What is the Claims Process?

In Massachusetts, the process for assessing Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI) applicants is handled by the Disability Determination Services (DSS). The program is funded 100 percent by the Social Security Administration (SSA) and administered by the Massachusetts Rehabilitation Commission (MRC).

That’s a lot of acronyms, and at Jeffrey Glassman Injury Lawyers, our Boston disability attorneys know bureaucracy of the claims process can seem daunting. Our legal team not only knows how the system works, we have proven success in helping clients navigate it.

Understanding the claims process helps to relieve some of the anxiety and also keeps expectations realistic, which in turn helps us to better serve our clients.

In general, claims will follow this track:

• Application filed
• Initial review
• Reconsideration
• Hearing before an Administrative Law Judge (ALJ)
• Appeal to the Social Security Appeals Council
• Federal court appeal

There are some situations in which claims can be fast-tracked, and there are also circumstances that might delay findings. Your attorney can inform you if you may qualify for an expedited claim.

Once benefits are awarded, there will be periodic Continued Disability Reviews, which will determine whether an individual should continue receiving benefits. If a person’s benefits are revoked, they can appeal that decision by requesting a Disability Hearing.

The Massachusetts DDS is one of three branches of the state agency, the MRC, which is responsible for administrating the:

• Vocational Rehabilitation Division – Works to assist those with disabling conditions in finding or returning to work.
• Community Living Division – Provides specialized services to those with brain injuries, disabled persons who have been abused and disabled persons seeking assistance with independent living, technology training, assistive technology and life skills.
• Disability Determination Services (DDS) – Funded by the federal SSA, the agency determines the initial and continued eligibility for those applying for SSI and SSDI. There are also special outreach efforts made to persons with HIV and those living in homeless shelters.

The DDS, in addition to claims reviewers, also employs more than 70 consultants with medical and psychological expertise in house. An additional 300 or so across the state also sometimes assist with claim eligibility assessments.

Applications for both SSI and SSDI are initially filed at one of the 33 local field offices in Massachusetts for the Social Security Administration. Workers in those field offices will conduct a cursory review to determine eligibility.

• For SSDI, local field office workers will examine whether claimant has enough “work credits” earned by working in covered employment.
• For SSI, the agency will examine whether claimant qualifies based on income and asset levels.

If the claimant meets these criteria, the claim is then forwarded to one of the state’s two DDS offices, either in Boston or Worcester. This is where it is assigned to a disability examiner who will more closely scrutinize medical records and other evidence to determine medical eligibility. A person must meet the strict definition of “disabled,” which for both is an assertion of being unable to work or engage in functional activities for at least a year.

In some of the more complex cases, the DDS will seek the opinion of an expert consultant. The expert is given the option to request an independent exam to obtain additional information. DDS examiner will also make sure all available relevant information regarding claimant’s work history, job skills and exertional levels is provided.

Once all that information is gathered, the examiner will collaborate with a medical doctor or psychologist on staff to make a determination, using a checklist evaluation.

The Evaluation Process is conducted with a questionnaire that poses a series of questions. The DDS and staff expert provide answers based on the facts. By requiring examiners to use a standard checklist, known as the Sequential Evaluation Process, the SSA hopes to ensure consistency and eliminate examiner biases.

Once a medical determination is made, the claim will either be approved, and then sent to the SSA for payment, or denied and sent to the SSA for appeal.

This whole process takes three to six months.

Claimants can request a reconsideration from the DDS, and though the outcome rarely changes at this level.

Claimants who disagree with the DDS decision can request a hearing before an administrative law judge (ALJ). The wait time for an administrative law judge is about 12 months.

ALJs are appointed by and work for the federal government at local Offices of Disability Adjudication and Review (ODAR). There are three ODAR offices in Massachusetts – Boston, Springfield and Lawrence.

The ALJ will review the cumulative file prior the hearing, and will examine the reasons why it was initially denied. Then, the applicant and the medical or vocational expert will be questioned by the ALJ, who will also take into consideration any new evidence.

Based on all this, the ALJ will make a finding.

When a claim is denied by an ALJ, the applicant can request a review by the SSA Appeals Council. The council can either agree or decline. If they decline or agree and still reject the claim, the person still has one more option: A federal appeal.

A federal appeal is handled in a federal courtroom before a sitting judge.