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Summary

In most states, the first level of appeal after denial of a claim for Social Security Disability Insurance (SSDI) and/or Supplemental Security Income (SSI) is a process known as "Reconsideration." However, a different system is being used in Alabama, Alaska, California (Los Angeles area), Colorado, Louisiana, Michigan, Missouri, New Hampshire, New York (Albany and Brooklyn areas), and Pennsylvania. If you are a resident of any other area, the first level of appeal is known as Reconsideration. See Reconsideration.

Disability Redesign Prototype is a trial program that is evolving and changes are being made as this program is fine tuned. The following should therefore be checked before being acted upon.

The concept behind the program is that if a reviewer is about to deny your claim, he or she contacts you to let you know that your request is about to be turned down. A date is then set for an interview during which you have a chance to add to the information the reviewer has before a final determination is made.

For purposes of this program, the reviewer is known as a Single Decision Maker (SDM) .

Maximize your chances of getting an approval by:

  • Not providing any substantive information during the first conversation with the SDM.
  • Collecting new evidence.
  • Presenting the new evidence in the most favorable light.

If, after the conversation and a review of new evidence, the SDM decides to deny your claim, your file is sent back to Social Security to notify you of the denial.

What To Do If You Receive A Phone Call From The SDM Which Starts the Process

If you receive a phone call from the Single Decision Maker informing you of the pending denial and giving you the opportunity to respond, it is preferable not to respond to any substantive questions during the call.

Instead -

  • Takes notes. If you don't have something with which to write handy, ask for a moment while you get a pen and paper to make notes. Start by making note of the date.
  • Get:
    • The full name of the person calling (and how to pronounce the name if it is unusual)
    • The office from which the person is calling
    • The person's direct phone number
    • The person's mailing address
  • Ask why you are being denied. Generally it will be that the medical record does not support your claim to be disabled.
  • Ask what records went into making the decision. Write down a list of all the records. If necessary, make the caller repeat the list and wait until you have written down all the information. It helps to read back your copy of the list to be sure you both have the same list.
  • Ask what is needed to change the denial to an approval. This is an open-ended question which the Single Decision Maker may refuse to answer or not answer directly. Still, it doesn't hurt to try. Ideally, you want to get the person to talk about your claim and what she or he found missing. Some people will tell you right off the bat. Others will require more talk with questions that vary. Listen carefully: if you get the Single Decision Maker talking, the person will usually provide clues about what she or he is looking for even if the caller doesn't come right out and say it.
  • Ask about what specific evidence would help your case. Consider mentioning other possible evidence such as medical records, the existence of other medical problems, and other types of proof like a letter from a doctor or third party testimony. (This is not the time to volunteer what additional records you may have or can get.)
  • Set an appointment for an interview. Set the date far enough in the future to give you time to get the evidence you need. This can take time - especially if you have to get records or a letter from your doctor(s). Stress that you need time to prepare for the actual Pre-Decision Interview. Jacques Chambers, a benefits specialist, suggests that you set an in person interview if you can. That way you can deliver the new documentation yourself and cover any questions that may come up. If the Single Decision Maker insists on a phone interview, set an appointment far enough in the future to allow time to collect documentation and to send it in before the telephone appointment.

How To Prepare For Your Interview

Gather the evidence indicated in the phone call with the Single Decision Maker. Depending on the reason for the SDM leaning toward denying your claim, and whether you are applying for SSDI and/or SSI see:

Reason For Denial: Not Eligible Medically, Reason For Denial: Not Eligible Financially For Purposes Of Social Security Disability Insurance (SSDI), Reason For Denial: Not Eligible Financially For Purposes Of Supplemental Security Income (SSI).

Take the evidence with you to the meeting or submit it to the decision maker before the interview.

As you're already aware, make a copy of everything before sending it to Social Security. Also be sure that whatever you mail will be received before any deadlines the two of you agree on. Of course, send all materials in a manner that provides a receipt, such as US Certified Mail, Return Receipt Requested.

Reason For Denial: Not Eligible Medically

A denial due to not meeting Social Security's standard for being totally disabled is the most common reason a claim is denied. Disputing whether you are disabled will take time, research and preparation.

Whether or not you are disabled, and exactly when you became disabled enough to qualify for benefits, is a very subjective issue despite Social Security's attempts to make it objective. Your goal will be to use records that Social Security hasn't seen, and/or reinterpret records Social Security already has.

