What Does a Claims Representative Do on a Social Security Disability Claim?

After you apply for Social Security disability, the claims representative will interview you and begin processing your disability claim. Here are the steps a Social Security claims representative performs for each claim.

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If you apply for Social Security disability benefits, your first contact with the Social Security Administration (SSA) will likely be with a claims representative at your local Social Security field office. (Note that Social Security also calls disability lawyers "representatives.")

Your Social Security claims representative is a local claims specialist charged with the first steps involved in processing your disability claim. Your claims representative will also serve as your primary point of contact while the SSA processes your disability application.

If you apply for disability by phone or in person, the Social Security claims representative will take your information and fill out the disability application with you. Then, no matter how you apply for benefits, the Social Security claims representative will conduct your initial interview and do the initial processing on your claim before sending it to a disability claims examiner.

Initial Social Security Disability Claims Interviews

A Social Security claims representative performs the initial interviews with Social Security disability applicants. Oftentimes the interview is just a short phone call where the claims rep asks you a few questions. During the interview, the claims representative will collect information about you and your medical history, including:

  • names and contact information of your doctors and other medical providers
  • your work history, and whether you're currently working
  • details about your medical condition, and
  • your educational background.

The Social Security claims representative might interview you by phone or in person (when you go into an office to fill out an application). The claims representative will use the information from your interview to go through the steps below, to find out whether you're eligible for benefits.

Here are the steps the claims representative will perform for each claim.

1) Claims Specialist Begins Non-Medical Eligibility Check

The Social Security claims representative will begin processing your application by checking your technical eligibility for benefits. The claims representative will determine if you're eligible to participate in either the Social Security disability insurance (SSDI) program or the Supplemental Security Income (SSI) program.

SSDI eligibility depends on how many years you've worked at a job paying Social Security taxes (FICA or self-employment taxes). To be eligible for SSDI, you must be a disabled worker, and if you're still working, your income must be below a set amount.

SSI eligibility depends on the amount of income and assets you have. SSI disability benefits are for those who haven't worked long enough to qualify for SSDI benefits, low-income workers, and those who've never worked.

If you don't have enough work credits for SSDI, or your income or assets are too high for SSI, your claims representative will issue a technical denial on your claim.

2) Claims Representative Conducts a Substantial Work Test

The claims representative will check to see whether you've been working in the last month. If you've been able to work, the claims specialist will look at your earnings to determine if you're doing a substantial amount of work, which would disqualify you for disability benefits.

Social Security considers making more than $1,350 per month (in 2022) to be "substantial gainful activity" (SGA). (But you can earn up to $2,260 per month if you're blind.) If you make more than the SGA limit, you won't qualify for SSDI or SSI.

3) Claims Representative Submits Your Claim to DDS

The Social Security claims specialist will determine whether or not you're eligible to participate in SSDI and/or SSI under all of these technical (non-medical) screening tests. If you meet the non-medical requirements, the claims examiner will send your disability claim to your state disability agency (usually called Disability Determination Services, or DDS).

The DDS claims examiner will make the medical disability determination and decide your claim. The disability claims examiner at DDS usually works with a medical consultant, like a doctor or psychologist to determine whether you're disabled. The medical determination process can take several months to complete. But your local claims representative can expedite your claim under certain circumstances.

If your claim is denied because DDS determined that you weren't medically disabled, you'll receive a denial letter, and you can appeal the decision.

4) Local Claims Representative Does Final Eligibility Check

Once the state disability agency has made a medical decision on your claim, DDS will return it to your local Social Security office. If the DDS has found you medically eligible for disability, the claims representative will again check your non-medical eligibility for SSDI and/or SSI. The claims representative will recheck the following:

  • whether you've worked and performed SGA since you applied for SSDI disability benefits, and
  • whether you still qualify financially for SSI by meeting the income and asset tests (if applicable).

(Remember, it could be months between the time you apply for disability and when you receive a decision on your claim. A lot can change during that time.)

How Can a Claims Representative Help You With Your Claim?

Social Security claims reps can let you know where your claims is at while you're waiting for a decision, expedite your claim (in some situations), and grant advance payments (to some SSI recipients with severe disabilities).

Claims Representative Can Update You on Your Claim Status

While your Social Security disability claim is being processed, your local claims representative will serve as your point of contact with the SSA. You can contact your claims representative to check the status of your disability claim. You can also contact your local claims specialist when you need to share additional information (such as new test results or a new doctor's contact information).

Claims Representative Might Expedite Your Claim

Under certain circumstances, Social Security can expedite your disability claim—meaning DDS will process your claim faster. The claims representative can expedite your claim if one of the following is true:

The Social Security claims representative would 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. Learn more about when Social Security will expedite your claim.

Claims Representative Can Grant Advance Disability Payments

If you applied for SSI and you have a serious medical condition, you might be able to get disability payments before your claim is fully processed. If it's clear from your application (or the claims representative's observations) that you have a medical condition that's severe enough to qualify, the claims representative can grant you "presumptive disability" payments.

Many serious conditions can qualify you for presumptive SSI disability payments, including:

Likewise, if you bring in a child with Down syndrome or low birth weight, presumptive disability payments should be available. Learn more about qualifying for presumptive disability payments (SSI applicants only).

What Should You Do If Your Claims Representative Denied Your Claim?

You'll likely be disappointed if you receive a denial letter from Social Security. But don't despair. You have the right to appeal if your disability claim has been denied.

Most disability claims are initially denied, and most people who eventually get disability win their claims on appeal. Your chance of winning improves if you hire a disability lawyer to help with your appeal.

Your local claims representative can provide information about how to appeal your claim, and you'll also find that information in your denial letter. Pay particular attention to the deadlines for appeal. You have 60 days after your denial to request an appeal.

Learn more about what to do if your Social Security disability claim is denied.

Updated September 23, 2022

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