# Process Reengineering Program; Disability Reengineering Project Proposal

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URL: https://www.frixlaw.com/law-library/documents/fr%3A94-8265

## Record

- **Collection:** Federal Register
- **Document type:** Uncategorized Document
- **Published:** April 15, 1994

## Text

SUMMARY: The Disability Process Reengineering Team of the Social
Security Administration (SSA) announces a proposal to redesign the
disability claims process for Social Security Disability Insurance and
Supplemental Security Income (SSI) Disability and Blindness benefits.
This notice contains the Proposal (as well as background information)
of the Disability Process Reengineering Team (composed of SSA and State
Disability Determination Service (DDS) employees). The aim of the
proposal is to achieve dramatic improvements in customer service to the
public. Accordingly, we seek comments on the proposal to ensure that it
meets the needs of the public. The comments will be weighed in the
Agency's subsequent decisions on implementation.

DATES: To be sure that your comments are considered we must receive
them no later than May 27, 1994.

ADDRESSES: Submit your comments as follows: (1) Mail them to the Social
Security Administration, PO Box 17052, Baltimore, MD 21235, or (2)
telefax them to (410) 966-9884, or (3) deliver them to 4-N-3 Operations
Building, 6401 Security Boulevard, Baltimore, MD 21235, between 8 a.m.
and 4:30 p.m. on regular business days. If you telefax your comments,
please do not also mail a hard copy document.

FOR ADDITIONAL COPIES CONTACT: Social Security Administration, PO Box
17052, Baltimore, MD 21235, (410) 966-8255. The Proposal is available
in alternative formats for visually impaired individuals. Please use
this same telephone number to request the document in an alternative
format.

SUPPLEMENTARY INFORMATION:

Background--What is the Reengineering Program?

SSA began an Agency-wide program of Process Reengineering in the
summer of 1993. The Process Reengineering Program is one way SSA is
seeking to improve its overall service delivery process.
The Process Reengineering Program essentially asks the question,
``If SSA had the opportunity today to design the processes, what would
they look like?'' In other words ``how would we design a process if we
were starting over?'' The Program's objective is to fundamentally
rethink and radically redesign SSA's work processes to achieve dramatic
improvements in critical measures of performance. In this rethinking
and redesign process, the ultimate aim is to achieve dramatically
improved levels of service from the customer's perspective while
enriching and improving the work lives of employees.
The Process Reengineering Program is the culmination of an
investigation by SSA of the reengineering efforts conducted by
companies, public organizations, academic institutions, and consulting
firms with ``hands on'' experience. The very positive findings from
that investigation, combined with our concerns about our ability to
provide the very best service to the public, led to the conclusion that
a process reengineering effort was absolutely critical to SSA's
objective of providing ``world class'' service to the American public.
Based on analysis of what has worked best in other organizations,
SSA developed a customized reengineering methodology. This methodology
uses a reengineering team approach and combines a strong customer focus
with classic management analysis techniques and computer modeling and
simulation to intensely review a single business process. While the
reengineering team is comprised of employees and experts who are very
knowledgeable about the SSA process being redesigned, the methodology
focuses heavily on obtaining the views of a broad segment of the
public.

What Does the Disability Project Address?

Despite the outstanding efforts of SSA and State DDS employees
throughout the country, we continue to have difficulty providing a
level of service to claimants for disability benefits that approaches
what would be considered ``good'' service. The steps in the current
disability process have not changed in any important way since the
beginning of the Disability Insurance program in the 1950s. Yet case
loads, types of disabilities, and the demographic characteristics of
individuals with disabilities who are potentially eligible for benefits
have changed radically.
The State DDSs make the initial decisions about whether an
applicant for Disability Insurance or SSI benefits is disabled. In
1989, SSA forwarded to the State DDSs 1.6 million claims for disability
benefits in the Disability Insurance and SSI programs. Claims have
increased significantly in every year since that time. In 1994, the
number of disability claims we will forward to the State DDSs is
expected to reach about 2.7 million. The number of requests for
hearings on denied claims is expected to reach 522,000--an increase of
about 60 percent in the last 3 years. The result is that many claimants
have to wait much too long at each stage in the process. SSA and State
DDS employees are working longer and harder, while becoming
increasingly frustrated about their inability to provide the type of
service the public deserves.
For these reasons, the first SSA reengineering project focuses on
the process for claiming benefits--beginning with the initial claim and
continuing through the payment of benefits or the final administrative
appeal--under both the Disability Insurance program and the disability
component of the SSI program.
The scope of the assignment to the disability reengineering project
team did not include making any changes to the statutory definition of
disability or the amount of benefits for which individuals are
eligible. Other issues relating to the disability programs are being
addressed by SSA in other ways, including the continuing disability
review process and the referral of individuals for vocational
rehabilitation services.

What the Proposal Contains

The proposal contained in this announcement is the product of the
disability reengineering team. It begins by providing background on the
current disability determination process. It discusses input received
in person, by telephone and by mail, from almost 3,000 Social Security
and State DDS employees, 750 members of the external community of
individuals and organizations interested in SSA's disability programs,
and from focus groups conducted with members of the public.
We next provide a conceptual proposal for a new disability claims
process; it gives a view of how the new process will work from the
applicant's perspective. Many readers will want to know how these
concepts will actually work in detail. However, the development of that
level of information will not be done until SSA is confident that the
basic concepts presented here have the potential to achieve the level
of service we seek to provide. We are committed to extensive future
dialogue on the next level of detail once we make the final decision on
these concepts.
The proposal contains many charts, some of which may be difficult
to read in the Federal Register format. We considered deleting some of
them but decided that the greater public interest was served by
publishing the entire proposal as it was presented on March 31, 1994,
to the Executive Steering Committee.

How Should Comments Be Presented to the Project Team?

The Project Team seeks public reaction to the concepts in the
proposal. We are particularly interested in your response to the
following questions concerning the proposal's goals:
Does the proposal have the potential to provide a process
that is easy for claimants and those who assist claimants to access and
understand?
Will it enable SSA and the State DDS to make the right
decision the first time a case is adjudicated?
Will it result in dramatically improved process times?
Will it result in a more efficient use of SSA and State
DDS personnel?
Will it create jobs for employees in the process that are
satisfying?
In considering these questions, you are encouraged to identify
factors that would assure that the concepts presented will achieve
these goals. To the extent that the proposal is not seen as achieving
these goals, alternative suggestions about how to do so will be
welcome.

What Happens Next?

The Project Team will receive all comments from the public and
employees. The comments will be analyzed and used to revise and/or
refine the proposal. The final proposal of the team will be presented
to the Executive Steering Committee for the project for its review and
recommendations. Members of this committee include SSA and HHS General
Counsel executives, the presidents of the 8 union locals/councils that
represent SSA employees, a State DDS Administrator, and the presidents
of 6 associations of SSA and State DDS employees that work in the
disability process.
The Commissioner of Social Security will seek the advice and
recommendations of the Executive Steering Committee in making her
decisions on how SSA will proceed.

Dated: March 29, 1994.
Rhoda M. G. Davis,
Director, Process Reengineering Program.

Introduction

A claimant for disability benefits from the Social Security
Administration faces a lengthy, bewildering process. An initial
decision from SSA will likely take more than three months. Anywhere
from 16 to 26 employees will handle the claim before the initial
decision is reached. If that decision is a denial, and the request for
reconsideration is also denied, chances are the claimant will hire an
attorney. It will likely be an additional eight months or more before a
response on the hearing is received, and even longer before a check is
issued or eligible dependents' benefits are paid. As many as 45
employees could handle the claim.
If the claim for benefits is approved after a hearing, the claimant
will view the SSA disability application process as one which requires
jumping through lengthy bureaucratic hoops. Dealing in person or on the
telephone with SSA field office staff and, possibly, the State
disability determination service (DDS) staff at the initial and
reconsideration levels, the claimant must appear at a hearing and
finally talk to a person in a position to make a decision on the claim.
The claimant will rate SSA employees as courteous and knowledgeable,
but the disability determination process as bureaucratic and
unresponsive.
Congress agrees with this assessment; in May 1991, the House Ways
and Means Committee cited SSA for an excellent job of delivering
retirement benefits, but gave SSA a failing grade for the way it
processes applications for disability benefits, with Chairman Dan
Rostenkowski stating, ``* * * those who are unfortunate enough to
become disabled find their problems compounded by inefficiencies at
SSA.''
SSA employees reiterate this belief, as illustrated in the
following statement by a claims representative, ``I wish we could stop
shuffling all this stuff back and forth. I don't really know what the
DDS is looking for, so I try to do the best generic job I can on these
forms.''
The report of the National Performance Review reflected
Administration concern by directing SSA to ``Improve Social Security
disability claims processing to better serve people with disabilities *
* *''.
SSA has reached a critical juncture; disability claims receipts at
the initial claims and appeals levels have reached all time highs--
Fiscal Year (FY) 1995 claims requiring a disability determination will
increase 69 percent over FY 1990 levels; appeals workloads will
increase 75 percent over FY 1990 receipt levels; employees in field
offices, DDSs and hearing offices are overburdened despite recent
significant increases in productivity. As an agency, SSA must vie for
scarce administrative resources in an era of spending limitations and
competing social spending priorities. The ability of SSA to cope with
further workload increases is questionable; it is clear that only
radical change can address the disability service delivery problems
facing the Agency today.
SSA is meeting this challenge with an unprecedented effort to
reengineer the entire disability process--from the point a potential
claimant first contacts the Agency to file for disability benefits,
through the disability allowance or final administrative appeal.
Reengineering the disability process involves asking the question,
``Given what we know about technology and resources available to us
today, how can we best design a disability process for the 1990s and
beyond?'' This report will answer that question by proposing a radical
redesign of disability program policies and procedures, to ensure
dramatic improvements in the way the entire process works and is
managed to serve the American public.
The report represents the collective efforts and recommendations of
the 18-member Disability Reengineering Team, composed of Federal and
State DDS employees, operating under the auspices of the Director of
the SSA Process Reengineering Program, and the SSA Executive Steering
Committee formed to provide advice to the Commissioner on the
disability reengineering process change proposal development.
The Executive Steering Committee provided the following parameters
for the disability reengineering proposal: ``Every aspect of the
process except the statutory definition of disability, individual
benefit amounts, the use of an administrative law judge as the
presiding officer for administrative hearings and vocational
rehabilitation for beneficiaries is within the scope of this
reengineering effort.''
The recommendations in this report represent the Team proposal to
SSA for reengineering the disability process; this is not a final SSA
proposal. The Commissioner of SSA asks interested parties to comment on
the proposal within the next 60 days. The Team looks forward to
receiving comments from the community concerned with the delivery of
disability benefits.

Current Process

The procedures in the current process have not changed in any
significant way since the Social Security Disability Insurance (DI)
program began in the 1950s, a time when caseloads, demographic
characteristics of claimants, types of disabilities, and available
technology were radically different.
In the 1970s, Congress federalized State programs of cash
assistance to the aged, blind and disabled into the Supplemental
Security Income (SSI) program and added this to the responsibilities of
SSA. SSA then adopted the DI disability determination procedures for
SSI blind and disabled claims.