  • First, the denial letter will list each doctor whose records were used by Social Security. Check the list against the list of doctors about which you informed Social Security. Then review the list of medical records described in the letter.
  • In order to find medical records that Social Security has not seen, get copies of the medical records each doctor filed, plus copies of any medical records that were not filed or were filed but that Social Security did not list.
    • When looking for additional medical information Social Security has not seen, keep in mind that all of your medical problems do not have to come from the same condition. For example, if you are dealing with a physical condition, consider submitting records from your therapist treating you for depression or other mental condition.
  • Get a letter from your doctor.
    • Show your doctor the denial letter and review the medical records with him or her. Point out where you think the documentation of your symptoms is weak. Also point out items you may have reported to your doctor that didn't make it into the record. Ask your doctor to write a letter identifying from a medical point of view:
    • His/her opinion of your inability to work
    • Exactly what keeps you from working and how each of those items specifically keeps you from working. To learn more, see Physician's Statement.
  • Get third party testimony.

    • Especially if you didn't submit any with your initial application, obtain letters from people you work with as well as people you live with or are close to. Ask them to write their observations about why you can't work and any changes in you they've noticed. Ask them to be specific and to pinpoint dates as much as they recall. For samples, see Affidavits and Statements From Friends And Co-Workers.
  • Pull together other evidence.
    • A great source of other supporting evidence can be work or school records which sometimes contain a wealth of information about job performance and psychological testing. Any records that were generated before applying for Social Security benefits will be given greater weight than those which are generated afterward.
  • If the question is the onset date of your disability (the date your disability started), go through the medical records to show that you had the same symptoms at the earlier time as you did at the time Social Security used to declare you disabled.

Reason For Denial: Not Eligible Financially For Purposes Of Social Security Disability Insurance (SSDI)

When the question is whether you meet the financial eligibility requirements for a Social Security program -- such as whether you earned enough credits to qualify for SSDI -- the appeal is pretty cut and dried. It's an argument over numbers. If you can prove your numbers are right, you'll win. If not, Social Security's numbers will prevail.

When looking for evidence to support your position, remember that in the absence of some pretty convincing proof, Social Security's numbers are presumed to be correct.

Social Security may claim that you did not pay into Social Security for enough quarters to qualify. Or your benefit could be lower than you think it should be because Social Security missed five years of earnings on which you paid taxes. In order to prove your case, Social Security will generally not accept your word without additional evidence.

If you were an employee

Look for paycheck stubs which will show how much was paid in F.I.C.A. tax each pay period.

  • If you can't find them, the W-2 form you receive from an employer will show the amount of tax that was paid. If you don't have a separate file for W-2 forms, look at your tax return for the year in question. A W-2 should have been attached.
  • If all else fails, request a statement from the employer that shows how much was paid in F.I.C.A. taxes.

If you were self-employed: Your tax return would indicate how much you paid into the system in the particular year.

Reason For Denial: Not Eligible Financially For Purposes Of Supplemental Security Income (SSI)

The proof needed depends on the reason for the rejection. The most common reason for denial of SSI due to financial ineligibility is a misunderstanding of what is income .

Perhaps the way you reported something caused Social Security to mistakenly call it income or resources when it was not.

Perhaps income has been deemed to exist, when it didn't. For instance in the areas of free rent or gifts/in kind assistance:

  • Free Rent: Sometimes benefits are denied because Social Security claims that because you live rent-free, the value of your rent should be included in your income so that your total income exceeds the SSI minimum. To dispute this, you will need proof that you are not living rent-free. Two examples of situations where it could appear an applicant lives rent free, but doesn't, are:
    • A written agreement showing that the claimant has been loaned money from the property owner each month equal to the amount of rent. The agreement would have to include a statement that the transaction is a loan, a rate of interest and a date on which the loan will be repaid.
    • A written agreement showing that the claimant is loaned money each month equal to the rent, and that the loan plus interest will be paid from the death benefit of a life insurance policy that is described in the agreement. (For your information, you can still obtain life insurance despite your health history. See How To Obtain Life Insurance.)
  • Other in-kind or gift assistance: Many people think that unless they are given cash, it doesn't count as income. If you are denied SSI for this reason, re-read Supplemental Security Income (SSI) to see if your gifts may be exempt.

If Your Claim Is Denied

If your claim is denied, your next level of appeal is before an Administrative Law Judge.

The denial will describe the procedure and include a form called Request for a Hearing Before an Administrative Law Judge (which you can see at: www.ssa.gov/online/ha-501.html offsite link.)

Before you complete the form, to maximize your chances for a positive outcome, see Administrative Law Judge.

 

Social Security allows your 60 days plus 5 days for mailing time from the date of the denial to submit your request for an Administrative Law Judicial Hearing.