1. Social Security Disability
Questions to open with: How many people here think everyone is denied the first time they apply for benefits? Is there a “quota” on how many claims to approve or deny?
How Claims are Evaluated
Shiwanda Leonard, Professional Relations Officer

2. Disability Determination Services
The State Agency that makes the medical determinations for Social Security Disability

3. Definition of DISABILITY
The inability to engage in any substantial gainful activity as a result of any medically determinable physical or mental impairment(s)
Which has lasted or can be expected to
last for a continuous
period of not less than
12 months
Or result in death

4. Disability in Children
A child under age 18 if he or she has a medically determinable physical or mental impairment or combination of impairments that causes marked and severe functional limitations
Which has lasted or can be expected to last for a continuous period of not less than 12 months
Or result in death
Point out the difference from adult: Looking at child’s function vs. ability to perform SGA/work
Title 16/SSI: Administrative requirements based on parent’s income and resources

5. Substantial Gainful Activity
$1, for non-blind individuals
$2, for blind individuals
If you are working and your earnings average more than $1, per month, you generally cannot be considered disabled.

6. How Do You Apply? In person at one of the 37
local Social Security Offices
By phone at
On the Internet at

7. What can applicants do to expedite the process?
Provide complete information about treating sources & include the following:
Names
Addresses
Phone Numbers
List of Medications
Submit any medical records that they may already have
Gather all information before attempting to complete application
Refer to past bills (name, address, dates of service)

8. Fast-Track Quick Disability Determinations (QDD)
Compassionate Allowances (CAL)
QDD - process uses a computer-based predictive model to screen initial applications to identify cases where a favorable disability determination is highly likely and medical evidence is readily available
CAL - a way of quickly identifying diseases and other medical conditions that invariably qualify under the Listing of Impairments based on minimal objective medical information

9. What’s Next?
Once the application is completed, the local Social Security Office will determine if the basic administrative requirements are met.
Title II {Insured Status}
Title XVI {Income & Resources}
Title 2 – SSDI – Social Security Disability Insurance is a social insurance program that workers and employers pay for with their Social Security taxes. Eligibility based on work history.
Title 16 – SSI – Supplemental Security Income – SSI benefits are paid on the basis of financial need. There is no qualifying work requirement, but there is a limit on the amount of income and resources that a person can have and be eligible.
From a medical standpoint, the programs are treated identically.

10. Where Does the Claim Go? NC Disability Determination Services
Is located in Raleigh, NC

11. What the DDS does:
Obtains medical evidence from doctors, hospitals, clinics and institutions where treated
Reviews vocational information
Makes medical disability determination via a team consisting of a Disability Analyst and Licensed Physician and/or Psychologist
Write to the sources listed on the application.
Obtain work history.

12. Agency Statistics
760+ employees when fully staffed (including 50+ doctors, psychologists, and SLPs)
7th largest of 52 DDS’ based on volume of claims processed
131,930 cases closed out of DDS in FY2018
36,305 Medicaid cases received in FY2018
Currently receiving approximately 2,730 federal cases per week

13. What Should Doctors Send?
What is the impairment(s)?
History of the condition
When did the impairment begin?
How does it limit activities/functioning?
Type(s) of treatment and responses
Specific physical findings
Results of medical testing (e.g. lab work, x-ray, etc)

14. How to Send Records Options: Fax – 1-866-885-3235 (secure & toll free)
SSA offers a range of electronic options for submitting medical records to DDS
Options:
Fax – (secure & toll free)
Web – Electronic Records Express (ERE)
Most federal claims processed at the DDS have electronic claim files. If paper, the system will print out the documents.

15. Keep In Mind:
The treating physician is not asked to decide if the person is disabled.
It is an administrative decision made by DDS.
If more information is needed, a consultative examination will be purchased.
The TP is not asked to decide – their definition of disability maybe different than SSAs

16. Consultative Examination
An examination purchased at the expense of Social Security to secure information about the person’s condition.
About 1,600 Consultative Exams ordered per week in fiscal year 2018.
We try to schedule as early and as close to an individual’s location as possible.

17. SEQUENTIAL EVALUATION A Five Step Process
Is the person engaging in SGA?
Is the person’s impairment(s) severe?
Does the person’s impairment(s) meet or equal a listing?
Does the person’s impairment preclude the ability to perform their past work?
Does the person’s impairment(s) prevent them from performing another type of work?
BETWEEN STEP 3 and 4 Discuss RFC/MRFC and providing limitations which are utilized in steps 4 and 5.
At Step 5 we look at the limitations they were given, the age of the individual, past education, and the skill level of their past work.

18. Listing of Impairments

19. Onset
Established Onset Date (EOD) – the date DDS determines an impairment meets the definition of disability and the claimant is no longer working
Title XVI – benefits start with filing date or EOD if established as a later date
Title II – there is a 5 month waiting period from the EOD before benefits begin
Death in the Waiting Period
EOD (established onset date) & AOD (alleged onset date) can be different
Title XVI – earliest payment is related to your filing date
Title II – can be retroactive (up to 1 year from filing date)

20. Medicaid Vs. Medicare
Medicaid (State) – If a claimant is found disabled under Title XVI (SSI) they often times qualify for Medicaid but must file at their local DSS.
Medicare (Federal) – If a claimant is found disabled under Title II (Insured), they will get Medicare coverage automatically after they have received disability benefits for two years.

21. Four Levels of Appeals
Reconsideration – NC DDS (appeal within 60 days)
Hearing by ALJ (ODAR) – face to face hearing within 75 miles of home or video hearing, attorney/representative can explain your case, can have witnesses
Review by Appeals Council
Federal Court Review
Very important that all appeals filed timely. An individual has 60 days to file an appeal from the date of the decision.

22. Average Monthly Payment
TITLE II {SSDI} $1,165.00
Title XVI {SSI} $735.00
Title II - the amount of the benefit is based on an individual’s earnings.
Title XVI – The monthly payment is a fixed amount, although some states supplement the Federal payment (NOT NC).

23. Questions? Shiwanda Leonard Professional Relations Supervisor
ext 2779
Questions to close with: So now do you still think everyone is denied the first time they apply for benefits? So now do you still think there is a “quota” on how many claims to approve or deny?
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