Overview

A claim must now pass through from 1 to 4 decisional paths within
SSA to receive a favorable disability decision. The initial claim,
reconsideration, administrative law judge (ALJ) hearing and Appeals
Council review levels all involve multi-step uniform procedures for
evidence collection, review, and decisionmaking.
The process starts at the initial level when an individual first
applies for DI or SSI disability benefits on the basis of a disabling
physical or mental condition. An individual calls the national toll-
free telephone number and is referred to a local SSA field office or
visits or calls one of 1,300 local field offices to apply for benefits.
Field office personnel assist with application completion, obtain
detailed medical and vocational history and screen nonmedical
eligibility factors. Field office personnel forward the claim to 1 of
54 State disability determination services where medical evidence is
developed and a final determination is made regarding the existence of
a medically determinable impairment which meets the definition of
disability.
After possible quality assurance review in the DDS or in the SSA
regional Disability Quality Branch, the claim is returned to the field
office. Thirty-nine percent of these claims were paid in FY 1993;
denials are retained pending possible appeal. Allowed DI claims are
sent to one of 7 processing centers (which include the Office of
Disability and International Operations and the 6 Program Service
Centers) for final processing and storage, as well as adjudication of
claims for dependents. Allowed SSI claims remain in the field office
for payment and retention.
An initial claim currently takes an average of 100 days to process
from the time it is filed until a final decision is made according to
SSA's computer-based processing time measurements. However, a better
understanding of how long the process takes from the claimant's
perspective comes from a 1993 study conducted by SSA's Office of
Workforce Analysis, which showed that an average claimant waits up to
155 days from the initial contact with SSA until receiving an initial
claim decision notice. Sixteen to 26 employees will handle the claim
during this period.

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An appeal of the initial decision can be made within 60 days of the
denial notice (see Fig. 2). Reconsiderations were requested on 48
percent of denied claims in FY 1993. The local field office receives
the request, updates the information, and forwards the claim file to
the DDS for review, possible medical development, and final medical
decision. The determination is made by a different adjudicative team
than the one that made the initial determination.
After possible quality assurance review in the DDS or in the
regional Disability Quality Branch, about 14 percent of these claims
are returned to the field office for payment, and forwarding to the
processing centers, while the remaining denials are forwarded to the
field office for retention, pending a request for a hearing before an
ALJ. The average reconsideration itself takes about 50 days according
to SSA's computer-based processing time reports--however, according to
the Office of Workforce Analysis study, a claimant has now been
involved with the SSA process for roughly 8 months from the point of
initially contacting the Agency, and up to 36 different employees could
have handled the claim.

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Within 60 days of receiving an unfavorable reconsideration
decision, a claimant can request a hearing before an ALJ (Fig. 3). In
FY 1993, about 75 percent of all reconsideration denials were appealed
to ALJs. At this point, a claimant has usually retained an attorney or
other representative to assist in pursuing the claim for benefits.
About 75 percent of all claimants retain a representative at the
hearing. The local field office receives the request for hearing and
forwards it with the claim file to one of 132 local SSA hearings
offices. Hearing office personnel review the file for possible
additional development, conduct a hearing, and render a final decision.
Allowed DI claims are sent to a processing center for final action
and storage, as well as adjudication of claims for dependents. Allowed
SSI claims are returned to the local field office for income and
resource development, and payment. Denied claims are forwarded to the
Appeals Council for retention in case a request for review is filed.
The hearing process itself takes about 265 days according to computer-
based reports. However, according to the Office of Workforce Analysis
study, a claimant has been dealing with SSA for over a year and a half
at this point in the process.

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If still dissatisfied with an unfavorable decision, a claimant or
representative has 60 days to request a review of the ALJ decision by
the Appeals Council (Fig. 4). About 23 percent of hearing decisions are
unfavorable and forwarded to the Appeals Council pending possible
appeal. The Appeals Council considers about 18 percent of all ALJ
dispositions, including cases it reviews on its own motion.
Requests for Appeals Council review are typically received directly
from the claimant's representative. The Appeals Council may either deny
review, issue a decision, or remand the claim to an ALJ. The Appeals
Council remands claims to the ALJ level about 27 percent of the time
for subsequent development and decision. Denied claims, representing
about 70 percent of the Appeals Council dispositions, are held in the
Appeals Council for possible appeal to Federal District court.
Allowed DI claims are sent to a processing center for final action
and storage, as well as adjudication of claims for dependents. Allowed
SSI claims are returned to the local field office for income and
resource development, and payment. According to processing time
reports, this part of the process takes on average about 100 days;
however, according to the Office of Workforce Analysis study, a
claimant has spent almost 2 years dealing with SSA since initially
contacting the Agency.

Trends

The current disability process served SSA and the public well for a
number of years. However, over the last several years, as workloads
have increased dramatically, the current process has been placed under
increasing stress. The upward trend in the number of claims for
benefits SSA has received is reflected as follows:

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The growth in claims and benefits awarded is reflected in increases
in the number of beneficiaries SSA pays and the growth in Federal
program outlays over recent years.

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The increase in workload has occurred concurrently with significant
downsizing activity in SSA and staffing fluctuations in the State DDSs.

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Even with the downsizing, the total costs for processing initial
disability and appeals determinations (excluding the costs for
processing the Sullivan v. Zebley court case) remain enormous--more
than half of the total administrative costs (including DDS costs) for
SSA in FY 1993 were devoted to this task.

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Despite these funds, and despite directing a larger percentage of
the SSA resources toward disability initial claims and appeals
processing in recent years, average processing times for initial
claims, as well as appeals, have escalated dramatically since 1988.

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At least part of the increase in processing time results from the
time added as the claim moves from one employee or facility to another
(handoffs), and waits at each employee's workstation to be handled
(queues). As workloads increase, the amount of time a claim waits at
each processing point grows.
``Task time'' is the time employees actually devote to working
directly on a claim, rather than the total amount of time it takes for
a claimant to receive a final decision. Based on the Office of
Workforce Analysis study, a claimant can wait as long as 155 days from
the first contact with SSA until receiving an initial claim decision
notice--of which only 13 hours of this is actual task time. The same
study reveals a claimant can wait as long as 550 days from that initial
contact through receipt of the hearing decision notice--of which only
32 hours is actual task time.

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The Team's research revealed that the problems of queues, handoffs,
and task time are compounded by problems with the way SSA takes claims,
collects evidence, and determines disability. These problems are
discussed in the following section.

Research Summary and Analysis

Overview of Methodology and Findings

The Team's methodology called for extensive site visits and
interviews with members of the disability community. Team members
visited 421 locations in 33 States and conducted over 3,600 interviews.
Almost 2,900 of these involved front-line employees, managers and
executives. The interviews provided insights into the problems
confronting the disability program and recommendations for solving
these problems. The Team conducted an additional 111 interviews by
telephone.
The Team also interviewed over 750 parties external to SSA--members
of the medical, legal, advocate and interest group community--for their
views. Finally, the Team has analyzed the results of focus groups
involving disability claimants and the general public in order to
determine what SSA customers experience and expect from the disability
process.
The information collected from these activities resulted in the
framework for the analysis and recommendations that follow. At a
minimum, the Team was determined to address the most pressing problems
identified by SSA employees, claimants, and other interested parties.
Not surprisingly, all three groups were in general agreement regarding
many of the problems with the SSA disability process. All agreed that
the current fragmented process takes too long to provide applicants a
decision, and leaves them confused about who has responsibility for
their claim, and puzzled about the status of their claim during various
points in the process. Additionally, nearly all believe that many
claimants can and should assume more responsibility for submitting
evidence and pursuing their claim.
Most view the reconsideration step as little more than a rubber
stamp of the initial determination, creating additional work for
employees and yet another bureaucratic obstacle for claimants and their
representatives. Some believe a face-to-face interview with the
decisionmaker is vital to reaching a fair, accurate determination;
others believe just as strongly that the decision should be reached on
the basis of a paper review, and that a face-to-face interview can lead
to subjective decisions that are not based on objective criteria.
Higher allowance rates at the ALJ level lead to the perception that
different adjudicative standards apply at the initial and appeals
levels. The public, in particular, believes that it is necessary to
hire an attorney to maneuver through this process, and voices
resentment at having to do so. Quality reviews and Appeals Council
reviews are often mentioned as areas where opportunities exist for
improving current processes.

The Case for Change

The Public and Third Parties Find the Current Process Confusing

Many applicants enter the SSA disability process uninformed about
the process itself and the definition of disability. They are unaware
of the criteria for establishing disability and the evidence they will
be required to submit. Even third parties and advocate organizations,
often more knowledgeable than the general public about SSA procedures,
experience difficulty obtaining meaningful information about the status
of their clients' claims, finding that they often are transferred from
one employee to another.
Disability claimants face a ``one size fits all'' approach to the
intake and processing of their claim, finding themselves answering
questions they believe are intrusive and irrelevant to their claim.
Front-line employees currently devote hours to completing forms and
obtaining information which may not be necessary for a finding of
disability. If the claim is approved, whether at the initial or
appellate level, claimants and their representatives, as well as front-
line employees, are concerned about the complicated procedures and
length of time it takes to effectuate payment and entitle eligible
dependents.

Evidence Collection and Decision Methodology Pose Problems

The collection of medical evidence presents problems as the case is
developed in the DDS. Medical providers who have treated the claimant
often do not understand the requirements for establishing disability,
and find the forms for the collection of medical evidence confusing. In
order to compensate for poor or missing medical evidence, DDSs purchase
consultative examinations, devoting substantial resources to
scheduling, purchasing, and processing these examinations.
Once the medical evidence has been collected, the methodology used
to reach a decision on the case is complex and controversial. Criteria
originally developed to identify and evaluate cases simply and rapidly
have grown increasingly complex as a result of court decisions and
changes in medical technology. Today's 330 different vocational rules,
which have been added to SSA's regulations since 1980, can lead to
varying interpretations resulting in inconsistent decisions.
Claimants and their representatives have learned their chances for
a favorable decision improve if they appeal their claim to an ALJ. A
variety of factors may be contributing to this. The facts of many cases
change over time as a claimant's condition changes. ALJs often have
access to information not considered at lower levels in the process
because earlier decisionmakers are not as likely to have face-to-face
interaction with the claimant. Finally, the fragmented nature of SSA's
policy making, policy issuance, training and review apparatus all
reinforce the differences.

