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Who Makes the Decision in my Case?

A Social Security disability decision is made in two parts: one) there is the medical portion to your claim which requires that the Social Security Administration (SSA) determine whether you meet the medical criteria such that a finding of “disabled” under Social Security’s rules can be made and two) there are the non-medical aspects of the claim which can involve one of a number of issues.

Upon the taking of an initial application, one’s local Social Security office is tasked with making one of a number of determinations: some of which come at the initial part of the claim and some of which may need to be made following the issuance of a fully favorable decision. Likewise, the District Office is also tasked with the job of obtaining the initial application material, including a Social Security medical authorization so that the material can be passed along to the agency responsible for determining whether one is “disabled” under Social Security’s rules.

For one, a disability claimant’s local office (referred to as their District Office) will look to see whether one has obtained sufficient quarters of coverage in order to qualify for Social Security disability insurance benefits (SSDI). Assuming one has not worked sufficiently to qualify for a potential SSDI check, the District Office will issue an initial denial notifying the claimant that there are earnings requirements associated with obtaining an SSDI check and will notify the disability claimant if the work reflected in their earnings record has come up short. Likewise, the District Office is tasked with obtaining information regarding the income and assets of a claimant who is seeking Supplemental Security Income (SSI) benefits so as to determine whether in fact the individual claimant has too much in the way of resources to qualify for an SSI check. Assuming this to be the case, the District Office will issue a determination that denies the claimant on their SSI claim based on their failure to meet the income/asset limitations set forth under the regulations that govern SSI.

Assuming there remains a basis for either SSI or SSDI (and that one has not been preliminarily disqualified by the District Office for both), then the claim will be transferred to the State agency office that has been tasked with making a medical determination in the case. For claims that are brought in the Commonwealth of Massachusetts, the disability claim will be transferred to the Massachusetts Rehabilitation Commission and to one of the Disability Determination Services (DDS) offices (located in Boston, MA or Worcester, MA). In Maine, the case would be transferred to the one DDS office located in Augusta, Maine, while cases out of New Hampshire, will be transferred to the state agency office (also termed DDS) located out of Concord, NH.

The DDS offices are responsible for obtaining the medical records and necessary medical documentation so as to determine, ultimately, whether and to what extent the medical conditions being claimed have remained severe and disabling under Social Security’s rules. They are required to ensure that the available medical documentation is obtained from one’s various medical practitioners, and for setting up appointments with one or more of their own doctors in the event there remains insufficient treatment or documentation of one of the claimant’s medical conditions that the claimant is suggesting has been impacting their ability to function. They are likewise responsible for coordinating a review and determination by one of the doctors contracted to review the available medical records/evidence as to whether one or more of the medical listings of impairment have been met, and likewise the extent to which these conditions have remained severe and disabling in terms of the claimant’s ability to undertake functions that are necessary in a competitive work environment. Ultimately, the DDS office is responsible for not only coming up with a decision as to whether the medical conditions have met the medical criteria necessary for a finding of “disabled,” but also evaluating the vocational background of the individual and their ability to transfer either to work they have performed in the past or which exists in the national economy (or various regional economies) in significant numbers. The DDS adjudicator remains responsible for reviewing the extent to which one of the medical-vocational guideline rules (called Grid Rules) may call for either a finding of disabled or not disabled.

Following the medical/vocational determination by DDS, and assuming a favorable medical determination has been recommended, the case will be send the claim back to a claimant’s District Office (assuming it has not been picked up by Quality Review) for the issuance of the decision itself. Prior to issuing a decision on the claim, it may be necessary for the local office to take into account other factors (such as whether the individual has continued to work or returned to work in the interim) before rendering a decision.