| | | | | denied. If the DDS finds the claimant disabled, SSA will |
| | | | | complete any outstanding non-disability development, |
| The Social Security Administration (SSA) administers | | | | compute the benefit amount, and begin paying benefits. |
| two programs that provide benefits based on disability: | | | | If the claimant is found not disabled, the file is retained |
| the Social Security disability insurance program (title II of | | | | in the field office in case the claimant decides to |
| the Social Security Act (the Act) and the supplemental | | | | appeal the determination. |
| security income (SSI) program (title XVI of the Act). | | | | If the claimant files an appeal of an initial unfavorable |
| Title II provides for payment of disability benefits to | | | | determination, the appeal is usually handled much the |
| individuals who are “insured” under the Act by | | | | same as the initial claim, except that the disability |
| virtue of their contributions to the Social Security trust | | | | determination is made by a different adjudicative team |
| fund through the Social Security tax on their earnings, | | | | in the DDS than the one that handled the original case. |
| as well as to certain disabled dependents of insured | | | | Office of Hearings and Appeals |
| individuals. Title XVI provides for SSI payments to | | | | Claimants dissatisfied with the first appeal of a |
| individuals (including children under age 18) who are | | | | determination may file subsequent appeals. A hearing |
| disabled and have limited income and resources. | | | | office within the Office of Hearings and Appeals |
| The Act and SSA’s implementing regulations | | | | (OHA) processes the second appeal. An |
| prescribe rules for deciding if an individual is | | | | administrative law judge makes the second appeal |
| “disabled.” SSA’s criteria for deciding if | | | | decision, usually after conducting a hearing and |
| someone is disabled are not necessarily the same as | | | | receiving any additional evidence from the |
| the criteria applied in other Government and private | | | | claimant’s medical sources or other sources. |
| disability programs. | | | | Medical development by OHA is frequently conducted |
| Definition of Disability | | | | through the DDS. However, hearing offices may also |
| For all individuals applying for disability benefits under | | | | contact medical sources directly. In rare circumstances, |
| title II, and for adults applying under title XVI, the | | | | an administrative law judge may issue a subpoena |
| definition of disability is the same. The law defines | | | | requiring production of evidence or testimony at a |
| disability as the inability to engage in any substantial | | | | hearing. |
| gainful activity (SGA) by reason of any medically | | | | The Role of the Health Professional |
| determinable physical or mental impairment(s) which | | | | - Health professionals play a vital role in the disability |
| can be expected to result in death or which has lasted | | | | determination process and participate in the process in |
| or can be expected to last for a continuous period of | | | | a variety of ways: |
| not less than 12 months. | | | | - As treating sources or other medical sources who |
| Disability in Children | | | | provide medical evidence on behalf of their patients; |
| Under title XVI, a child under age 18 will be considered | | | | |
| disabled if he or she has a medically determinable | | | | - As CE sources to perform, for a fee, examinations |
| physical or mental impairment or combination of | | | | and/or tests that are needed; |
| impairments that causes marked and severe functional | | | | |
| limitations, and that can be expected to cause death or | | | | - As full-time or part-time medical or psychological |
| that has lasted or can be expected to last for a | | | | consultants reviewing claims in a DDS, in one of |
| continuous period of not less than 12 months. | | | | SSA’s regional offices, or in SSA central office; or |
| What is a “Medically Determinable Impairment”A | | | | |
| medically determinable physical or mental impairment is | | | | - As medical experts who testify at administrative law |
| an impairment that results from anatomical, | | | | judge hearings. |
| physiological, or psychological abnormalities, which can | | | | |
| be shown by medically acceptable clinical and | | | | Treating Sources |
| laboratory diagnostic techniques. A physical or mental | | | | A treating source is a claimant’s own physician, |
| impairment must be established by medical evidence | | | | psychologist, or other acceptable medical source that |
| consisting of signs, symptoms, and laboratory findings | | | | has provided the claimant with medical treatment or |
| — not only by the individual’s statement of | | | | evaluation and has or has had an ongoing treatment |
| symptoms. | | | | relationship with the claimant. The treating source is |
| | | | | usually the best source of medical evidence about the |
| The Disability Determination Process | | | | nature and severity of an individual’s impairment (s). |
| Social Security Field Offices | | | | If an additional examination or testing is needed, SSA |
| Most disability claims are initially processed through a | | | | usually considers a treating source to be the preferred |
