What Is the Job of a Social Security Disability Examiner?

To receive Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI), you must meet both the medical and nonmedical requirements for at least one disability program. After an employee with the Social Security Administration concludes that you satisfy the legal and financial eligibility criteria for SSDI or SSI, your case file is reviewed by a disability claims examiner who makes the initial determination about whether you're medically disabled.

Claims examiners play an important role in the disability determination process. But because they usually work behind the scenes—as opposed to administrative law judges, who are often seen in person—few applicants are aware of what exactly the claims examiners do. Knowing what role the examiners perform in reviewing your claim can give you an advantage if you need to appeal a denial or request expedited processing.

Where Do Disability Examiners Work?

Most disability claims examiners work at state agencies rather than at a federal Social Security office. These state agencies are often referred to as Disability Determination Services (DDS), but might also be called the Disability Determination Bureau or Bureau of Disability Adjudication, depending on your state.

Each state has at least one DDS facility, and larger states with decentralized systems have several DDS offices. A state DDS office may have almost one hundred disability examiners. Each examiner may be assigned a case load consisting of dozens of disability applications, and each application has procedural requirements that must be completed ("worked up") before the examiner can make a decision on the claim. Below are some of the typical steps involved when an examiner works up a disability claim.

Disability Claims Examiners Gather Medical Evidence

The primary function of the Social Security disability examiner is to decide if your medical condition—whether physical or mental—is severe enough to prevent you from working full-time in any type of job. The examiner is also responsible for maintaining contact with you (or your representative) during the decision making process. For example, the examiner may call you or send you a questionnaire asking you to fill out more information about your work history or medical providers.

What Kind of Medical Information Does the Examiner Collect?

The claims examiner will want to see medical records covering the entire time period since you became disabled, including information about all the medical treatments and therapies you've undergone since your alleged onset date. You'll need to submit contact information for all the doctors and clinics you've visited for your medical impairments and sign a release form allowing the claims examiner to obtain records based on the information you provided.

The exact type of medical information the claims examiner will be on the lookout for varies depending on your conditions. Examples of common documentation the examiner will want to see include:

• results from lab tests, such as blood panels
• medical imaging, like X-rays, CT scans, or MRIs
• surgical reports, including biopsies
• physical examinations or occupational therapy reports
• mental status evaluations
• medication lists, and
• clinical progress notes that your doctor takes after each visit.

In addition to your doctors or therapists, the examiner might also contact non-medical sources to gather information about your ability to work, including your previous employers, teachers, or vocational rehabilitation counselors. Third parties, such as friends or family members that you've listed on your application as helpful contacts, may be asked for information about any limitations in your activities of daily living if they've witnessed these limitations first-hand.

Doctor Statements Can Help the Disability Examiner Decide

Getting a supportive medical statement from your treating physician or psychologist can be very helpful to the examiner reviewing your claim. Social Security cares about the opinions of medical providers whom you've seen regularly and have special insight into your conditions. Statements that go into specific details about how and why your impairments prevent you from working are especially valuable, provided they're backed up by the rest of your medical evidence.

Disability Examiners May Send You to See a Doctor

Sometimes, even after reading your medical records, the disability examiner might find that they still don't have enough information to make a legally sufficient decision on your claim. In these cases, the examiner can schedule you for a consultative examination (paid for by Social Security) with an outside doctor or psychologist. You're more likely to get scheduled for a consultative exam if you haven't seen a doctor recently or your medical records are very light.

Disability Examiners Work With Medical Consultants

Because disability examiners aren't medical professionals, they need help in interpreting medical records. So, once the examiner has obtained all the medical records available for a claimant, they will ask a medical consultant to review these records and provide an opinion on your residual functional capacity, or RFC.

Your RFC is a set of restrictions on what you can and can't do, physically and mentally, in a work environment. The medical consultant is supposed to look at your records for evidence of functional limitations and make an educated assessment of what restrictions to include in your RFC. For example, if you have an MRI showing degenerative disc disease in your upper back, the medical consultant may reasonably conclude that you should avoid jobs where you'd have to lift and carry heavy objects. Such strength-related restrictions in your RFC are also called "exertional limitations."

Ideally the medical consultant is supposed to fully develop your RFC, but in reality, this doesn't always happen. The disability examiner should at least get the consultant's opinion about the nature and severity of your medical conditions and the kind of additional evidence needed to decide your claim. In most cases, the examiner will complete a medical decisional write-up and ask the medical consultant to review and sign it if they agree with the assessment.

