/her Past Relevant Work?
Step 5: Can the individual make an adjustment to any other work?

Question 82

Past Relevant Work (PRW)

Answer 82

Citations: 404.1565(a), 416.965(a)

Must meet the following requirements:
* It has to have been performed within the last 15 years (prior to date of adjudication or DLI, whichever is earlier)
* It must have lasted long enough for the claimant to learn how to do it
* It must have been SGA

Question 83

Exertional Limitations

Answer 83

Citations: 404.1569(a), 416.969(a)

Affect an individual’s ability to meet the strength demands of jobs. The classification of a limitation as exertional is related to the United States Department of Labor’s classification of jobs by various exertional levels (sedentary, light, medium, heavy, and very heavy) in terms of the strength demands for sitting, standing, walking, lifting, carrying, pushing, and pulling. When the limitations and restrictions imposed by the impairment(s) and related symptoms, such as pain, affect only the claimant’s ability to meet the strength demands of jobs, we consider that the claimant has only only exertional limitations. If an individual only has exertional impairments and a grid rule applies, SSA will directly apply that rule to decide whether he or she is disabled.

Question 84

Non exertional Limitations

Answer 84

Citations: 404.1569(a), 416.969(a)
Non-exertional limitations or restrictions affect an individual’s ability to meet the demands of jobs other than the strength demands. Some examples of non-exertional limitations or restrictions include the following:

• Difficulty functioning because an individual is nervous, anxious, or depressed;
• Difficulty maintaining attention or concentrating;
• Difficulty understanding or remembering detailed instructions;
• Difficulty in seeing or hearing;
• Difficulty tolerating some physical feature(s) of certain work settings, e.g., cannot tolerate dust or fumes; or
• Difficulty performing the manipulative or postural functions of some work such as
  reaching, handling, stooping, climbing, crawling, or crouching.

Question 85

Residual Functional Capacity (RFC)

Answer 85

Physical RFC

SSA will first assess the nature and extent of physical limitations and then determine a claimant’s RFC for work activity on a regular and continuing basis. A limited ability to perform certain physical demands of work activity, such as sitting, standing, walking, lifting, carrying, pushing, pulling, or other physical functions (including manipulative or postural functions, such as reaching, handling, stooping or crouching), may reduce the ability to do past work and other work.

Mental RFC
SSA will assess the nature and extent of mental limitations and restrictions and then determine a claimant’s RFC for work activity on a regular and continuing basis. A limited ability to carry out certain mental activities such as limitations in understanding, remembering, and carrying out instructions, and in responding appropriately to supervision, coworkers, and work pressures in a work setting, may reduce the claimant’s ability to do past work and other work.

Question 86

Sedentary work

Answer 86

Maximum lifting 10 pounds; mostly sitting, but often requires walking and standing occasionally. Occasionally lifting or carrying articles like docket files, ledgers, and small tools.

Question 87

Light work

Answer 87

Maximum lifting 20 pounds; frequent lifting or carrying up to 10 pounds; requires a good deal of walking or standing, or when it involves sitting most of the time, requires pushing and pulling of arm or leg controls. To be considered capable of performing light work, an individual must have the ability to do substantially all of these activities. If someone can do light work, he or she can also do sedentary work, unless there are additional limiting factors such as loss of fine dexterity or inability to sit for long periods of time.

Question 88

Medium work

Answer 88

Maximum lifting 50 pounds; frequent lifting or carrying up to 25 pounds. If someone can do medium work, he or she can also do sedentary and light work.

Question 89

Heavy work

Answer 89

Maximum lifting 100 pounds; frequent lifting or carrying up to 50 pounds. If someone can do heavy work, he or she can also do medium, light, and sedentary work.

Question 90

Very heavy work

Answer 90

Maximum lifting 100 pounds; frequent lifting or carrying of 50 pounds or more. If someone can do very heavy work, he or she can also do heavy, medium, light and sedentary work.

