DECISION PROCESS

Initial Decisions

Most Social Security disability claims are initially processed through a network of local SSA field offices and state agencies, usually called Disability Determination Services (DDSs). DDSs, which are fully funded by the federal government, are responsible for developing and evaluating medical evidence and making the initial disability determination.

SSA field office staff are responsible for verifying nonmedical eligibility requirements. If the nonmedical eligibility requirements are met, the field office then sends the case to the DDS for evaluation of disability. The DDS first attempts to obtain medical records from the claimant’s medical sources. If that evidence is unavailable or insufficient to make a determination, the DDS will arrange for a consultative examination to obtain the additional information needed. This information is preferred to be from the claimant’s treating source, but the DDS may also obtain it from an independent source.

Based on all the medical and other information, the DDS staff make the initial disability determination. Determinations are most often made by an adjudicative team composed of a medical consultant (e.g., a licensed physician) and a disability examiner. Reasonable efforts must be made to ensure that an appropriate specialist evaluates cases involving mental disorders or those involving children.

Appeals Process

After the initial decision, applicants have the opportunity to appeal the determination, following an administrative process that is the same for adult and child claims. There are four levels of appeal: reconsideration, administrative hearing by an administrative law judge (ALJ), review by the appeals council, and federal court review. If the claimant disagrees with the initial disability decision, he may request a reconsideration. A different adjudicative team in the DDS then reviews the initial decision.

If the claimant disagrees with the reconsideration decision, he may ask for a hearing before an ALJ. A claimant may appear before the ALJ in person with an attorney or other representative. The ALJ may ask for testimony from a “medical expert,” although usually the decision is usually based on the claimant’s RFC rather than the Listings. The ALJ may reverse the denial (thus allowing the claim), affirm the denial, or remand the case to the DDS for further development.

If the claimant disagrees with the hearing decision, he may ask for a review by the SSA’s appeals council. If the claimant disagrees with the appeals council’s decision, the claimant may file a civil lawsuit in a federal court.



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