The Fragmented Process Contributes to Difficulties

The fragmented nature of the disability process is driven by and
exacerbated by the fragmentation in SSA's policy making and policy
issuance mechanisms. Policy making authority rests in several
organizations with few effective tools for ensuring consistent guidance
to all disability decisionmakers. Different vehicles exist for
conveying policy and procedural guidance to decisionmakers at different
levels in the process. While the standards for disability
decisionmaking are uniform, they are expressed in different wording in
the various policy vehicles.
Training on disability is not delivered in a consistent manner, nor
is it provided simultaneously to disability decisionmakers across or
among levels in the process. Mechanisms for reviewing application of
policy among levels of the process are fragmented and inconsistent.
Review of DDS decisions is heavily weighted toward allowances; no
systematic quality assurance program is in place for hearing decisions
although the opportunity for feedback from the appeals council or court
cases is heavily weighted toward denials.
The organizational fragmentation of the disability process creates
the perception that no one is in charge of it. SSA measures the process
from the perspective of the component organizations involved, rather
than the perspective of the claimant. Multiple organizations (field
offices, DDSs, hearings offices, Appeals Council operations, and
processing centers) have jurisdiction over the claim at various points
in time, with each line of authority managing toward its own goals
without responsibility to the overall outcome of the process.
Additionally, the impact of one component's work product on other
components is not measured, further contributing to the fragmentation
of the process. Each component's narrow responsibilities reinforce a
lack of understanding among component employees of the roles and
responsibilities of other employees in different components.

Customer Research and Demographics

Customer Research

The National Performance Review report, released in the fall of
1993, calls upon agencies to establish customer service standards equal
to the best in the business to guide their operations. Federal agencies
are encouraged to identify ``the customers who are, or should be served
by the agency,'' and survey these customers ``to determine the kind and
quality of services they want and their level of satisfaction with
existing services.''
SSA customers include the individuals who file for social security
or supplemental security income disability benefits, or who are
potential filers for these benefits. They were surveyed through a
series of 12 focus groups conducted throughout the country last fall.
Participants represented a demographically diverse cross-section of
current claimants, including those who had been initially denied, and
who filed for a reconsideration or hearing; new beneficiaries; and the
general public. Two focus groups were conducted with non-English
speaking participants.
Focus group participants were quick to offer their frank opinions;
the general view was that they:

--Wait too long for a decision--this is the most common complaint; the
claim process is a struggle characterized by stress, fear, and the
anger associated with running out of funds;
--Do not understand the program or process--what happens to the claim
after initial contact with SSA is unclear, they view SSA multiple
requests for medical information with skepticism, do not understand
their decision and believe it was reached arbitrarily;
--Want more information and personal contact--while they would prefer
to deal with one person for all claim business, their major preference
is to receive accurate, consistent information from all SSA sources and
to be provided substantive status reports on their claim;
--View the initial and reconsideration denials as bureaucratic
precursors to final approval at the ALJ level--they believe the process
is designed ``to make you go away'';
--Resent the need for attorney assistance to obtain benefits--the
process should not be so complicated that an attorney is needed; and
--Want more active involvement in pursuit of their claim--they want to
make their case directly to the decisionmaker, and would personally
obtain needed additional evidence to speed the decision on their claim.

Demographics

Changes in demographics of the general population and in SSA's
claimant population present challenges as well as opportunities for SSA
as it focuses on claimant needs and reengineers its disability
determination process.
American society has changed dramatically since the DI program
began in the 1950s. This is reflected in an increased demand for SSA's
services, changes in the characteristics of claimants seeking benefits,
and complexities in claim related workloads and processes.
The demographic character of the SSA disability claimant population
has changed as well. The enactment of the SSI program in the 1970's
added individuals who have sketchy work histories, increased the number
of individuals filing based on disabilities such as mental impairments,
and provided for eligibility of disabled children. Additionally, the
requirements of the SSI program added complex and time consuming
development of non-disability eligibility factors such as income,
resources and living arrangements. The 1990 U.S. Supreme Court
decision, Sullivan v. Zebley, resulted in increased claims for
children; children comprised 21 percent of all SSI claims in 1992, up
from 11 percent in 1988. Claims for homeless individuals and others
with special needs have increased in recent years. These claimants
require significant intervention and assistance to navigate the
disability claims process.
A trend in the general population which is reflected in SSA's
disability claimant population is the increased number of people in the
United States for whom English is not the native language. Recent
national Census data indicate that 1 in 7 people speak a language other
than English in the home; this is an increase of almost 38 percent in
the last 10 years. SSA will need to accommodate the special
communication needs of these claimants in its ongoing claimant contacts
and in public information vehicles.
Forty percent of claimants filing for disability benefits and
polled in a recent SSA survey had filed for or received benefits from
Aid to Families with Dependent Children, welfare or social services
within the past year. Approximately three-fourths of them were awarded
this assistance and three-fourths of those awardees were still
receiving benefits when they applied for disability benefits. SSA has
the opportunity to develop productive relationships with these entities
to improve the processing of disability claims for mutual customers.
Technological advances such as personal computers, facsimile
machines, electronic mail, and videoconferencing are increasingly
available to our claimants, their representatives, medical providers
and other third parties involved in the disability process. SSA can
take advantage of these capabilities to offer expanded service options
and to modernize evidence collection.

New Process

Overview

A claimant for disability benefits under the proposed process will
be provided a full explanation of SSA's programs and processes at the
initial contact with SSA. The claimant and third parties will be able
to assist in the development of the claim, deal with a single contact
point in the Agency, and request a personal interview with the
decisionmaker at each level of the process. Additionally, if the
claimant requests a hearing, the issues and evidence to be addressed at
the hearing will be focused, the responsibilities of representatives
clarified and, if the claim is approved, the effectuation of payment to
the claimant, eligible dependents and the representative streamlined.
The new process will result in a correct decision at the initial
level by simplifying the decision methodology, providing consistent
direction and training to all decisionmakers, enhancing the collection
and development of medical evidence, and employing a single quality
review process across all levels.
A single claim manager will handle most aspects of the initial
level claim, thus eliminating many steps caused by numerous employees
handling discrete parts of the claim (handoffs) and the time lost as
the claim waits at each employee's workstation to be handled (queues).
This will reduce the time needed to rework files and redevelop
information from the same medical sources. Levels of appeal will be
combined and improved, reducing the need to redevelop nonmedical
eligibility factors after a favorable decision because less time will
have elapsed since initial filing.
The proposed process will enable the current work force to handle
an increased number of claims, freeing the most highly skilled staff
(physicians and ALJs) to work on those cases and tasks that make the
best use of their talents, and targeting expenditures for medical
evidence to those areas most useful in determining disability.
Employees will perform a wider range of functions, using their
skills to their full potential, enabling them to meet the needs of
claimants and minimize unnecessary rework. The proposed process will
facilitate employees' ability to do the total job by providing
technology and the support to use that technology.

The New Process--A Brief Description

Under the proposed process, the number of appeal steps will be
reduced and opportunities for personal interaction with decisionmakers
will be increased. At the initial claim level, the claimant will be
offered a range of options for filing a claim, pursuing evidence
collection, and conferring with a decisionmaker, using various modes of
technology to interact with SSA. At the hearing level, the claimant
will have an additional opportunity to participate in a personal
conference and meet with a decisionmaker.

BILLING CODE 4190-29-P

TN15AP94.016

A Disability Claim Manager Will Handle Initial Disability Claims
Processing

Claimants initially will deal almost exclusively with a disability
claim manager--a front-line employee knowledgeable about the medical
and nonmedical factors of entitlement--responsible for making the
initial determination, with technical support if necessary, to allow or
deny the claim.
The disability claim manager will determine the level of
development needed to make a disability decision using a simplified
determination methodology; relying on evidence submitted by or through
the efforts of the claimant (whenever the claimant is able to do this);
requesting medical evidence or a functional assessment; or referring
complex medical questions to a medical consultant for expert advice and
opinion, if necessary. The disability claim manager will contact the
claimant if the decision on a claim appears to be a denial. The claim
manager will explain the situation including the evidence that was
considered, and offer the claimant an opportunity to submit additional
information as well as an option for an interview in-person or via
telephone, before the claim is formally denied.
All initial claims will be subject to a randomly selected
postadjudicative national sample review designed to determine whether
disability policies are being properly applied. Extensive ongoing
training will enable adjudicators to consistently issue correct
decisions. By the time the initial decision is issued, the claim will
have been handled by seven or eight employees.

An Adjudication Officer Will Prepare the Claim for a Hearing

A claimant wishing to appeal an unfavorable initial decision to an
ALJ will continue to have 60 days to file a request for a hearing. The
disability claim manager will assist the claimant with the request, and
forward the claim to an adjudication officer. The adjudication officer
will be responsible for explaining the hearing process to the claimant,
as well as conducting personal conferences, preparing claims, and
scheduling hearings. The adjudication officer will have the authority
to allow the claim at any point prior to the hearing that sufficient
evidence becomes available to support a favorable decision.

An ALJ Will Conduct the Hearing

The ALJ will conduct the hearing and issue the decision. At any
point in the process where the claim is approved, it will be returned
to the claim manager for payment effectuation, whether the claim is DI,
concurrent, or SSI. Denied claims will be forwarded to the Appeals
Council, for retention in the event of civil action. At this point, an
average claimant will have been dealing with SSA for approximately five
months from the first contact with the Agency. A total of up to 14
employees will have been involved with the process during this entire
period.
An ALJ decision will be the final decision of the Secretary,
subject to judicial review, unless the Appeals Council reviews the ALJ
decision on its own motion. The Appeals Council will conduct reviews of
ALJ allowances and denials prior to effectuation, at its discretion,
and on its own motion. The Appeals Council will also review all claims
in which a civil action has been filed, and decide whether the ALJ
decision should be defended as the final decision of the Secretary. If
a claim is selected for own motion review, a total of 17 employees will
have been involved in the process from first claimant contact with SSA
through Appeals Council review.

Claimants Will Receive World-Class Service

The time from a claimant's first contact with SSA until issuance of
a final initial decision, will be reduced from an average of 155 days
(as cited in SSA's Office of Workforce Analysis study) to less than 40
days, enhancing SSA's capacity to provide world-class service.
Available employees will be able to process a greater number of claims,
and devote more time to each claimant, providing more personalized
service.
The time from a claimant's first contact with SSA until issuance of
a hearing decision, will be reduced from an average of a year and a
half (as cited in SSA's Office of Workforce Analysis study) to
approximately 5 months.