Question 91

Work Which Exists in the National Economy

Answer 91

Citations: 404.1566D & 416.966D

Social Security considers that work exists for a claimant when there is a significant number of jobs (in one or more occupations) that the claimant is able to perform even with their physical and/or mental disabilities. The work must exist in the national economy, i.e. in significant numbers in either the regions where the claimant lives or in several regions of the country. The following has no effect on determining whether work exists.

1. None of the identified work exists in the immediate area where the claimant lives.
2. No specific job vacancy exists.
3. The claimant would not be hired if he or she applied for the work.
4. The claimant is unable to secure the work.
5. The hiring practices of employers.
6. Technological changes in the industry.
7. Cyclical economic conditions.
8. The claimant does not wish to do a particular type of work.

SSA recognizes reliable job information from various governmental and other publications. For example: Dictionary of Occupational Titles, published by the Department of Labor; County Business Patterns, published by the Bureau of the Census; Census Reports, also published by the Bureau of the Census; Occupational Analyses, prepared for the Social Security Administration by various State employment agencies; and Occupational Outlook Handbook, published by the Bureau of Labor Statistics.

Vocational experts and other specialists may be called to determine whether the claimant can still do their past work or whether their work skills can be used in other work and, if so, the specific occupations in which they can be used.

Question 92

Younger person

Answer 92

Citations: 404.1563, 416.963

under age 50. Generally, age will not seriously affect your ability to adjust to other work. However, in some circumstances, we consider that persons age 45-49 are more limited in their ability to adjust to other work than persons who have not attained age 45.

Question 93

Person closely approaching advanced age

Answer 93

Citations: 404.1563, 416.963
50-54 years old. Age may seriously affect your ability to adjust to other work.

Question 94

Person of advanced age

Answer 94

Citations: 404.1563, 416.963

55 and older. Ages significantly affects a person ability to adjust to other work.

Question 95

Person closely approaching retirement age

Answer 95

Citations: 404.1563, 416.963
60 and older. Included in the person of advanced age category, special rules apply if the claimant is age 60 or older.

Question 96

Borderline Age

Answer 96

Appendix 2, Subpart P
Age categories are not applied mechanically in borderline situations. If the individual is within a few days to a few months of reaching an older age category, and using the older age category would result in a favorable decision, Social Security may use the older age category.

Question 97

Literacy

Answer 97

Citations: 404.1564(1), 416.964(1)
Illiteracy means the inability to read or write. We consider someone illiterate if the person cannot read or write a simple message such as instructions or inventory lists even though the person can sign his or her name. Generally, an illiterate person has had little or no formal schooling.

Question 98

Marginal Education

Answer 98

404.1564, 416.964
Marginal education means ability in reasoning, arithmetic, and language skills which are needed to do simple, unskilled types of jobs. We generally consider that formal schooling at a 6th grade level or less is a marginal education.

Question 99

Limited Education

Answer 99

404.1564, 416.964
Limited education means ability in reasoning, arithmetic, and language skills, but not enough to allow a person with these educational qualifications to do most of the more complex job duties needed in semi-skilled or skilled jobs. We generally consider that a 7th grade through the 11th grade level of formal education is a limited education.

Question 100

High School (or GED) or More:

Answer 100

404.1564, 416.964
High school education and above means abilities in reasoning, arithmetic, and language skills acquired through formal schooling at a 12th grade level or above. We generally consider that someone with these educational abilities can do semi-skilled through skilled work.

Question 101

Arduous Unskilled Physical Labor (worn-out worker)

Answer 101

404.1562, 416.962
If you have no more than a marginal education and work experience of 35 years or more during which you did only arduous unskilled physical labor, and you are not working and are no longer able to do this kind of work because of a severe impairment(s), we will consider you unable to do lighter work, and therefore, disabled.

