What Does a Social Security Claims Representative Do on a Disability Claim?
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A Social Security claims representative performs the initial interviews with potential Social Security disability claimants. The claim representative may conduct these interviews by phone or in person. Once the Social Security claims representative has completed the interview, in which information on your medical sources, work history, and education background have been collected, the claims representative does initial processing on your claim.
Preliminary eligibility check. This includes checking your eligibility for either Social Security Disability Insurance (SSDI) or SSI. SSDI eligibility depends on the number of years you've worked at a job paying FICA taxes. SSI eligibility depends on the amount of income and assets you have.
Substantial work test. The claims representative will also perform a check to see whether you've been working, and if so, whether you've been doing a substantial amount of work, which would disqualify you for disability benefits. Social Security considers making over $1,090 per month (in 2015) to be substantial gainful activity (SGA).
Submission to DDS. If you are found eligible under all of these tests, the claims representative sends your disability claim to your state disability agency (Disability Determination Services) for a medical disability determination. The claims representative may expedite your claim under certain circumstances.
Expedited claims. If you have a medical condition on the compassionate allowances list (CAL), you have a terminal illness (TERI), or your case qualifies for quick disability determination (QDD, the claims representative should route your application to DDS in a way that alerts DDS that your claim qualifies as a CAL, TERI, or QDD case, and your claim will be expedited. For more information, see our section on expedited disability benefits.
Advance disability payments. If you applied for SSI and the claims representative sees from your application or from personal observation that you have a serious medical condition that qualifies for advance payment of disability, the claims representative can grant you presumptive disability payments. For instance, if you have AIDS, a double amputation, total blindness or deafness, or are confined to a wheelchair, or you bring in a child with Down syndrome or low birth weight, presumptive disability payments may be available. See our article on presumptive disability for more information (SSI applicants only).
Status checks. While your Social Security disability claim is being processed, you may contact your claim's representative to provide additional information or check the status of your disability claim.
Final eligibility check. Once the state disability agency has made a medical decision on your claim, the claim will be returned to your local Social Security office. If your claim has been medically eligible for disability, the claims representative will again check whether you have worked and performed SGA since you applied for disability benefits and whether you still qualify financially for SSI. (Remember, it may be months in between the time you apply for disability and when you receive a decision.)
If your claim was denied because you were found not medically disabled, you will be sent a denial letter, and you can appeal the decision.