BILLING CODE 4190-29-P

TN15AP94.017

TN15AP94.018

TN15AP94.019

TN15AP94.020

TN15AP94.021

BILLING CODE 4190-29-C

Detailed Description of New Process

Process Entry and Intake

SSA Will Customize Its Disability Claims Entry and Intake Processes to
Maximize Access, Efficiency, Accuracy, and Personal Service
The disability claims entry and intake processes will reflect the
SSA commitment to providing world-class service to the public. The
hallmarks of the process will be accessible, personal service that
ensures timely and accurate decisions. SSA will work to make potential
claimants better informed about the disability process and fully
prepare them to participate in it. SSA will also be flexible in
providing modes of access to the claims process that best meet the
needs of claimants and the third parties who act on their behalf. SSA
will provide claimants with a single point of contact for all claims-
related business. Finally, SSA will ensure that the disability
decisionmaking process promotes timely and accurate decisions.
SSA Will Make Information About Its Disability Programs Available to
Potential Claimants Prior to Entry Into the Process
SSA will make available to the general public comprehensive
information packets about the Disability Insurance (DI) and
Supplemental Security Income (SSI) disability programs. The packets
will include information about the purpose of the disability programs;
the definition of disability; the basic requirements of the programs; a
description of the adjudication process; the types of evidence needed
to establish disability; and the claimant's role in pursuing a claim.
SSA will make disability information packets commonly available in
the community, both at facilities frequented by the general public
(libraries, neighborhood resource centers, post offices, the Department
of Veterans Affairs offices, and other Federal government
installations) and at facilities frequented by potential claimants
(hospitals, clinics, other health care providers, schools, employer
personnel offices, State public assistance offices, insurance
companies, and advocacy groups or third party organizations that assist
individuals in pursuing disability claims). SSA studies have shown that
claimants frequently rely on advice from their physicians and from
State public assistance personnel in deciding whether to file a claim
for disability benefits. Therefore, SSA will make a special effort to
target its public information activities at these and other known
sources of referrals for claims. SSA will also make the disability
information packets available electronically.
In addition to comprehensive program information, the packets will
describe the types of information that a claimant will need to have
readily available when the individual files a claim. It will also
contain two basic forms: the first, designed for completion by the
claimant, will include general identifying information and will serve
as the claimant's starter application for benefits; the second,
designed for completion by the treating source(s), will request
specific medical information about a claimant's alleged impairments.
SSA will encourage claimants to review the information in the packet
and have the basic forms completed prior to telephoning or visiting an
SSA office to apply for disability benefits. Claimants filing will be
encouraged to immediately submit starter applications to protect the
filing dates for benefits. The starter application will serve as a
claim for both programs, but it will include a disclaimer should the
claimant want to preclude filing for benefits based on need (i.e.,
SSI).
SSA Will Permit Claimants to Choose the Mode of Entry Into the Process
That Best Meets Their Individual Needs
The disability claims entry process will be multi-faceted, allowing
claimants the maximum flexibility in deciding how they will participate
in the process. Claimants may choose to enter the disability claims
process by telephoning the SSA toll-free number, electronically, by
mail, or by telephoning or visiting a local office. Claimants may also
rely on third parties to provide them assistance in dealing with SSA.
Finally, claimants may formally appoint representatives to act on their
behalf in dealing with SSA. SSA field managers will also have the
flexibility to tailor the various service options to their local
conditions, considering the needs of client populations, individual
claimants, and the availability of third parties who are capable of
contributing to the application process.
If an individual submits a starter application by mail or
electronically, SSA will contact the claimant to schedule an
appointment for a claims intake interview or, at the claimant's option,
conduct an immediate intake interview by telephone.
If an individual telephones SSA to inquire about disability
benefits, the SSA contact will explain the requirements of the
disability program, including the SSA definition of disability, and
provide a general explanation of evidence requirements. The SSA contact
will determine whether the individual has the disability information
packet, and mail it or advise the claimant regarding possible means of
electronic access. If an individual indicates a desire to file a claim
at that time, the SSA contact will complete the starter application
available on-line as part of the automated claims processing system to
protect the claimant's filing date and schedule an appointment for a
claims intake interview. The interview may be in person or by telephone
at the claimant's option. If the individual has no medical treating
sources, the SSA contact will annotate this information within the on-
line claim record.
If a claimant visits an SSA office, the SSA contact will refer the
claimant for an immediate claims intake interview or, at the claimant's
option, complete the starter application and schedule a future
appointment for an intake interview.
In all cases, appointments for claims intake interviews will be
made available within a reasonable time period, generally 3 to 5
working days, but no later than two weeks.
Local management will determine how to best accommodate claimants'
needs in learning about the disability process and completing a claims
intake interview. Depending on an individual's circumstances, such
accommodation may involve: referral to the nearest location for
obtaining an information packet which can then be mailed in; an
immediate telephone or in-person interview; arranging for an on-site
visit from an SSA representative; or referral to appropriate third
parties who can provide assistance. Additionally, depending on the
nature of the individual's disability, SSA may encourage the individual
to file in person when it appears that a face-to-face interview will
assist in the proper claims intake and development. Face-to-face
interviews, when considered necessary by either the claimant or SSA,
can also be accomplished via videoconferencing. In any case, SSA will
make every reasonable effort to meet the needs of the claimant in
completing the application process.
Similarly, local managers will modify the claims entry and intake
process to provide maximum flexibility for representatives who act on
behalf of claimants or third parties who can assist claimants in
completing the application process. Such accommodations may include,
but are not limited to: (1) Using automated means to interact with SSA
to protect a claimant's date of filing (e.g., telephone, fax, or E-
mail); (2) providing appointment slots for third parties to accompany
claimants to interviews or to provide assistance during telephone
claims on a claimant's behalf; (3) out-stationing SSA personnel at a
third-party location to obtain applications and/or medical evidence,
when appropriate; and (4) providing open appointment'' scheduling to
permit claimants to contact SSA within a flexible band of time.
Interested third parties will be encouraged to participate in the
development of claims by becoming certified by SSA to do so.
Local managers will also conduct outreach efforts that are designed
to meet the needs of hard-to-reach populations or assist those
individuals unable to access the SSA claims process without
considerable intervention. As appropriate, outreach efforts may be
facilitated through videoconferencing, teleconferencing or other
electronic methods of obtaining and processing claims information to
provide timely service despite claimants' geographic or social
isolation.
A Disability Claim Manager Will Be Responsible for a Disability Claim
From Intake Through Payment
A disability claim manager will have responsibility for the
complete processing of an initial disability claim. The disability
claim manager will be a highly-trained individual who is well-versed in
both the disability and nondisability aspects of the program and has
the necessary knowledge, skills, and abilities to conduct personal
interviews, develop evidentiary records, and adjudicate disability
claims to payment. However, the disability claim manager will also be
able to call on other SSA resources such as medical and technical
support personnel to provide advice and assistance in the claims
process.
The disability claim manager will rely on an automated claims
processing system that will permit the disability claim manager to:
gather and store claims information; develop both disability and
nondisability evidence; share necessary facts in a claim with SSA
medical consultants and specialists in nondisability technical issues;
analyze evidence and prepare well-rationalized decisions on both
disability and nondisability issues; and produce clear and
understandable notices that accurately convey all necessary information
to claimants.
The disability claim manager will be the focal point for claimant
contacts throughout the claim intake and adjudication process. The
disability claim manager will explain the disability program to the
claimant, including the definition of disability and how SSA determines
if a claimant meets the disability requirements. The disability claim
manager will also convey what the claimant will be asked to do
throughout the process; what the claimant may expect from SSA during
this process, including anticipated timeframes for decision; and how
the claimant can interact with the disability claim manager to obtain
more information or assistance. The disability claim manager will
advise the claimant regarding the right to representation and provide
the appropriate referral sources for representation. The disability
claim manager will also advise the claimant regarding community
resources, including the names of organizations that could help the
claimant pursue the claim. The goal will be to give claimants access to
the decisionmaker and allow for ongoing, meaningful dialogue between
the claimant and the disability claim manager.
Claims Intake and Development Will Be Directed at Reaching a Decision
in the Most Timely and Accurate Manner
The disability claim manager will conduct a thorough screening of
the claimant's disability and nondisability eligibility factors. If the
claimant appears ineligible for either disability program based on the
claimant's allegations and evidence presented during the claim intake
interview, the disability claim manager will explain this to the
claimant. If the claimant decides not to file a claim, the disability
claim manager will give the claimant an informal denial notice.
If the claimant decides to file, the disability claim manager will
complete appropriate application screens from the automated claims
processing and decision support system. Impairment-specific questions
will assist the claim manager in obtaining information that is relevant
and necessary to a disability decision. Based on the claimant's
statements and the evidence that is available at that interview, the
disability claim manager will determine the most effective way to
process the claim. If the evidence is sufficient to decide the claim,
the disability claim manager will take necessary action to issue a
decision and, if necessary, effectuate payment. The disability claim
manager will determine what additional evidence is required to
adjudicate the claim and will take steps to obtain that evidence. Such
steps may include asking the claimant to obtain further medical or
nonmedical evidence where feasible, requesting medical evidence
directly from treating sources, or ordering further medical
evaluations.
The disability claim manager will decide whether to defer
nondisability development (e.g., requesting SSI income and resource
information, or developing DI dependents' claims) or do it
simultaneously with development of the disability aspects of the claim.
In making this decision, the disability claim manager will take into
account the type of disability alleged, evidence and other information
presented by the claimant, and other relevant circumstances, e.g.,
terminal illness, homelessness or difficulty in recontacting the
claimant. Because the disability claim manager maintains ownership of
the claim throughout the initial decision-making process, the
disability claim manager will be in the best position to choose the
most efficient and effective manner of providing claimants with timely
and accurate decisions while meeting claimants' individual service
needs.
Although the disability claim manager will be responsible for the
adjudication of an initial claim, the disability claim manager will
call in other staff resources, as necessary. With respect to disability
decisionmaking, the disability claim manager will, in appropriate
circumstances, refer claims to medical consultants to obtain expert
advice and opinion. Similarly, other staff resources will be called
upon for technical support in terms of certain claimant contacts and
status reports; development of nondisability issues including auxiliary
claims or representative payee issues; and payment effectuation.
However, the disability claim manager will make final decisions on both
the disability and nondisability aspects of the claim.
Claimants Will Be Partners in the Processing of Their Disability Claims
Throughout the disability claims process, SSA will encourage
claimants to be full partners in the processing of their claims. To the
extent that they are able, claimants and their families and other
personal support networks will actively participate in the development
of evidence to substantiate their claim for disability benefits. SSA
will provide assistance and/or engage third party resources, when
necessary and appropriate. SSA will keep claimants informed of the
status of their claims, advise claimants regarding what additional
evidence may be necessary, and inform claimants what, if anything, they
can do to facilitate the process.
At the completion of the claims intake interview, the disability
claim manager will issue a receipt to the claimant that will identify
what to expect from SSA and the anticipated timeframes. It will also
identify what further evidence or information the claimant has agreed
to obtain. Finally, it will provide the name and telephone number of
the disability claim manager for any questions or comments which the
claimant may have.
SSA Will Recognize That Some Third Parties Can Develop Complete
Application Packages
Certain third party organizations may be willing to provide a
complete disability application package to SSA. Based on local
management's assessment of service area needs and the availability of
qualified organizations, SSA will certify third party organizations who
are capable of providing a complete application package, including
appropriate application forms and medical evidence necessary to
adjudicate a disability claim. In such claims, SSA will permit the
third party to identify potential claimants, screen for disability and
nondisability criteria, and contact SSA to protect the filing date. The
third party will interview the claimant; complete all applications and
related forms; obtain completed treating source statements; and obtain
additional medical evaluations, when appropriate. Using procedures
agreed on with local management, the third party will submit claims for
adjudication by a disability claim manager. The disability claim
manager may elect to contact the claimant for the purpose of verifying
identity or other claims-related issues, as appropriate. SSA will
monitor such third parties to ensure that quality service is provided
to claimants and to prevent fraud.
Claimants Will Have the Opportunity for a Personal Interview Before SSA
Makes an Initial Disability Denial Decision
When the evidence does not support an allowance, the disability
claim manager will provide the claimant an opportunity for a personal
interview before issuing the initial denial determination. The
interview will be in person, by videoconference, or by telephone, at
the claimant's option and as the disability claim manager determines is
appropriate under the circumstances. In appropriate circumstances, the
predenial interview may follow the initial intake interview. The
purpose of the predenial interview will be to advise the claimant of
what evidence has been considered and to identify what further
evidence, if any, is available that bears on the issues. If such
further evidence exists, the disability claim manager will advise the
claimant to obtain the evidence or, as appropriate, assist the claimant
in obtaining it.
Initial Disability Decisions Will Use a ``Statement of the Claim''
Approach
The initial disability determination will use a ``statement of the
claim'' approach. The statement of the claim will set forth the issues
in the claim, the relevant facts, the evidence considered, including
any evidence or information obtained during the predenial interview,
and the rationale in support of the determination. The statement of the
claim not only reflects the SSA commitment to fully explaining the
basis for its action but also recognizes that claimants need clear
information about the basis for the determination to make an informed
decision regarding further appeal.
Much of the information that will provide the basis for the
statement of the claim will be available on-line as part of the
automated claims processing and decision support system. Adjudicators
will create the statement of the claim and whatever supplementary
information is necessary for a legally sufficient notice to the
claimant based on the information in the decision support system. For
allowance decisions, the statement of the claim will be more
abbreviated than for denial decisions; however, it will contain
sufficient information to facilitate quality assurance reviews and/or
continuing disability reviews. The statement of the claim will be part
of the on-line claim record and will be available to other adjudicators
as the basis and rationale for the Agency action, if the claimant seeks
further administrative review.

