OVERVIEW OF CASE PROCESSING

Question 1

APPLICATION LEVELS

Answer 1

There are four adjudicative or application levels within the Social Security disability process. These levels are:

1. Initial Application
2. Reconsideration Appeal - 1st appeal
3. Administrative Law Judge Appeal - 2nd appeal
4. Appeal Counsel - 3rd appeal level - Highly experienced advocate only

Question 2

DISABILITY SERVICES IMPROVEMENT PROGRAM (DSIP)

Answer 2

In 206, SSA began to implement pieces of the Disability Services Improvement Program (DSIP). The (DSIP) takes the four traditional adjudicative steps above and internally changes which will perform specific duties within that level. Result: The four traditional levels still exist but have internally expanded.

The primary objective of the (DSIP) or DSI program is to speed up the disability process without sacrificing adjudicative standards. The result has been incremental changes in how SSA processes cases internally.
Changes to SSA’s internal processes affect who and what will be done within a given case level, but it does not eliminate the level.

Question 3

DISABILITY DETERMINATION SECTION (DDS)

Answer 3

The DDS under the DSI program is still responsible for developing medical evidence and making the initial or first determination. The SSA medical consultant assists the examiner and is usually a licensed physician who is also directly reviewing the claimant’s medical evidence.

Those cases not ready for an immediate decision are sent to the Disability Determination Section (DDS) for further development. A decision is made within the DDS. If the DDS decision is a denial, the claimant or his representative may request a Federal Review Official (FRO) appeal (Recon).

Question 4

DUTIES OF A MEDICAL CONSULTANT INCLUDE

Answer 4

In-house evaluation of medical evidence
Assessing impairment severity
Determining if a consultative exam is appropriate
Advising examiner on medical issues
The DDS examiner and an SSA medical consultant work together to make the initial case decision.

Question 5

THE APPLICATION PROCESS UNDER DSI

Answer 5

The initial case level is the first adjudicative level. Under the Disability Services Improvement DSI program, cases on the initial level are divided into two categories. Those cases are ready for an immediate decision and sent to the DDS for further processing. Those prepared for immediate decision are processed by a special DO-based group of case processors. This group is specially trained to process cases that either meet the medical listing or are technical denials.

A technical denial is based on an eligibility rule like income and resources. However, an immediate decision case can be processed based on medical issues. An immediate decision case is one that is an obvious allowance or denial.

Question 6

FEDERAL REVIEW OFFICIAL (FRO) APPEAL (RECON) -RECONSIDERATION LEVEL

Answer 6

If the DDS decision is a denial, the claimant or his representative may request a Federal Review Official (FRO) appeal (Recon).
If the FRO denies the case, the claimant or representative may request a de novo hearing or an Administrative Law Judge (ALJ) decision. A de novo ALJ hearing is an entirely new hearing without being bound by the findings from a prior determination.

Question 7

ADMINISTRATIVE LAW JUDGE (ALJ DECISION - DE NOVO ALJ HEARING

Answer 7

If the FRO denies the case, the claimant or representative may request a de novo hearing or an Administrative Law Judge (ALJ) decision. A de novo ALJ hearing is an entirely new hearing without being bound by the findings from a prior determination.
If the ALJ denies the case, it is sent to the Decision Review Board.

Question 8

DECISION REVIEW BOARD

Answer 8

If the ALJ denies the case, it is sent to the Decision Review Board. This Board will review the ALJ’s decision to determine the accuracy of the decision. If the Board agrees with the ALJ denial decision, the case can be appealed to the U.S. DISTRICT COURT- APPEAL COUNSEL.