Question 102

55 years old, no more than limited education, with no PRW:

Answer 102

404.1562, 416.962
If you have a severe, medically determinable impairment(s), are of advanced age, have a limited education or less, and have no past relevant work experience, we will find you disabled. If the evidence shows that you meet this profile, we will not need to assess your residual functional capacity or consider the rules in appendix 2 to this subpart.

Question 103

Special Vocational Profiles (SVP)

Answer 103

404.1562, 416.962

Arduous Unskilled Physical Labor (worn-out worker):
55 years old, no more than limited education, with no PRW:

Question 104

Special Vocational Profiles (SVP)

Answer 104

The period of time in which it takes a worker to learn the skills associated with a particular occupation.

Question 105

Unskilled (SVP)

Answer 105

404.1568 (skill levels)

By its own definition, does not afford the worker development of any skill.
SVP (1-2) (1) Short demonstration to (2) 30 days or less to learn

Question 106

Semi-skilled (SVP)

Answer 106

404.1568 (skill levels)
requires greater complexity and perhaps greater dexterity and/or coordination
SVP (3-4) (3) 30 days to 3 months to (4) 3 to 6 months to learn

Question 107

Skilled (SVP)

Answer 107

404.1568 (skill levels)requires elements such as exercising judgment, interacting with others and greater complexity.
SVP (5-9) (5) 6 months to 1 year; (6) 1 year to 2 years; (7) 2 years to 4 years; (8) 4 years to 10 years; (9) 10 years or more to learn

Question 108

Transferability

Answer 108

(1) Transferable skills are acquired from a skilled or semi-skilled occupation can be used in other skilled or semi-skilled work which depends upon the similarity of the work activities of the different (alternative) occupation.
(2) The existence of transferable skills is “most probable and meaningful” when the same or lesser skill level is required; the same or similar tools/machines are used; and, the same or similar raw materials/products/processes OR services are used to perform the occupation.
(3) Complete similarity is NOT necessary for all 3 of the above factors to establish transferability
(4) Other factors are relevant to assessment of transferability at age 55 and over specific to the ability to adjust to alternative work.

Question 109

Who May Be A Representative

Answer 109

1. Any attorney in good standing who-
   a. Has the right to practice law before the appropriate court;
   b. Is not disqualified or suspended from acting as a representative in dealings with SSA; and
   c. Is not prohibited by any law from acting as a representative.
2. Any person who is not an attorney if the person -
   a. Is capable of giving valuable help in connection with your claim;
   b. Is not disqualified or suspended from acting as a representative in dealings with SSA;
   c. Is not prohibited by any law from acting as a representative; and
   d. Is generally known to have good character and reputation.

Note: You do not have to have passed the EDPNA exam to represent a claimant before SSA. Passing the EDPNA exam only means that SSA will pay you fees directly.

Question 110

Appointment of a Representative

Answer 110

SSA will recognize a person as a representative if the following are done:
1. A claimant signs a written notice (1696 Appointment of Representation form) stating that they want the person to be their representative in dealings with SSA.
2. That person signs the notice, if the person is not an attorney. Attorneys do not have to sign the notice (but most do).
3. The notice is filed at the SSA office, or OHO if the claim is pending a hearing, or Appeals Council if the claim is pending a review of the ALJ’s decision.

Question 111

Authority of a Representative

Answer 111

A representative may take certain actions on behalf of a claimant including:

1. Obtain information about the claim to the same extent that the claimant is able to do.
2. Submit evidence;
3. Make statements about facts and law; and
4. Make any request or give any notice about the proceedings before SSA.

A representative may not sign an application on behalf of a claimant except under special authorized circumstances.

Question 112

Conducting Business Electronically

Answer 112

Conducting Business Electronically
Explain this

Test Tip: SSA wants representatives to submit applications and appeals online whenever possible. If a question is asking about whether it is better to submit the application at the field office with a claims representative or use the online application; the answer is always online!

A representative must conduct business with SSA electronically at the times and in the manner we prescribe on matters for which the representative requests direct fee payment.

This rule requires, among other things, that representatives file applications and appeals online, submit medical records via fax with barcode or via upload to Electronic Records Express.