| network of local Social Security field offices and State | | | | source for performing the examination or test for his |
| agencies (usually called disability determination services | | | | or her own patient. |
| or DDSs). Subsequent appeals of unfavorable | | | | The treating source is neither asked nor expected to |
| determinations may be decided in the DDSs or by | | | | make a decision whether the claimant is disabled. |
| administrative law judges in SSA’s Office of | | | | However, a treating source will usually be asked to |
| Hearings and Appeals (OHA). | | | | provide a statement about the claimant’s ability, |
| SSA representatives in the field offices usually obtain | | | | despite his or her impairments, to do work-related |
| applications for disability benefits, either in person, by | | | | physical or mental activities. |
| telephone, or by mail. The application and related forms | | | | Program Medical Professionals |
| ask for a description of the claimant’s | | | | Physicians of virtually all specialties and psychologists |
| impairment(s), names, addresses, and telephone | | | | at the State, regional or national levels review claims |
| numbers of treatment sources, and other information | | | | for disability benefits. The review work is performed in |
| that relates to the alleged disability. (The | | | | the State DDSs or SSA’s regional office or |
| “claimant” is the person who is requesting | | | | headquarters. It is strictly a paper review in which the |
| disability benefits.) | | | | program physician or psychologist usually has no |
| The field office is responsible for verifying non-medical | | | | contact with the claimant. |
| eligibility requirements, which may include age, | | | | Medical Experts |
| employment, marital status, or Social Security | | | | Because there is no direct involvement of medical |
| coverage information. The field office sends the case | | | | professionals in the disability decisions made by |
| to a DDS for evaluation of disability. | | | | administrative law judges in the Office of Hearings and |
| Disability Determination Services | | | | Appeals, administrative law judges sometimes request |
| The DDSs, which are fully funded by the Federal | | | | expert testimony on complex medical issues. Each |
| Government, are State agencies responsible for | | | | hearing office maintains a roster of medical experts |
| developing medical evidence and rendering the initial | | | | who are called to testify as expert witnesses at |
| determination on whether the claimant is or is not | | | | hearings. The experts are paid a fee for their services. |
| disabled or blind under the law. | | | | Confidentiality of Records |
| Usually, the DDS tries to obtain evidence from the | | | | Two separate laws, the Freedom of Information Act |
| claimant’s own medical sources first. If that | | | | and the Privacy Act, have special significance for |
| evidence is unavailable or insufficient to make a | | | | Federal agencies. Under the Freedom of Information |
| determination, the DDS will arrange for a CE in order | | | | Act, Federal agencies are required to provide the |
| to obtain the additional information needed. The | | | | public with access to their files and records. This |
| claimant’s treating source is the preferred source | | | | means the public has the right, with certain exceptions, |
| for the CE; however, the DDS may also obtain the CE | | | | to examine records pertaining to the functions, |
| from an independent source. (See Part III for more | | | | procedures, final opinions, and policy of these Federal |
| information about CEs.) | | | | agencies. |
| After completing its initial development, the DDS | | | | The Privacy Act permits an individual or his or her |
| makes the disability determination. The determination is | | | | authorized representative to examine records |
| made by a two-person adjudicative team consisting of | | | | pertaining to him or her in a Federal agency. For |
| a medical or psychological consultant (who is a | | | | disability applicants, this means that an individual may |
| physician or psychologist) and a disability examiner. If | | | | request to see the medical or other evidence used to |
| the adjudicative team finds that additional evidence is | | | | evaluate his or her application for disability benefits |
| still needed, the consultant or examiner may recontact | | | | under the Social Security or the SSI programs. (This |
| a medical source (s) and ask for supplemental | | | | evidence, however, is not available to the general |
| information. | | | | public.) |
| The DDS also makes a determination whether the | | | | SSA screens all requests to see medical evidence in a |
| claimant is a candidate for vocational rehabilitation | | | | claim file to determine if release of the evidence |
| (VR). If so, the DDS makes a referral to the State VR | | | | directly to the individual might have an adverse effect |
| agency. | | | | on that individual. If so, the report will be released only |
| After the DDS makes the disability determination, it | | | | to an authorized representative designated by the |
| returns the case to the field office for appropriate | | | | individual. |
| action depending on whether the claim is allowed or | | | | |