TN 2 (02-10)

CITATIONS: Regulations – 20 CFR Sections 404.601 -404.633 , 404.701 -404.780 , 404.1512 ; 416.301 -416.351 , 416.701 -714 , 416.801 -806 , 416.912

To become entitled to Disability Insurance Benefits (DIB) or to be eligible for Supplemental Security Income (SSI) payments, a disability claimant (or proper applicant on his or her behalf) must:

• file a valid application;

• furnish medical and other evidence in support of his or her claim; and

• meet all factors of entitlement.

A. FO responsibilities to the claimant

The claimant must file a valid application and furnish certain evidence to support a claim for disability, but it is the role of the FO, specifically, the claims representative (CR), to ensure complete and accurate claims development. The FO informs and assists the claimant through the disability claim process and makes certain the claimant is aware of his or her rights and responsibilities.

B. During the application process

• Explain the disability requirements under Social Security DIB and SSI;

• Conduct the disability interview;

• Complete and review the disability application(s) and report forms; and

• Develop and adjudicate non-medical aspects of the disability claim.

C. During the initial determination process

Explain to the claimant the process for making a determination about his or her entitlement to, or eligibility for, disability benefits and SSI payments. This includes information about work activity, the medical evaluation, consultative exams (CE), continuing disability review (CDR), and the claimant’s rights and responsibilities.

1. Work activity

Explain to the claimant that:

• He or she must timely report all work activity.

• We may deny the claim if he or she engages in substantial gainful activity (SGA) during the first year of disability.

• We do not necessarily stop or reduce benefits due to work activity. Program rules exist to encourage beneficiaries to return to work by allowing the beneficiary to keep all or part of his or her benefits for a specified period of time.

If the claimant would like additional information, provide him or her with the pamphlet “Working While Disabled – How We Can Help” (SSA Publication No. 05-10095).

• Provide a copy from the local supply (if available) if the claimant is in the office.

• Direct him or her to SSA’s forms and publication website to obtain an electronic copy of the pamphlet at http://www.ssa.gov/pubs/10095.html; or

• Use the Public Information Request System (PIRS) at http://pirs.sspf.ssa.gov/PIRSWeb to send the pamphlet through the mail if the claimant does not have internet access.

Resources:

• Work incentive policies are summarized in SSA’s Red Book, which is available online at http://www.socialsecurity.gov/redbook/eng/main.htm.

• Members of the public may find additional information at the SSA Online Work Site at http://www.socialsecurity.gov/work/index.html.

2. Medical evaluation

Explain the role of the Disability Determination Services (DDS) in the disability process. Tell the claimant that the DDS:

• Obtains and evaluates medical evidence; and

• Pays for copies of medical reports obtained by the DDS, but not for actual medical examination(s); and

• Schedules and pays for a consultative examination (CE) if the medical evidence received by the DDS is insufficient and an examination is necessary.

Tell the claimant that the DDS may need his or her assistance and that full cooperation is required. For more information, see Payment for Medical Evidence of Record, DI 11010.545.

3. Consultative Examination (CE)

Explain the CE procedure to the claimant and stress the importance of his or her full cooperation in cases where a special examination is scheduled. Explain that failure to cooperate can delay the claim and may result in an unfavorable determination. If the claimant asks questions about a possible CE, provide him or her with the pamphlet “A Special Examination is Needed for Your Disability Claim” (SSA Publication No. 05-10087). You may:

• Provide a copy from the local supply if the claimant is in the office;

• Direct him or her to SSA’s forms and publication website to obtain an electronic copy of the pamphlet at http://www.ssa.gov/pubs/10087.html; or

• Use the Public Information Request System (PIRS) at http://pirs.sspf.ssa.gov/PIRSWeb to send the pamphlet through the mail if the claimant does not have internet access.

References:

• DI 23007.009, Refusal to Attend a Consultative Examination (CE) Appointment

• DI 23007.010, Failure to Attend a Consultative Examination (CE) Appointment

4. Continuing Disability Reviews (CDRs)

Explain that after SSA finds a claimant disabled, the law requires SSA to evaluate his or her impairment(s) as well as any work activity, from time to time, to determine whether or not disability continues.

Emphasize that benefit payments may not be permanent. Describe the three categories of medical reviews and the frequency that we conduct these CDRs.

References:

• DI 13001.001, The Obligation to Review Continuance of Disability

• DI 13001.005, Events Which May Initiate a CDR

• DI 13005.001, Field Office Role in Medical Issue Cases

• DI 13010.010, Events That Initiate a Work CDR

5. Claimant rights and responsibilities

Review with the claimant his or her reporting responsibilities as detailed in the claims material. Explain that any return to work or improvements in the claimant’s disabling condition(s) must be reported and that he or she must fully cooperate with the DDS in obtaining medical evidence. Ensure the claimant understands these responsibilities.

D. During the appeals process

Explain that if the claimant disagrees with an initial determination or decision he or she may request further review. This is called an appeal.

The appeals process consists of several levels of administrative review that must be requested within certain time periods and at the proper level.

The levels of administrative review are

1. Reconsideration,

2. Administrative Law Judge (ALJ) hearing, and

3. Appeals Council (AC) review.

Provide the claimant with information about filing his or her appeal online at www.socialsecurity.gov.

For a complete overview of the appeals process, see GN 03101.001, Summary of Administrative Appeals.

NOTE: Reconsideration is not the first level of appeal for medical determination on initial claims in Prototype states (Alabama, Alaska, California, Colorado, Louisiana, Michigan, Missouri, New Hampshire, New York, and Pennsylvania), unless expedited reinstatement is involved. For additional information, see DI 13050.085, Appeals Process Under Expedited Reinstatement.

References:

• GN 00204.001, Valid Application

• GN 03102.100, The Reconsideration Process

• DI 11005.001, Field Office Disability Interviews

• DI 12001.000, Handling Appeals Pending on SDW Cases

• DI 12005.000, Reconsiderations - Initial Claims

• DI 12025.000, Reconsideration - Postentitlement (PE)

• DI 12026.000, Reconsideration - Disability Hearing for a Medical Cessation/Adverse Medical Reopening Determination - Title II and Title XVI

• DI 12027.000, Statutory Benefit Continuation (SBC)

• SI 04010.020, SSI Appeals Considerations

• SI 04020.020, Requests for SSI Reconsideration

• DI 81010.150, Processing Claims Appeals of Medical Decisions in Electronic Disability Collect System (EDCS)