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

Social Security claims representatives performs interviews with Social Security disability claimants and processes the claim.

Social Security claims representatives take information from disability applicants about their claim and then do the initial processing on the claims before sending them to a disability claims examiner. Here are the steps they perform for each claim.

Interview. A Social Security claims representative performs the initial interviews with Social Security disability claimants. During the interview, the claims representative will collect information about your doctors and other medical providers, your work history, your medical condition, and your educational background. The claim representative may conduct the interview by phone or in person (when you go into an office to fill out an application).

Preliminary eligibility check. This includes checking your eligibility for either Social Security disability insurance (SSDI) or Supplemental Security Income (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 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 $1,180 per month (in 2018) to be substantial gainful activity (SGA).

    Submission to DDS. If you are found eligible under all of these non-medical screening tests, the claims representative sends your disability claim to your state disability agency (usually called Disability Determination Services, or DDS) for a medical disability determination. A disability claims examiner at DDS then handles the disability determination, usually with the help of a medical consultant (doctor). 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 benefits, 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 should 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 claims representative to check the status of your disability claim or to provide additional information (such as new test results or a new doctor's contact information).

    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 found medically eligible for disability, the claims representative will again check to see whether you have worked and performed SGA since you applied for disability benefits and whether you still qualify financially for SSI by meeting the income and asset tests. (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.

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