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If you plan to apply for Social Security Disability benefits, you may be curious about what happens to your claim once it’s submitted. While it can feel time-consuming and confusing, knowing more about the process the Social Security Administration undertakes to review your disability benefits claim can help set you up for success from the very beginning. We’ll walk you through every step of the disability determination process so that you can prepare a claim that answers all major questions associated with the review. Keep reading.
5 Steps in the SSDI Determination Process
The Social Security Administration will follow a basic, five-step sequential process to determine your eligibility for disability benefits. These questions originate directly from the Social Security Act. We’ve outlined the basic review questions below:
- Is the applicant working above the Substantial Gainful Activity level?
- Is the applicant’s condition considered severe enough?
- Does the impairment or condition meet the severity to be considered one of the listings in Social Security’s Blue Book of Impairments?
- Can the claimant still perform any of his or her relevant past work?
- Can the claimant adjust to doing other similar kinds of work?
The eligibility process is fairly simple – following the set of questions listed above, a claims examiner will sequentially compare each claim to the list of questions. If the review at that level determines that the claimant meets the criteria for disability benefits, the review continues. But if at any point, reviewers determine that the applicant doesn’t meet a step’s criteria for eligibility, the claim will be denied and the disability determination process goes no further. In addition to meeting the criteria outlined in these five steps, a claimant also must have worked long enough under Social Security to qualify for disability benefits.
Before beginning the claims process, you should know that the Social Security Administration follows a strict definition of “disability,” which is defined as, “the inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or is expected to last for a continuous period of not less than 12 months.” This narrow definition forms the basis of the five criteria the SSA will use to evaluate your claim. Being clear on those criteria before you start is key to making sure your claim can meet this level of scrutiny.
Initial disability benefits claims are typically reviewed by SSA representatives in field offices. Your local Social Security office can usually take your application in person or you can also mail it in or submit it online through the SSA website. The application asks for detailed information regarding the claimed disability, medical treatment sources, and other documentation that can help make the case for the claimed disability. Once the SSA has received your application, it will likely send it to the Disability Determination Services division for your state, where it goes through the five-step review process with a disability examiner.
5 Steps of the SSDI Determination Process
Now it’s time for a deeper look into the questions the SSI will explore to determine the success of your claim. Every claim is examined according to the sequential process outlined below to ensure that they all receive the same level of scrutiny and consideration.
Is the Applicant Working Above the Substantial Gainful Activity Level?
SSA reviewers will first consider this question: Is a person making more money than what would be supplied through Social Security disability benefits? If so, this could negate a claim from the very beginning, even if your condition might otherwise qualify for benefits. This is known as denial for a technical reason. However, if an applicant’s limited income falls below the limit available through Social Security – which changes every year, and was $1,260 per month or more in 2020 – or the applicant is earning no income at all because of a disability, then reviewers will move on to the next question.
Is the Applicant’s Condition Considered Severe Enough?
This criterion begs the question, “What is ‘severe enough?’” For the SSA’s purposes, a disability is considered “severe enough” if it interferes with basic work activity as simple as lifting, driving, walking, pushing, pulling, making work-related judgment calls, responding appropriately to supervisor instruction, or communicating with colleagues.
Disabilities can be either physical or mental, or a combination of both. If the disability in question meets this criterion, the claims examiner will move to the next step in the disability determination process. But if reviewers conclude that the claimed disability is not severe enough to impede normal, day-to-day, work-related activities, then at this point the claim will be denied. It’s not just the presence of a condition that matters – you have to prove that the condition prevents you from being able to work.
To fully consider this point, anyone reviewing your application will need to consult with a health professional. If you have supporting medical evidence of any conditions, you should make sure to include that when you submit your claim. If the medical information you provide is sufficient, reviewers may not need to consult with an outside medical consultant. However, if the information you provide isn’t comprehensive enough to allow reviewers to make a final decision, they may call for a consultative examination, either with your physician of choice or a medical consultant the SSA chooses.
Does the Impairment or Condition Meet the Severity to be Considered One of the Listings in Social Security’s Blue Book of Impairments?