Examiners Make the Initial Disability Determination

Once the disability examiner is satisfied that they have all available and relevant information to decide your claim, they will use a combination of your medical records and your vocational background to decide whether you're disabled in a process called the five-step sequential evaluation. The examiner will apply the information in your file to answer the following questions:

1. Are you currently working and, if so, are your earnings above or below the level considered substantial gainful activity (SGA)?
2. If you aren't earning SGA, is your medical condition severe enough to have more than a "minimal impact" on your daily activities?
3. If you have a severe condition, does that condition automatically qualify as disabling under the Listing of Impairments?
4. If your condition doesn't meet or equal a listing, does it keep you from performing your past relevant work?
5. If you can't do your past jobs, can you be expected to do any other type of work?

In order to answer the last question, the claims examiner will consider a combination of factors, including your residual functional capacity, age, education, work experience, and transferable skills. Because of the special medical-vocational rules for applicants over 50, it's generally easier for older claimants to get approved for SSDI or SSI.

Advice from a Disability Examiner

As "on the ground" employees who are the first people to substantively review applications for Social Security benefits, claims examiners can provide insider knowledge about the disability determination process. Below are some tips from a former claims examiner about what you can do to increase your chances of success.

Visit the Doctor Regularly

Since your Social Security disability claim will be evaluated mainly on the basis of your medical records, the best advice is to get regular, ongoing treatment for your conditions in the months (preferably years) before you apply. If you aren't seeing a doctor regularly, claims examiners might not think that your conditions are that serious, so try to see a doctor at least once every two or three months. Should you lose your health insurance, consider seeking out free clinics or county health departments to get ongoing medical treatment for your impairment.

Don't Wait to File for Benefits

Disability claims can take a long time to process, and many applicants experience financial hardship simply because they had no idea how long the process would be. Claimants may realize too late that they should have filed an application much sooner. This is especially important for people filing for SSDI because you don't want your disability insurance to expire. And for SSI, it's important to file as soon as you can because Social Security won't pay past due benefits before your application date.

Get a Lawyer to Appeal a Denial

On average, claims examiners approve only about 35% of initial applications, so the majority of claimants will need to appeal—sometimes several times—before they're awarded benefits. Having an experienced Social Security attorney who can help you appeal (and represent you at a disability hearing, if necessary) can increase your chances of getting approved at each stage.

Get Help With the Disability Application If You Need it

If you think you may have problems doing the paperwork for your disability claim, you should get assistance in filling out the application. Too many people who apply for disability benefits don't fill out the forms adequately or fail to submit the appeals requests on time—and missed deadlines will result in a denial. You can get help from a lawyer, nonattorney advocate, family member, or field representative at your local Social Security field office.

Understand the Forms You Need Your Doctor to Fill Out

Claims examiners value the opinions of your regular medical providers, so if your doctor is willing to fill out an RFC form or write a letter to Social Security discussing why your condition keeps you from working, it can influence the examiner's decision. You can print out a blank physical or mental RFC form and bring it to your doctor's office at your next appointment. Ask them to complete the form with reference to specific medical findings in your record. You (or your representative) can then submit the completed form to the DDS office handling your claim.

Take Your Prescribed Medications

Make sure that you follow your doctor's advice, including taking your medicine as prescribed. If the claims examiner reviewing your records finds that you aren't engaging in recommended treatment, they can deny your claim for "failure to comply." This is because the examiner doesn't know whether the recommended treatment would be effective enough to let you return to work (or comes with side effects that could keep you from working) if you don't take it.

Don't Call the Social Security Toll-Free Number for Status Updates

Not only are there long wait times when you call Social Security's national number, but you might not get the most up-to-date information. Instead, you should call your local DDS or the Social Security field office where you first filed your claim. (If and when your claim reaches the hearing level, you should then contact the Office of Hearings Operations for status updates.)

Be Kind to the Claims Examiner

The disability process can be anxiety-provoking and frustrating at times, but maintaining good relations with the people working on your case is important. Even if your case has been mishandled or you've had to endure a long wait to hear back about the status of your claim, it never pays to be rude or lose your temper. Keep in mind that employees at DDS usually have many cases to work on and hundreds of phone calls to deal with each week, and they'll be less inclined to go out of their way for unpleasant claimants.

More Information about the Disability Determination Process

If you've already received an initial denial of benefits, you'll likely want to appeal the denial by requesting reconsideration. During reconsideration, another claims examiner at DDS—not the same one who denied you the first time—will review your file again and determine whether the initial denial was correct. You have 60 days from the date you received your initial denial to request reconsideration, or you'll need to start over with a new application.

Reconsideration decisions are often issued a bit faster than initial decisions, but few claimants (around 15%) get awarded at this stage. If you're denied again, you can ask for a hearing with an administrative law judge. The hearing level is where most claimants who are ultimately awarded benefits are approved. Your odds of winning are even greater if you have an attorney, so it's a smart move to hire a representative at this time if you haven't already.