Disability Decision Methodology

The Methodology for Deciding Disability Claims Will Promote Consistent,
Equitable, and Timely Disability Decisions

SSA must have a structured approach to disability decisionmaking
that takes into consideration the large number of claims (2.7 million
initial disability decisions in FY 1994) and still provides a basis for
consistent, equitable decisionmaking by adjudicators at each level. The
approach must be simple to administer, facilitate consistent
application of the rules at each level, and provide accurate results.
It must also be perceived by the public as straightforward,
understandable and fair. Finally, the approach must facilitate the
issuance of timely decisions.
The cornerstone of any approach is, of course, the statutory
definition of disability. Under the statute, disability (for adults)
means the: ``* * * inability to engage in any substantial gainful
activity by reason of any medically determinable physical or mental
impairment which can be expected to result in death or which has lasted
or can be expected to last for a continuous period of not less than 12
months * * * An individual shall be determined to be under a disability
only if his physical or mental impairment or impairments are of such
severity that he is not only unable to do his previous work but cannot,
considering his age, education, and work experience, engage in any
other kind of substantial gainful work which exists in the national
economy * * *'' (section 223(d) of the Social Security Act)
The decision-making approach is the foundation on which SSA will
base the claim intake process and evidence collection. The focus will
be, first, to establish a solid medical basis for documenting that an
individual has a medically determinable physical or mental impairment.
Second, once the evidence establishes a medically determinable
impairment, SSA will use additional medical findings to provide a solid
link between the disease entity and the loss of function caused by the
impairment(s).

Disability Decisionmaking for Adult Claims Will Be a Four-Step
Evaluation Process

The disability decision methodology will consist of four steps that
are based on the statutory definition of disability. They are:

Step 1--Is the individual engaging in substantial gainful activity?
If yes, deny.
If no, continue to Step 2.
Step 2--Does the individual have a medically determinable physical
or mental impairment?
If no, deny.
If yes, continue to Step 3*.
Step 3--Does the individual have an impairment that is included in
the Index of Disabling Impairments?
If yes, allow*.
If no, continue to Step 4.
Step 4--Does the individual have the functional ability to perform
substantial gainful activity?
If yes, deny.
If no, allow*.

*An impairment must meet the duration requirement of the
statute; a denial is appropriate for any impairment that will not be
disabling for 12 months.
Step 1--Engaging in Substantial Gainful Activity
Any individual who is engaging in substantial gainful activity will
not be found disabled regardless of the severity of the individual's
physical or mental impairments. If a claimant is performing substantial
gainful activity at the time a claim is filed, SSA will determine that
the claimant is not disabled based on the demonstrated ability to
engage in substantial gainful activity.
Under the current process, in determining whether a claimant is
performing or has performed substantial gainful activity, SSA generally
considers the amount of the claimant's earnings, less any impairment-
related work expenses. However, there are several threshold levels of
earnings that need to be considered and, depending on the actual amount
earned, SSA evaluates whether a claimant's work is comparable to that
of unimpaired individuals in the community who are doing the same or
similar occupations, or whether the work is substantial gainful
activity based on prevailing pay scales in the community.
Under the new process, SSA will simplify the monetary guidelines
for determining whether an individual (except those filing for benefits
based on blindness) is engaging in substantial gainful activity. In
making this determination, SSA will evaluate the work activity based on
the earnings level that is comparable to the upper earnings limit in
the current process (i.e., $500). A single earnings level will simplify
the evidentiary development necessary to evaluate work activity and
establish the appropriate onset date of disability. SSA will continue
to exclude impairment-related work expenses in evaluating whether a
claimant's earnings constitute substantial gainful activity. SSA will
continue to use separate earnings criteria to evaluate the work
activity of blind individuals as in the current process.
Step 2--Medically Determinable Impairment
Because the statute requires that disability be the result of a
medically determinable physical or mental impairment, the absence of a
medically determinable impairment will justify a finding that the
individual is not disabled.
Under the current regulations, SSA considers, as a threshold
matter, whether an individual has a medically determinable impairment
or combination of impairments that is ``severe.'' A severe impairment
is defined as one that significantly limits the individual's physical
or mental abilities to do work activities such as walking, standing,
sitting, hearing, seeing, understanding, carrying out, or remembering
simple instructions, using judgment, etc.
Under the new approach, SSA will consider whether a claimant has a
medically determinable impairment, but will no longer impose a
threshold severity requirement. Rather, the threshold inquiry will be
whether the claimant has a medically determinable physical or mental
impairment. To establish the presence of a medically determinable
impairment, evidence must show an impairment that results from
anatomical, physiological, or psychological abnormalities which are
demonstrable by medically acceptable clinical and laboratory diagnostic
techniques.
SSA will continue to evaluate the existence of a medically
determinable impairment based on a weighing of all evidence that is
collected, recognizing that neither symptoms nor opinions of treating
physicians alone will support a finding of disability. There must be
medical signs and findings established by medically acceptable clinical
or laboratory diagnostic techniques which show the existence of a
physical or mental impairment that results from anatomical,
physiological, or psychological abnormalities which, in the opinion of
the Secretary, could reasonably be expected to produce the symptoms or
substantiate any opinion evidence provided. Depending on the nature of
a claimant's alleged impairments, SSA will consider the extent to which
medical personnel other than physicians can provide evidence of a
medically determinable impairment.
There will be an exception to the requirement that evidence include
medically acceptable clinical and/or laboratory diagnostic techniques.
This will occur when, even if SSA accepted all of the claimant's
allegations as true, SSA still could not establish a period of
disability; under these circumstances, SSA will not require evidence to
establish the existence of a medically determinable impairment. For
instance, if a claimant describes a condition as one that will clearly
not meet the 12-month duration requirement, (e.g., a simple fracture),
SSA will deny the claim on the basis that even if the allegations were
medically documented, SSA could not establish a period of disability.
Step 3--Index of Disabling Impairments
If an individual has a medically determinable physical or mental
impairment documented by medically acceptable clinical and laboratory
techniques, and the impairment will meet the duration requirement, SSA
will compare the claimant's impairment(s) against an index of severely
disabling impairments. In contrast to the Listing of Impairments in the
current regulations, the index will contain fewer impairments and have
less detail and complexity. The index will describe impairments that
will result in death or impairments that are so debilitating that any
individual would be unable to engage in substantial gainful activity
regardless of any reasonable accommodations that an employer might make
in accordance with the Americans with Disabilities Act. The index will
be designed to be equitable, easy to understand, and consistent with
the statutory definition of disability.
The index will function to quickly identify severely disabling
impairments; the index will not attempt to describe ideal medical
documentation requirements for each and every body system as occurs
with the current Listings. The index will consist of descriptions of
specific impairments and the medical findings that are used to
substantiate the existence and severity of the particular disease
entity. The index will not attempt to measure the functional impact of
an impairment on the individual; functional impact will be considered
at Step 4 in the process. The medical findings in the index will be as
nontechnical as possible and will exclude such things as calibration or
standardization requirements for specific tests and/or detailed test
results (e.g., pulmonary function studies or electrocardiogram
tracings). The index will be simple enough so that laypersons will be
able to understand what is required to demonstrate a disabling
impairment in the index. Additionally, SSA will draw no inferences or
conclusions about the effect of a claimant's impairments on his or her
ability to function merely because a claimant's impairment(s) does not
meet the criteria in the index. Finally, SSA will no longer use the
concept of medical equivalence'' in relation to the index, as it now
uses in applying the Listing of Impairments.
Step 4--Ability to Engage in Any Substantial Gainful Activity
In the final step in determining disability, SSA will consider
whether an individual has the ability to perform substantial gainful
activity despite any functional loss caused by a medically determinable
physical or mental impairment. If an individual retains the ability to
perform substantial gainful activity, then an individual does not meet
the statutory definition of disability.
Presently, there are no generally accepted measurement criteria for
determining an individual's ability to function in relation to work-
related activities. Currently, SSA assesses residual functional
capacity by analyzing the objective medical findings and other
available evidence and translating this information into functional
loss and residual capacity for work activities.
Additionally, there are also no definitive sources for identifying
the physical and mental requirements of ``baseline'' work functions
that are required to engage in substantial gainful activity. SSA
currently relies on the Department of Labor definitions regarding the
physical and mental demands of work in the national economy, and relies
on related reference sources and independent experts regarding the
existence of particular occupations and jobs in the national economy.
Under the new process, SSA will define the physical and mental
requirements of substantial gainful activity and, will measure as
objectively as possible whether an individual meets these requirements.
How SSA will achieve this is described in the following sections.