There are technical issues that sometimes prevent representatives from being able to utilize online services. For example, a representative is helping a client appeal an onset date. The system will show that the claim has been processed and will not allow an online appeal. When technical issues prevent the use of online services, print the error message and submit the application or appeal electronically with the printed error message showing that you attempted to submit electronically.

Question 113

Fee Issues

Answer 113

To charge and receive a fee for services, a representative must file a written request with SSA (most representative submit a fee agreement form), and SSA will determine the amount of the fee a representative may charge or receive.

A representative must not charge or receive any fee unless SSA has authorized it, and a representative must not charge or receive any fee that is more than the amount SSA authorizes. (Note: administrative expenses such as medical records, mail costs, etc. can be billed to the client without authorization from SSA)

Fees are paid from past-due benefits directly to the eligible non-attorney. The claimant and the representative receive a letter explaining the fee amount. Within 30 days of that letter, the claimant or the representative may request a review of the fee determination.

Question 114

Affirmative Duties

Answer 114

Affirmative Duties
Explain this

Test Tip: Memorize this citation! 404.1740 for Affirmative Duties and Prohibited Actions. On the test, it will be much easier to look up this citation, than memorize all of the affirmatives duties and prohibited actions individually.

Affirmative duties. A representative must, in conformity with the regulations setting forth our existing duties and responsibilities and those of claimants (see § 404.1512 in disability and blindness claims):

(1) Act with reasonable promptness to help obtain the information or evidence that the claimant must submit under our regulations, and forward the information or evidence to us for consideration as soon as practicable.

(2) Assist the claimant in complying, as soon as practicable, with our requests for information or evidence at any stage of the administrative decision making process in his or her claim. In disability and blindness claims, this includes the obligation pursuant to§ 404.1512(c) to assist the claimant in providing, upon our request, evidence about:
(i) The claimant’s medical source(s);
(ii) The claimant’s age;-
(iii) The claimant’s education and training;
(iv) The claimant’s work experience;
(v) The claimant’s daily activities both before and after the date the claimant alleges that he or she became disabled;
(vi) The claimant’s efforts to work; and
(vii) Any other factors showing how the claimant’s impairment(s) affects his or her ability to work. In §§ 404.1560 through 404.1569a, we discuss in more detail the evidence we need when we consider vocational factors;

(3) Conduct his or her dealings in a manner that furthers the efficient, fair and orderly conduct of the administrative decision making process, including duties to:
(i) Provide competent representation to a claimant. Competent representation requires the knowledge, skill, thoroughness and preparation reasonably necessary for the representation. This includes knowing the significant issue(s) in a claim and having a working knowledge of the applicable provisions of the Social Security Act, as amended, the regulations and the Rulings; and
(ii) Act with reasonable diligence and promptness in representing a claimant. This includes providing prompt and responsive answers to our requests for information pertinent to processing of the claim; and
(iii) When requested, provide us, in a manner we specify, potential dates and times that the representative will be available for a hearing. We will inform the representative how many potential dates and times we require to coordinate the hearing schedule.
(iv) Only withdraw representation at a time and in a manner that does not disrupt the processing or adjudication of a claim and that provides the claimant adequate time to find new representation, if desired. A representative should not withdraw after we set the time and place for the hearing (see § 404.936) unless the representative can show that a withdrawal is necessary due to extraordinary circumstances, as we determine on a case-by-case basis.
(v) Maintain prompt and timely communication with the claimant, which includes, but is not limited to, reasonably informing the claimant of all matters concerning the representation, consulting with the claimant on an ongoing basis during the entire representational period, and promptly responding to a claimant’s reasonable requests for information. When we evaluate whether a representative has maintained prompt and timely communication with the claimant, we will consider the difficulty the representative has in locating a particular claimant (e.g., because the claimant is homeless) and the representative’s efforts to keep that claimant informed.

