A Brief Overview of the Disability

Determination Process

Journey of a Claim

• Claims are filed at the local Social Security offices (in person, by phone or online)

• The local SSA office sends the claim to the Bureau of Disability Determinations (BDD)

• Once it is received in BDD, it is assigned to an adjudicator, who reviews the application and any other information provided

Journey Continued: Adjudicator Duties

• The adjudicator determines which are the relevant sources of information

• The medical evidence of record (MER) is requested by the adjudicator

• The adjudicative team (adjudicators, medical and vocational experts, etc.) analyzes all available evidence

• The adjudicative team determines the claimants’ ability to do work related activities and eligibility for SSA disability benefits

5 Steps of Sequential Evaluation

• Engaging in Substantial Gainful Activity (SGA)commonly known as work?

• Does the person have a severe impairment?• Does the impairment meet or equal the

listings?• Does this prevent past work?• Does this prevent other work?

The Role of the Health Care Professional

• Hospitals, doctors, psychologists, case workers and other treating sources are sent questionnaires or requests for medical evidence to help document the severity of the alleged impairment

• These sources are asked to send the relevant information that they have in a timely manner

• The adjudicative team does not see the claimant and must rely on the medical records for a thorough assessment of the claimants’ condition(s)

What information are we looking for?

• Dates of treatment• Diagnosis and capability statement• Mental health status• Office notes• IP and ER stays• Therapy notes• Any available testing results• Description of functional limitations due to

symptoms

What criteria will Social Security use to determine if a person with a Brain Injury

is Disabled?• Brain injury or traumatic brain injury is

described under Cerebral Trauma in the Social Security Blue Book of Listings

• It is evaluated under the body systems the brain injury has affected

• The impairment may be evaluated under physical criteria or mental criteria or both

Recovery period• The rate and extent of recovery can be highly variable and

the long-term outcome may be difficult to predict in the first few months post-injury

• In some cases, evidence of a profound neurological impairment is sufficient for a finding of disability without waiting for a recovery period

• If not, we will defer adjudication until we have evidence regarding the impairment(s) at least 3 months post-injury

• At this point, if a finding of disability is still not possible, we will defer adjudication until 6 months post-injury

Physical Criteria for a Brain Injury

• Seizures—If the cerebral trauma has resulted in grand mal or petit mal seizures, the severity of the those seizures will be evaluated for disability

• Speech—If the injury results in sensory or motor aphasia which is affecting speech or communication, the severity of the speech loss will be evaluated

• Motor function—If the injury results in motor dysfunction of the extremities, the extent to which it affects the person’s movements or ability to stand and walk will be evaluated

Mental Criteria for a Brain Injury

• Loss of specific cognitive abilities or affective changes with at least one of the following:– Disorientation to time and place– Memory impairment– Perceptual or thinking disturbances– Change in personality– Disturbance in mood– Emotional lability and impairment in impulse control– Loss of measured intellectual ability of at least 15 I.Q.

points

What evidence will Social Security need to document the impairment?

• Medical records from the time of the TBI and follow-up services

• Head injury rehabilitation records discussing cognition, impulse control, basic mental functioning, insight, degree of supervision needed

• Mental health consults while hospitalized or in rehabilitation/long-term care

• Neuropsychological evaluations• Vocational rehabilitation records• Statements from employers about changes in functioning

after the Brain Injury

Mental impairments and functioning

• Residual mental impairments after a brain injury must significantly affect a person’s functioning to meet disability requirements

• Significant restrictions in activities of daily living, social functioning or in maintaining concentration

• Repeated episodes of decompensation• More than minimal limitations in the ability to do basic work

activities for at least 2 years due to the chronic organic mental disorder

• Inability to function outside a highly supportive living arrangement

Information from 3rd parties

• Information regarding the claimant’s can also come from a 3rd party source, such as a family member, friend, social worker, case worker, etc.

• The 3rd party source should be familiar with the claimant’s daily activities and it is helpful if they are familiar with claimants functioning prior to the injury as well

What can you do to help the disability decision process?

• Medical personnel can submit all requested records and/or information as soon as they receive the request from Social Security

• Social workers, case workers, case managers can be advocates for their clients by helping them with them apply for benefits, encouraging their clients to cooperate with the disability process and providing functional information about their client

• Family and friends can help fill out disability forms and provide 3rd party information about the person’s functioning

Submitting Records/Evidence

• ERE—Electronic Records Express

• Fax Gateway

• Mail

What is ERE?

• ERE is an initiative to offer electronic options for submitting records related to disability claims via a secure website

• Records that are submitted via ERE are automatically associated with the correct disability claim fold

http://eme.ssa.gov

How secure is the ERE website?

• The website has restricted access

• Only authorized users can access the secure website by using their assigned user ID and password

• Data transmission is protected by the industry encryption standard for providing network security

Useful Resources• Resources for 3rd parties:

www.ssa.gov/thirdparties.htm

• Social Security Disability:www.socialsecurity.gov/disability

• Listing of Impairments Adults:www.ssa.gov Search Blue Book, then click on Disability Evaluation Under Social Security

Ohio Disability Determination Services Professional Relations Officers

Rebecca Billingslea614-438-1312800-282-2654, ext. 1312Rebecca.Billingslea@ssa.gov

Heidi Block614-438-1967800-282-2654, ext. 1967Heidi.Block@ssa.gov

Tammy Polter614-438-1661800-282-2654, ext. 1661Tammy.Polter@ssa.gov

Raymond Rhone614-438-1904800-282-2654, ext. 1904Raymond.Rhone@ssa.gov

Ohio Disability Determination Services Professional Relations Officers

Mike DeNoble614-438-1381800-282-2654, ext. 1381Michael.Denoble@ssa.gov

Scott Maietta614-438-1700800-282-2654, ext. 1700Scott.Maietta@ssa.gov

Michelle Rinehart614-438-1685800-282-2654, ext. 1685Michelle.Rinehart@ssa.gov

Orlando Rodriguez614-438-1354800-282-2654, ext. 1354Orlando.Rodriguez@ssa.gov

Thank you. Questions?