SSA Will Develop Instruments That Provide A Standardized Measure of
Functional Ability

Under the current process, SSA relies on available clinical and
laboratory findings, treating source opinions, the claimant's
description of his or her abilities and limitations, and third party
observations of the claimant's limitations in determining the
claimant's residual functional capacity. Residual functional capacity
is the claimant's remaining capacity for work activities despite the
limitations or functional loss caused by his or her impairments.
Under the new process, SSA will develop, with the assistance of the
medical community and other outside experts from public and private
disability programs, standardized criteria which can be used to measure
an individual's functional ability. These standardized measures of
functional ability will be linked to clinical and laboratory findings
to the extent that SSA needs to document the existence of a medically
determinable impairment that results from anatomical, physiological, or
psychological abnormalities which could reasonably be expected to
produce the functional loss. However, extensive development of all
available clinical and laboratory findings is not necessarily effective
in evaluating an individual's functional ability to perform basic work
activities.
Functional assessment instruments will be designed to measure, as
objectively as possible, an individual's abilities to perform a
baseline of occupational demands that includes the principal dimensions
of work and task performance, including primary physical,
neurophysical, psychological, and cognitive processes. Examples of task
performance include, but are not limited to: Physical capabilities,
such as sitting, standing, walking, lifting, pushing, pulling; mental
capabilities, such as understanding, carrying out, and remembering
simple instructions; using judgment; responding appropriately to
supervisors and co-workers in usual work situations; and responding
appropriately to changes in the routine work setting; and postural and
environmental limitations. Functional assessment instruments will be
designed to realistically assess an individual's abilities to perform a
baseline of occupational demands.
SSA will be primarily responsible for documenting functional
ability using the standardized measurement criteria. In the near term,
SSA will solicit functional information from treating medical sources,
other nonmedical sources, and from claimants in a manner that is
similar to the current process. In the future, the standardized
measurement criteria will be widely available and accepted so that
functional assessments may be performed by a variety of medical
sources, including treating sources. The SSA goal will be to develop
functional assessment instruments that are standardized, that
accurately measure an individual's functional abilities and that are
universally accepted by the public, the advocacy community, and health
care professionals. Ultimately, documenting functional ability will
become the routine practice of physicians and other health care
professionals, such that a functional assessment with history and
descriptive medical findings will become an accepted component of a
standard medical report.
The prospect of universal health coverage may offer a unique
opportunity for SSA to work with the public and private sector to
develop standards that both can use. For example, medical insurance
payors (whether public or private) may want some way of measuring the
effectiveness and necessity of treatment that is prescribed by the
individual's treatment source; SSA will want these same types of
measures to determine how well an individual is able to function
despite his or her impairment(s). Similarly, if all individuals have
treating sources under universal health coverage, SSA can expect that
complete functional assessment measurements will be readily available
from a treating source. Finally, universal health coverage may enable
SSA to access medical records from health care providers who may be
operating under some contractual or other relationship with Federal
agencies and/or a statutory requirement that health care providers
cooperate in providing evidence as a condition of receiving Federal
funds.
SSA will use the results of the standardized functional measurement
in conjunction with a new standard that SSA will develop to describe
basic physical and mental demands of a baseline of work that represents
substantial gainful activity and that exists in significant numbers in
the national economy.

SSA Will Identify Baseline Occupational Demands That Represent
Substantial Gainful Activity

Under the current regulations, after assessing a claimant's
residual functional capacity, SSA evaluates whether the claimant can
meet the physical and mental demands of his or her past relevant work.
Past relevant work is usually work that a claimant performed in the
last 15 years.
If the claimant is unable to perform his or her past work, SSA then
evaluates whether the claimant can perform other work in the national
economy. In making this decision, SSA relies on medical-vocational
guidelines (the ``Grid''). The Grid rules represent major functional
and vocational patterns and reflect the analysis of various vocational
factors (age, education and work experience) in combination with the
claimant's residual functional capacity (which is used to determine the
claimant's maximum sustained work capacity for sedentary, light,
medium, heavy or very heavy work).
In promulgating the Grid rules, SSA has taken administrative notice
of the existence of unskilled jobs that exist in the national economy
at the various functional levels. Therefore, when all the findings of
fact regarding a claimant's functional ability and vocational factors
coincide with the corresponding criterion of a rule, the existence of
other work in the national economy is conclusively established.
However, if any finding of fact does not coincide with the criterion of
a rule, the rules can only provide a framework for decisionmaking. In
these situations, adjudicators must consult vocational resources or
obtain expert testimony to resolve the question of whether other work
exists in the national economy that the claimant can perform.
Under the new approach, SSA will conduct research and, working in
conjunction with outside experts, will specifically identify the
activities that comprise a baseline of occupational demands needed to
perform substantial gainful activity. In the current process, an
example of comparable ``baseline'' criteria are the functional
requirements of unskilled, sedentary work. In establishing the
functional activities that comprise an appropriate baseline of
occupational demands, SSA will ensure that:
(1) The functional activities are a realistic reflection of the
demands of occupations that exist in significant numbers in the
national economy;
(2) The occupations are those that can be performed in the absence
of prior skills or formal job training; and
(3) The baseline of occupational demands that becomes the standard
for evaluating the ability to perform substantial gainful activity
considers any reasonable accommodations that employers are expected to
make under the Americans with Disabilities Act.

The Effect of Age on Ability to Perform Substantial Gainful Activity

The effect of aging on the ability to perform substantial gainful
work is very difficult to measure, especially in the context of today's
world when individuals are living longer than preceding generations.
Despite this change, the demographic characteristics of those preceding
generations continue to provide the framework for disability
decisionmaking because SSA's approach for deciding disability has
changed little since the inception of the DI program.
The statute recognizes that age should be considered in assessing
disability on the assumption that the ability to make a vocational
adjustment to work other than work an individual has previously done
may become more difficult with age. In determining the impact of age,
recognition should be given to the changes that occur with each
succeeding generation. Accordingly, in the new process, SSA will
establish age criterion in relation to the full retirement age. The
full retirement age will gradually increase over time, based on the
recognition that succeeding generations can expect to remain in the
workforce for longer periods than the preceding generation.
In applying age criterion under the new process, an individual who
falls within the prescribed number of years preceding the full
retirement age will be considered as ``nearing full retirement.'' In
establishing what the prescribed number of years should be, SSA will
conduct research and consult with outside experts on the relationship
between age and an individual's ability to make vocational adjustments
to work other than work the individual has done in the recent past.
SSA will rely on the age of the individual in relation to the full
retirement age to decide which of two decision paths to follow as
described in the next two sections.

Individuals Who Are Not Nearing Full Retirement

For an individual who is not nearing full retirement, SSA will
compare the individual's functional abilities against the functional
demands of the baseline work. SSA will no longer rely on the medical-
vocational guidelines and/or expert testimony to identify whether work
exists in the national economy that the claimant can perform. The
ability to perform the baseline work will represent a realistic
opportunity to perform substantial gainful activity that exists in
significant numbers in the national economy and a finding of disability
will not be appropriate.
However, anyone, regardless of age, who cannot perform the baseline
work will be considered unable to engage in substantial gainful
activity, and a finding of disability will be justified. The range of
work represented by less than the baseline will be considered so narrow
that despite any other favorable factors, such as young age or higher
education or training, an individual would not be expected to have a
realistic opportunity to perform substantial gainful work in the
national economy.
For individuals who are not nearing full retirement, the ability or
inability to perform previous work is not a significant factor. These
individuals should be capable of making a vocational adjustment to
other work, as long as they are functionally capable of performing the
baseline work.

Individuals Who Are Nearing Full Retirement

For individuals who are nearing full retirement, SSA will compare
the individual's functional abilities against the functional demands of
the individual's previous work. Individuals nearing full retirement age
can not be expected to make a vocational adjustment to work other than
work they have performed in the recent past. However, consistent with
the statute, if an individual, even one nearing full retirement age, is
capable of performing his or her previous work, SSA will find that the
individual is not disabled.
For those individuals who have no previous work, SSA will compare
the individual's functional abilities to the baseline work, and a
finding of not disabled will be appropriate if the individual is
capable of performing the baseline work. In such claims, the fact that
the individual has no previous work is usually not related to the
existence of his or her impairment(s), and a finding of disability will
not be appropriate for these individuals if they retain the capacity
for the baseline work.

The Effect of Education on Ability to Perform Substantial Gainful
Activity

The statute also recognizes that education may play a role in an
individual's ability to perform substantial gainful activity.
Experience demonstrates that educational level alone, i.e., the
numerical grade level that an individual has attained may not be a good
indicator of ability to function. Education is generally completed in
the remote past when compared to the age at which the majority of
disability claimants file for benefits. Completion of a certain
educational level in the remote past, without any practical application
of that education in recent work activity, has no positive effect on an
individual's ability to perform substantial gainful activity.
In relying on standardized functional assessments, SSA will be
measuring both the individual's physical and mental abilities, and
education will be appropriately reflected in the assessment of an
individual's cognitive abilities. However, further evaluation of a
claimant's educational level will not be required because, in
establishing the functional activities that comprise an appropriate
baseline of occupational demands, SSA will not assume that individuals
have prior skills or significant formal job training. Thus, additional
formal education will have little impact on an individual's ability to
perform the baseline of occupational demands.

SSA Will Rely on Medical Consultants to Provide Necessary Expertise in
the Decisionmaking Process

SSA will continue to rely on medical consultants to provide expert
advice and opinion regarding medical questions and issues that will
arise in deciding disability claims. Disability adjudicators at all
levels of the administrative review process will call on the services
of medical consultants to interpret medical evidence, analyze specific
medical questions, and provide expert opinions on existence, severity
and functional consequences of medically determinable impairments. If a
medical consultant is called on to offer expert advice and opinion, the
medical consultant will provide a written analysis of the issues and
rationale in support of his or her opinion. The written analysis will
be included in the record and will be considered with the other medical
evidence of record by disability adjudicators at all levels of
administrative review. Additionally, medical consultants will assist in
the training of other consultants and disability adjudicators; contact
other health care professionals to resolve medical questions on
specific claims; perform public relations and training with the medical
community; and participate in SSA quality assurance efforts.

Childhood Disability Methodology

As with adults, SSA must have a structured approach to disability
decisionmaking in childhood claims that takes into consideration the
relatively large number of claims and still provides a basis for
consistent, equitable decisionmaking by adjudicators at all levels of
administrative review. The approach for childhood claims must also
derive from the statute. Under the statute,

An individual will be considered to be disabled for purposes of
this title if he is unable to engage in any substantial gainful
activity by reason of any medically determinable physical or mental
impairment which can be expected to result in death or which has
lasted or can be expected to last for a continuous period of not
less than 12 months (or in the case of a child under the age of 18,
if he suffers from any medically determinable physical or mental
impairment of comparable severity). (Section 1614(a)(3)(A) of the
Social Security Act).

Disability Decisionmaking For Childhood Claims Will Be a Four-Step
Evaluation Process

The disability decision methodology for childhood claims will
consist of four steps that are based on the statutory definition of
disability.
As with adults, the approach is one that provides accurate
decisions that can be achieved efficiently and cost-effectively,
primarily by ensuring that documentation requirements are directed
toward the ultimate finding of disability. The four steps are:

Step 1--Is the child engaging in substantial gainful activity?
If yes, deny.
If no, continue to Step 2.
Step 2--Does the child have a medically determinable physical or
mental impairment?
If no, deny.
If yes, continue to Step 3*.
Step 3--Does the child have an impairment that is included in the
Index of Disabling Impairments?
If yes, allow*.
If no, continue to Step 4.
Step 4--Does the child have the functional ability to perform
activities that are comparable to an adult's ability to engage in
substantial gainful activity?
If yes, deny.
If no, allow*.