(4) Conduct business with us electronically at the times and in the manner we prescribe on matters for which the representative requests direct fee payment. (See 404.1713).

Practice: As a claimant’s representative you have been practicing since the early eighties. You became an EDPNA in 2005 under the Demonstration Project allowing non-attorneys to take an exam and become eligible for fee withholding basically giving you parity with your attorney colleagues and allowing you to collect your fees directly from SSA. Since then, your bottom line has improved significantly. All of your files are still paper. You scan and fax documents as needed. You appreciate the one on one time with your clients to complete the application on paper and submit it by mail to SSA. One day, you get a letter from SSA notifying you of possible EDPNA suspension. Why would SSA send you this letter?

You are in violation of 404.1740(4) - whereby, if you want direct fee payment, you must conduct business with SSA electronically at the times and in the manner they prescribe. AKA - you must file your claimant’s applications electronically or else you put yourself in jeopardy of becoming suspending from fee withholding.

Question 115

Prohibited Actions

Answer 115

Test Tip: Memorize 1740 so you can quickly find this section!

Prohibited actions. A representative must not:

(1) In any manner or by any means threaten, coerce, intimidate, deceive or knowingly mislead a claimant, or prospective claimant or beneficiary, regarding benefits or other rights under the Act;

(2) Knowingly charge, collect or retain, or make any arrangement to charge, collect or retain, from any source, directly or indirectly, any fee for representational services in violation of applicable law or regulation;

(3) Make or present, or participate in the making or presentation of, false or misleading oral or written statements, assertions or representations about a material fact or law concerning a matter within our jurisdiction;

(4) Through his or her own actions or omissions, unreasonably delay or cause to be delayed, without good cause (see § 404.911(b)), the processing of a claim at any stage of the administrative decision making process;

(5) Divulge, without the claimant’s consent, except as may be authorized by regulations prescribed by us or as otherwise provided by Federal law, any information we furnish or disclose about a claim or prospective claim;

(6) Attempt to influence, directly or indirectly, the outcome of a decision, determination, or other administrative action by offering or granting a loan, gift, entertainment, or anything of value to a presiding official, agency employee, or witness who is or may reasonably be expected to be involved in the administrative decision making process, except as reimbursement for legitimately incurred expenses or lawful compensation for the services of an expert witness retained on a non-contingency basis to provide evidence;

(7) Engage in actions or behavior prejudicial to the fair and orderly conduct of administrative proceedings, including but not limited to:

(i) Repeated absences from or persistent tardiness at scheduled proceedings without good cause (see § 404.911(b));

(ii) Behavior that has the effect of improperly disrupting proceedings or obstructing the adjudicative process, including but not limited to:
(A) Directing threatening or intimidating language, gestures, or actions at a presiding official, witness, contractor, or agency employee;
(B) Providing misleading information or misrepresenting facts that affect how we process a claim, including, but not limited to, information relating to the claimant’s work activity or the claimant’s place of residence or mailing address in matters where the representative knows or should have known that the information was misleading and the facts would constitute a misrepresentation; and
(C) Communicating with agency staff or adjudicators outside the normal course of business or other prescribed procedures in an attempt to inappropriately influence the processing or outcome of a claim(s).

(8) Violate any section of the Act for which a criminal or civil monetary penalty is prescribed;

(9) Refuse to comply with any of our rules or regulations;

(10) Suggest, assist, or direct another person to violate our rules or regulations;

(11) Advise any claimant or beneficiary not to comply with any of our rules or regulations;

(12) Knowingly assist a person whom we suspended or disqualified to provide representational services in a proceeding under title 11 of the Act, or to exercise the authority of a representative described in § 404.1710; or

(13) Fail to comply with our sanction(s) decision.

(14) Fail to oversee the representative’s employees, assistants, partners, contractors, or any other person assisting the representative on claims for which the representative has been appointed when the representative has managerial or supervisory authority over these individuals or otherwise has responsibility to oversee their work.