The Social Security Administration maintains a list of medical conditions considered severe enough that they automatically qualify for benefits. The list includes a wide range of physical and mental conditions, including some cardiovascular illnesses, some cancers, some mental health issues, and some muscular issues.
This list provides a federal standard and is organized by impairments for both children and adults. If the condition you’re filing under meets the list criteria, your claim will, in many cases, automatically be approved. Recognizing that it may be impossible to list every possible approved impairment or condition, the SSA also may determine that your claimed disability is equivalent in medical severity to one of those listed. If not, that doesn’t automatically mean that your claim is denied. It simply has to move through the rest of the disability determination process and your claim would move on to the next step.
Can the Claimant Still Perform Any of His or Her Relevant Past Work?
Even in the presence of a medical condition, can you continue to do the type of work you’ve done in the past? This step is where reviewers will consider your age, type of work experience, and other factors. They want to determine whether you are capable of functioning healthfully, both physically and mentally, within the typical 40-hour work environment of your past – or some other schedule, depending on your previous work history.
This step usually includes what’s called a Residual Functional Capacity evaluation to help determine if you’re capable of performing job duties. RFCs can evaluate both physical and mental limitations. If you pass the evaluation at this point, your claim will be denied, based on the rationale that you should be able to resume previous work tasks, but if an RFC shows that your condition prevents you from meeting the physical and/or mental challenges associated with your job, your claim will move on to the next and final step for consideration.
Can the Claimant Adjust to Doing Other Similar Kinds of Work?
Before approving a disability benefits claim, the SSA will consider whether an applicant might have both physical and mental skills that can be transferred to another type of work. Maybe your condition prevents you from performing every task associated with your previous work, but are there other types of work you still can complete?
Reviewers will consider other types of work that don’t include the kinds of activities a claimed condition might prevent. Using all the information from an RFC, medical documentation, and other information provided in your claim, the SSA may recommend that you adjust to pursue a different type of work that would still allow you to support yourself. The exception to this applies to workers over age 50, unless they have documented recent training or professional development that supports their move to a different type of work. If SSA reviewers decide that a different type of work is still possible with your condition at this point in the disability determination process, your claim will be denied.
If Your Claim is Denied
Once SSA reviewers have gone through every step in the process outlined above, you’ll receive a letter either informing you of your level of approved disability benefits or advising you that your claim has been denied. If you’re approved, your Social Security Award Letter will outline your level of benefits. But if you get a denial letter, don’t immediately lose heart – this is where the appeals process begins, and the letter you receive will clearly outline the steps you need to take to begin your appeal. Your first appeal is known as a Request for Reconsideration, and your application will go back through the same disability determination process, this time with a different set of reviewers.
Many claims are denied at first review and even at the reconsideration level. At this point, you may consider engaging an attorney who specializes in disability claims to make sure you have the best chance for success within the appeals process. Only about 10% of disability claims are approved by the time they go through reconsideration, so working with a qualified and knowledgeable disability lawyer can help you prepare for the next step, which is a hearing before an administrative law judge. The judge will review all evidence and will also allow you to share your perspective on how your condition limits day-to-day work activities and to call witnesses to testify on your behalf.
Beyond the hearing, your case can continue through the appeals process by getting a review from the Social Security Administration’s Appeals Council. And even if the appeals council rejects your claim, you still have the option of suing the SSA in federal court for either a reversal or a new hearing. You can also choose to file a new claim. A qualified disability attorney can help guide you through this entire appeals process.
After Filing a Disability Claim
When submitting a disability benefits claim, it’s important to make sure you’re providing the right level of detail and documentation that makes it easy for reviewers to approve your claim. By understanding the steps SSA reviewers will take to evaluate your claim, you can set yourself up for success from the very beginning, helping ensure that your claim is approved.
It’s important to understand that the disability determination process can take a long time. Patience and perseverance are often required. Because so few claims are approved the first time around, you should be prepared to commit to the appeals process. But with the right documentation and support, you’re more likely to see your claim through to a successful decision.