*An impairment must meet the duration requirement of the
statute; a denial is appropriate for any impairment that will not be
disabling for 12 months.
Step 1--Engaging in Substantial Gainful Activity
Any child who is engaging in substantial gainful activity will not
be found disabled regardless of the severity of his or her physical or
mental impairments. The guidelines for determining whether a child is
engaging in substantial gainful activity will be identical to the
guidelines for adults. Although the issue of work activity will arise
infrequently in childhood claims, the step is warranted for two
reasons:
(1) The approach for adults and children should be as similar as
possible; and
(2) As a child approaches age 18, it is increasingly likely that
work activity may be an issue.
Step 2--Medically Determinable Impairment
Because the statute requires that disability be the result of a
medically determinable physical or mental impairment, the absence of a
medically determinable impairment will justify a finding that a child
is not disabled. To establish the presence of a medically determinable
impairment, evidence must show an impairment that results from
anatomical, physiological, or psychological abnormalities which are
demonstrable by medically acceptable clinical and laboratory diagnostic
techniques.
The same guidelines and rules that apply for adults will apply
equally for children. SSA will continue to evaluate the existence of a
medically determinable impairment based on a weighing of all evidence
that is collected, recognizing that neither symptoms nor opinions of
treating physicians alone will support a finding of disability. There
must be medical signs and findings established by medically acceptable
clinical or laboratory diagnostic techniques which show the existence
of a physical or mental impairment that results from anatomical,
physiological, or psychological abnormalities which, in the opinion of
the Secretary, could reasonably be expected to produce the symptoms or
substantiate any opinion evidence.
SSA will use the same exception for evidence collection in
childhood claims that will be applied in adult claims. If a child has a
medically determinable physical or mental impairment that is not an
exception to further development, SSA will then evaluate whether the
impairment(s) is included in the index of disabling impairments.
Step 3--Index of Disabling Impairments
If a child has a medically determinable physical or mental
impairment documented by medically acceptable clinical and laboratory
techniques and the impairment will meet the duration requirement, SSA
will compare the child's impairment(s) against an index of disabling
impairments. As with adults, the index for childhood claims will
function to quickly identify severely disabling impairments; the index
will not attempt to describe ideal medical documentation requirements
for each and every body system.
The index for childhood claims will consist of descriptions of
specific impairments and the medical findings that are used to
substantiate the existence and severity of the particular disease
entity. As with adults, the childhood index will not attempt to measure
the functional impact of an impairment on the child; functional impact
will be considered at Step 4 in the process. The medical findings in
the index will be as nontechnical as possible and will be simple enough
so that laypersons will be able to understand what is required to
substantiate a disabling impairment in the index. As with adults, SSA
will draw no inferences or conclusions about the effect of a child's
impairments on his or her ability to function merely because a child's
impairment(s) is not included in the index. Additionally, SSA will no
longer use the concept of medical equivalence'' or functional
equivalence in relation to the childhood Index.
Step 4--Comparable Severity to Adult Ability to Engage in Substantial
Gainful Activity
In evaluating disability in adults, SSA will evaluate an
individual's functional ability to perform work-related activities
consistent with the ability to engage in any substantial gainful
activity. The difficulty with evaluating childhood claims is the
standard against which any functional measurement criteria are
compared. For older children, it is relatively easy because at some age
(somewhere between 14 and 18) the standard approaches the adult
standard, i.e., ability to engage in substantial gainful activity.
However, for younger children, the standard can be more difficult to
describe. Under the current process, SSA uses a standard that measures
the degree to which a child engages in age-appropriate activities which
corresponds fairly well with developmental milestones for different age
categories. However, the difficulty with this approach is that it may
not appropriately define how much functional loss or interference with
growth and maturity is comparable to inability to perform any
substantial gainful activity.
Consistent with the adult approach, SSA will develop baseline
criteria for a child's activities that are comparable to an adult's
ability to perform substantial gainful activity. In establishing a
baseline of functional activities, the functional abilities for a child
will represent a realistic comparison to an adult's ability to work.

Functional Assessment Instruments

Consistent with the approach for adult claims, SSA will develop,
with the assistance of the medical community and educational experts,
standardized criteria which can be used to measure a child's functional
ability. These standardized measures of functional ability will be
linked to clinical and laboratory findings to the extent that SSA needs
to document the existence of a medically determinable impairment that
results from anatomical, physiological, or psychological abnormalities
which could reasonably be expected to produce the functional loss.
These functional assessment instruments will be designed to
measure, as objectively as possible, a child's abilities to perform a
baseline of functions that are comparable to the baseline of
occupational demands for an adult. SSA will conduct additional research
to specifically identify activities that are comparable to those that
comprise a baseline of occupational demands needed to perform
substantial gainful activity by adults.
SSA will be primarily responsible for documenting functional
ability using the standardized measurement criteria. Ultimately, the
course of documenting and developing for the functional abilities for
childhood claims will mirror the adult approach.

Comparability Standard

SSA will develop realistic standards which represent activities
that are comparable to an adult's ability to engage in substantial
gainful activity. The standards will focus on a skill acquisition
threshold designed to measure broad areas of skill that are required to
ultimately develop the ability to engage in substantial gainful
activity. If the child is progressing satisfactorily in the development
of these skills, then the child will not have an impairment of
comparable severity and SSA will not find the child disabled.

Evidentiary Development

SSA's Ability To Issue Timely and Accurate Disability Decisions Depends
on the Efficient Collection of Quality Medical Evidence

SSA's ability to provide timely and accurate disability decisions
depends to a significant degree on the quality of medical evidence it
can obtain and the speed with which it can obtain it. The medical
evidence collection process accounts for a considerable portion of the
total time involved in processing disability claims.
Traditionally, the procurement of medical evidence has involved
multiple, often repetitive, requests for information from a variety of
health care providers. Health care providers believe that these
requests burden them with far too much paperwork and offer far too
little in the way of compensation for the time invested. Conversely,
adjudicators often find that this evidence is primarily treatment-
oriented and fails to provide the highly specialized clinical
information required by the current Listings, or the functional
information that is frequently necessary at various points in
disability decision-making process. Health care professionals,
particularly physicians, readily concede that their training is
oriented towards diagnosis and treatment, not the assessment of
function. Thus, the timely collection of medical information depends to
a significant degree on health care providers who have only a
tangential interest and understanding of the disability program, its
requirements, and, most importantly, the vital role that health care
providers' information has in the disability decision process.

Evidence Collection Will Focus on Core Diagnostic and Functional
Information Necessary to a Disability Decision

The goals of the evidence collection process will be to focus
requests for evidence on the critical diagnostic and functional
assessment information necessary for a disability decision and to form
a new partnership with the sources of this information so that it can
be obtained in the most efficient, cost-effective manner. Medical
evidence development will be driven by the four-step approach SSA will
use to decide disability. Two of the core elements of that approach
are: (1) Identifying an individual's medically determinable impairments
(including those that meet the Index of Disabling Impairments
criteria); and (2) assessing the functional consequences of those
impairments. SSA will develop medical evidence that is sufficient to
satisfy the core elements but target evidentiary development so that
SSA obtains only the evidence that is necessary to reach an accurate
decision on the ultimate question of disability.

Treating Sources Will be the Preferred Sources for Medical Evidence

SSA will give primary emphasis to obtaining medical information
from treating sources by way of brief, but specific, diagnostic
information regarding an individual's medically determinable
impairments and the functional consequences of those impairments.
Treating source statements will include diagnostic information about a
claimant's impairments, the clinical and laboratory findings which
provide the basis for the diagnosis, onset and duration, response to
treatment, and the functional limitations that can reasonably be linked
to the clinical and laboratory findings. SSA will develop, in
conjunction with the appropriate health care professionals and other
public and private disability programs, standardized criteria which can
be used to measure, as accurately and objectively as possible, an
individual's functional ability. SSA will also seek health care
providers' assistance in educating the medical community on the
clinical application of these instruments. Once developed and
universally accepted as the appropriate standard by the medical
community, the standardized measurement criteria will be widely
available. If a standardized functional assessment is available from a
treating source, SSA will obtain that information and accept it as
probative evidence. SSA may also request that the treating source or
another examining source perform the standardized functional assessment
at SSA expense.

SSA Will Use a Standardized Form To Request Medical Evidence From
Treating Sources

SSA will develop a standardized form which effectively tailors the
request for evidence to the specific diagnostic and functional
assessment information necessary to make a disability decision. The
standard form will also be available in electronic form to permit
treating sources to submit evidence electronically. Standardizing
requests for evidence in this manner will facilitate the participation
of claimants, representatives and third parties in the evidence
collection process.
The form will permit treating sources to provide necessary
diagnostic and functional assessment information on a single document.
In appropriate circumstances, SSA will accept a treating source's
statement on the standardized form as to these issues without resorting
to the traditional, wholesale procurement of actual medical records.
Depending on the nature and extent of an individual's impairments and
treating sources, statements from multiple medical sources may be
appropriate. In completing standard forms, treating sources will
certify that they have in their possession the medical documentation
referred to in the statement and that said documentation will be
promptly submitted at the request of SSA. The certification approach is
consistent with evidence collection methods used by private disability
insurance carriers, which request specific medical records in
individual claims, as appropriate to the individual circumstances, or
at random as part of a quality assurance program. SSA will monitor
treating source completion of the standardized forms and verify
evidence when appropriate.

SSA Will Provide Incentives for Treating Sources To Cooperate in the
Development of Medical Evidence

SSA will acknowledge the value of treating source information by
establishing a national fee reimbursement schedule for medical
evidence. Additionally, the fee reimbursement schedule will utilize a
sliding-scale mechanism to reward the early submission of medical
information. A national, sliding-scale fee schedule will provide
incentives for treating sources to cooperate in the evidentiary
development process and invest quality time to provide medical
certifications on behalf of their patients.
SSA will focus professional educational efforts and medical
relations outreach at the local and/or regional level to ensure that
treating sources are kept informed of program requirements and made
aware of specific evidentiary needs or problems as they arise in the
adjudication process.

SSA Will Use Consultative Examinations When There is No Treating Source
Able or Willing To Provide Necessary Evidence or There Are Unresolved
Conflicts in the Record

If a claimant has no treating source, or a treating source is
unable or unwilling to provide the necessary evidence, or there is
conflict in the evidence that can not be resolved through evidence from
treating sources, SSA will refer the claimant for an appropriate
consultative examination. Because the standardized measurement criteria
for assessing function will be widely available, consulting sources
will be able to perform functional assessments that, in the absence of
adequate treating source information or where there are unresolved
conflicts in the evidence, will be considered probative evidence.
Depending on the service area, SSA will consider contracting with large
health care providers to furnish consultative examinations for a
specified geographic location.
As part of an ongoing training and medical relations program, SSA
will ensure that providers of consultative examinations are provided
adequate training on disability requirements, both initially and as
program changes occur.