Practice: Jane Rhonda, your client, has experienced years of chronic back pain, since her entire career was as an aerobic instructor. Her orthopedic surgeon recently conducted a spinal fusion at L4 - LS of her lower lumbar spine. Jane has experienced immense relief, but still has mild pain most of the day and has trouble sleeping at night. During your pre-hearing conference, you are walking Jane Rhonda through the hearing proceedings and trying to help her understand what to expect at her hearing this Friday. You tell her that in order to show the judge just how much she is in, you need her to disrupt the hearing by calling out in pain at least 5 times and that she needs to sit and stand as much as she can, so the ALJ can get a visual of her inability to stay seated for more than 5 minutes at a time. You are in violation of which Prohibited Action?

404.1740(c)3 - you cannot direct your client to present misleading representations about her condition.

Question 116

Violations of Rules of Conduct

Answer 116

When we have evidence that a representative fails to meet our qualification requirements or has violated the rules governing dealings with us, we may begin proceedings to suspend or disqualify that individual from acting in a representational capacity before us. We may file charges seeking such sanctions when we have evidence that a representative:
(a) Does not meet the qualifying requirements described in § 404.1705;
(b) Has violated the affirmative duties or engaged in the prohibited actions set forth in 404.1740;
(c) Has been convicted of a violation under section 206 of the Act;
(d) Has been, by reason of misconduct, disbarred or suspended from any bar or court to which he or she was previously admitted to practice (see § 404.1770(a)); or
(e) Has been, by reason of misconduct, disqualified from participating in or appearing before any Federal program or agency (see 404.1770(a)).
(f) Who, as a non-attorney, has been removed from practice or suspended by a professional licensing authority for reasons that reflect on the person’s character, integrity, judgment, reliability, or fitness to serve as a fiduciary.

Question 117

Charges Against a Representative

Answer 117

(a) The General Counsel or other delegated official will prepare a notice containing a statement of charges that constitutes the basis for the proceeding against the representative.
(b) We will send this notice to the representative either by certified or registered mail, to his or her last known address, or by personal delivery.
(c) We will advise the representative to file an answer, within 14 business days from the date of the notice, or from the date the notice was delivered personally, stating why he or she should not be suspended or disqualified from acting as a representative in dealings with us.
(d) The General Counsel or other delegated official may extend the 14-day period for good cause in accordance with § 404.911.
(e) The representative must
(1) Answer the notice in writing under oath (or affirmation); and
(2) File the answer with the Social Security Administration, at the address specified on the notice, within the 14-day time period.
(f) If the representative does not file an answer within the 14-day time period, he or she does not have the right to present evidence, except as may be provided in 404.1765(9).

Question 118

Suspending a Representative

Answer 118

If the hearing officer finds that the charges against the representative have been sustained, he or she will either-
(i) Suspend the representative for a specified period of not less than 1 year, nor more than 5 years, from the date of the decision; or
(ii) Disqualify the representative from acting as a representative in dealings with us until he or she may be reinstated under§ 404.1799. Disqualification is the sole sanction available if the charges have been sustained because the representative has been disbarred or suspended from any court or bar to which the representative was previously admitted to practice or disqualified from participating in or appearing before any Federal program or Federal agency, or because the representative has collected or received, and retains, a fee for representational services in excess of the amount authorized.

The hearing officer shall mail a copy of the decision to the parties at their last known addresses. The notice will inform the parties of the right to request the Appeals Council to review the decision.

Effect of hearing officer’s decision.
(1) The hearing officer’s decision is final and binding unless reversed or modified by the Appeals Council upon review.
(2) If the final decision is that a person is disqualified from being a representative in dealings with us, he or she will not be permitted to represent anyone in dealings with us until authorized to do so under the provisions of§ 404.1799.
(3) If the final decision is that a person is suspended for a specified period of time from being a representative in dealings with us, he or she will not be permitted to represent anyone in dealings with us during the period of suspension unless authorized to do so under the provisions of§ 404.1799.