Administrative Appeals Process

The Administrative Appeals Process Will Be Simple and Accessible and
Maintain Public Confidence in the Integrity of the Process

The administrative appeals process will be simplified to increase
the accessibility of the process. The public perceives multiple,
mandatory appeal steps as obstacles to receiving timely, fair, and
accurate decisions. SSA will reduce the number of mandatory appeals
steps in the administrative process. Streamlining the appeals process
in this manner will not only promote more timely decisions but also
ensure that claimants do not inappropriately withdraw from the claims
process based on a perception that it is too difficult or time-
consuming to pursue their appeal rights.
Claimants will be able to fully participate in the administrative
appeals process with or without a representative. SSA will ensure that
claimants are fully advised of their right to representation and SSA
will routinely provide the appropriate referral sources for
representation. SSA will also encourage the early participation of a
representative when the claimant has appointed one and will give the
representative responsibility for developing evidence necessary to
decide a claim. However, the decision whether to appoint a
representative must remain with the claimant and SSA will neither
encourage nor discourage claimants in seeking representation.
The administrative appeals process will function so that it
maintains the public's confidence in the integrity of the system. To
instill such confidence, SSA will provide an initial decisionmaking
process that is thorough and results in fully developed records with
fair and accurate decisions. Additionally, SSA will explain the basis
of a decision in clear and understandable language. Finally, SSA will
ensure that disability claims are decided on the merits of the evidence
and that SSA regulations and policies have been consistently applied at
all levels of administrative review.
As noted previously, the initial disability determination will use
a ``statement of the claim'' approach which will set forth the issues
in the claim, the relevant facts, the evidence considered, including
any evidence or information obtained during the predenial interview,
and the rationale in support of the determination. The statement of the
claim will be part of the on-line claim record and will stand as the
basis and rationale for the Agency action, if the claimant seeks
further administrative review. SSA will standardize claim file
preparation and assembly, including the use of appropriate electronic
records, at all levels of administrative process until such time as the
claims record is fully electronic.

The Next Level of Administrative Appeal Will Be an Administrative Law
Judge Hearing

Because the initial determination will be the result of a process
that ensures fully developed evidentiary records and ample opportunity
for the claimant to personally present additional evidence prior to an
adverse determination, there will be no need for any intermediate
appeal (e.g., reconsideration) prior to the administrative law judge
(ALJ) hearing. If the claimant disagrees with the initial
determination, the claimant may, within 60 days of receiving notice,
request an ALJ hearing.

An Adjudication Officer Will Conduct All Prehearing Proceedings

If a claimant decides to request an ALJ hearing, an adjudication
officer will conduct an interview in person, by telephone, or by
videoconference, and become the primary point of contact for the
claimant. The adjudication officer will have the same knowledge, skills
and abilities as the adjudicators who decide claims initially. The
adjudication officer will also have specialized knowledge regarding
hearings and appeals procedures. The adjudication officer will be the
focal point for all prehearing activities but will be expected to work
closely with the ALJ, medical consultants and the disability claim
manager, when appropriate. The adjudication officer will explain the
hearing process; advise the claimant regarding the right to
representation; provide the appropriate referral sources for
representation; give the claimant, where appropriate, copies of
necessary claim file documents to facilitate the appointment of a
representative; and encourage the claimant to decide about the need for
and choice of a representative as soon as is practical.
The adjudication officer will also identify the issues in dispute
and whether there is a need for additional evidence. If the claimant
has a representative, the representative will have the responsibility
to develop evidence. The adjudication officer will also conduct
informal conferences with the representative, in person or by
telephone, to identify the issues in dispute and prepare written
stipulations as to those issues not in dispute. If the claimant submits
additional evidence, the adjudication officer may refer the claim for
further medical consultation, as appropriate. The adjudication officer
will have full authority to issue a revised favorable decision if the
evidence so warrants. If the adjudication officer issues a favorable
decision, the adjudication officer will refer the claim back to the
disability claim manager to effectuate payment.
The adjudication officer will consult with the ALJ during the
course of prehearing activities, as necessary and appropriate to the
circumstances in the claim. As a preliminary matter, the adjudication
officer will also set a date for the hearing that is 45 days after the
hearing request. The adjudication officer may exercise discretion in
establishing an earlier or later hearing date depending on the
individual circumstances. Electronic access to ALJs' calendars will
facilitate timely scheduling of hearings. The adjudication officer will
refer the prepared record to an ALJ only after all evidentiary
development is complete and the claimant or a representative agrees
that the claim is ready to be heard.
The ALJ will retain the authority and ability to develop the
record. However, use of an adjudication officer realigns most, if not
all, prehearing activities so that the burden of ensuring their
completion rests with other members of the adjudicative team. ALJs'
primary function will be hearing and deciding claims.

The Administrative Law Judge Hearing Will be a De Novo, Nonadversarial
Proceeding

The ALJ hearing will be a de novo proceeding in which the ALJ
considers and weighs the evidence and reaches a new decision.
A de novo hearing is consistent with the role of an ALJ envisioned
under the Administrative Procedure Act. Under that scheme, the ALJ is
an independent decisionmaker who must apply an agency's governing
statute, regulations and policies, but who is not subject to direction
and control by the agency with respect to the decisional outcome in any
individual claim. ALJs are independent triers of fact who perform their
evidentiary factfinding function free from agency influence. At the
same time, the Administrative Procedure Act ensures that an ALJ's
decision is subject to review by the agency, thus giving the agency
full power over policy. Policy responsibility remains exclusively with
the agency while the public has assurance that the facts are found by
an official who is not subject to agency influence.
A hearing before an ALJ will remain an informal adjudicatory
proceeding as it is under the current process. The claimant will have
the right to be represented by an attorney or a non-attorney with the
decision regarding representation made by the claimant alone. An
informal, nonadversarial proceeding is consistent with the public's
strong preference for a simple, accessible hearing process that
permits, but does not require, an attorney. An informal process
facilitates the earlier and faster resolution of the issues in dispute,
thus promoting more timely decisions.
As an independent factfinder in a nonadversarial proceeding, the
ALJ will still have a role in protecting both SSA interests and the
claimant's interests, particularly when the claimant is unrepresented.
However, an improved initial determination process with its focus on
early and comprehensive evidentiary development, predenial personal
conferences, fully rationalized initial decisions, and prehearing
analysis of contested issues should ensure that the Agency position is
fully explored and presented to the ALJ. Moreover, the primary burden
of compiling an evidentiary record will be shifted to the
representative--if one is appointed--or to the claimant (when able to
do so), with assistance (when appropriate), from SSA personnel.
Adjudication officers and other decision writers will assist ALJs
in preparing hearing decisions, using the same decision support system
that supports the preparation of initial disability determinations. A
simplified disability decisional methodology, in conjunction with the
use of prehearing stipulations that frame the issues in dispute, will
result in shorter, more focused hearing decisions. If the ALJ issues a
favorable decision, he or she will refer the claim back to the
disability claim manager to effectuate payment.

The Administrative Law Judge Decision Will Be the Final Decision of the
Secretary Subject to Judicial Review Unless the Appeals Council Reviews
the Administrative Law Judge Decision On Its Own Motion

Under the new process, if a claimant is dissatisfied with the ALJ's
decision, the claimant's next level of appeal will be to Federal
district court. A claimant's request for Appeals Council review will no
longer be a prerequisite to seeking judicial review.
As under the current process, the Appeals Council will continue to
have a role in ensuring that claims subject to judicial review have
properly prepared records and that the Federal courts only consider
claims where appellate review is warranted. Accordingly, the Appeals
Council, working with Agency counsel, will evaluate all claims in which
a civil action has been filed and decide, within a fixed time limit
whether it wishes to defend the ALJ's decision as the final decision of
the Secretary. If the Appeals Council decides to review a claim on its
own motion, it will seek voluntary remand from the court for the
purpose of affirming, reversing or remanding the ALJ's decision.
Favorable Appeals Council decisions will be returned to the disability
claim manager to effectuate payment.
Additionally, the Appeals Council will have a role in a
comprehensive quality assurance system. As part of this system which is
described in greater detail below, the Appeals Council will also
conduct its own motion reviews of ALJ decisions (both allowances and
denials) prior to effectuation. If the Appeals Council decides to
review a claim on its own motion, the Appeals Council may affirm,
reverse or remand the ALJ's decision. The Appeals Council's review will
be limited to the record that was before the ALJ.

Quality Assurance

Quality Assurance Will be a System of Agency Accountability

SSA will be accountable to the public, the ultimate judge of the
quality of SSA service, and SSA will strive to consistently meet or
exceed the public's expectations. SSA will have a comprehensive quality
assurance program that defines its quality standards, continually
communicates them to employees in a clear and consistent manner, and
provides employees with the means to achieve them. SSA will devote
resources to building quality into the system of adjudication to ensure
that the right decision is made the first time. SSA will also
systematically review the quality of the overall system of adjudication
to ensure the integrity of the administrative process and promote
uniform application of agencies policies nationally. Finally, SSA will
measure customer satisfaction against the SSA standards for service.

Ensuring That the Right Decision is Made the First Time Requires an
Investment in Employees

SSA's ability to ensure that the right decision is made the first
time depends on a well-trained, competent, and highly motivated
workforce that has the program tools and technological support to issue
quality decisions.
SSA will make an investment in comprehensive employee training to
ensure that employees have the necessary knowledge and skills to
perform the duties of their positions. SSA will develop national
training programs for initial job training and orientation as well as
continuing education to maintain job knowledge and skills. Such
training will include general communication skills and how to deal
effectively with the public generally, and disability claimants in
particular. National training programs will also address changes to
program policy.
In addition to initial program training, continuing education
opportunities will be made available to employees to enhance current
performance or career development. These opportunities may be in the
form of self-help instruction packages, videotapes, satellite
broadcasts, or non-SSA training or educational opportunities. SSA will
ensure that employees are given sufficient time and opportunity to
complete the required continuing education. Employees will be
encouraged to provide feedback on the value of these continuing
education opportunities, including the quality of training materials,
methods, and instructors.
Employees, other than ALJs (because of Administrative Procedure Act
limitations), who complete initial training and pass a set of
performance evaluations based on national quality standards will
receive a certificate of competence. This certificate will attest that
the employee has successfully completed both initial training and a
probationary period on the job. Certification will be renewed yearly
upon successfully completing required training and having no less than
a fully satisfactory performance rating. Those employees not certified
initially or renewed will be provided an improvement plan with goals
and time targets for improved performance.
In addition to formal program training, SSA will rely on a
streamlined and targeted system of in-line quality reviews and
monitoring of adjudicative practices. The elements include a mentoring
process for new employees and peer review for experienced employees.
SSA will encourage peers to discuss difficult claims or issues and
resolve them informally whenever possible. Peer reviews and mentoring
will not only promote timely and accurate development of disability
claims, but will also foster a spirit of teamwork. They will also
promote earlier identification and resolution of problems with policy
or procedures. As part of this process, managers will be expected to
oversee the adjudication process. They will conduct spot checks at key
points in the adjudication process or perform special reviews based on
profiles of error-prone claims. The goal of these reviews is to provide
immediate, constructive feedback on identified errors to reduce or
eliminate their possible recurrence.
To ensure that adjudicators have the necessary program tools to
issue accurate decisions, SSA will use a single mechanism for the
presentation of all substantive policies used in determining
eligibility for benefits. Additionally, an integrated claims processing
system will provide the necessary technological support for
adjudicators at all levels of the administrative process. Among other
things,

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Source: Frix Law Library, https://www.frixlaw.com/law-library/documents/fr%3A94-8265. Public record. Not legal advice.