using soar in the appeals process will connelly samhsa soar ta center september 13, 2011
TRANSCRIPT
Using SOAR in the Appeals Process
Will Connelly
SAMHSA SOAR TA Center
September 13, 2011
Welcome
Welcome to today’s webinar
Today we will provide an overview of the SSA appeals process and discuss strategies about how SOAR can be used to facilitate a timely review
Webinar Instructions
Recording availability Q&A segment and chat function Muting
Agenda Overview of the appeals process
– Will Connelly, SAMHSA SOAR TA Center, Delmar, NY
Reconsideration– Paul Berry, Ph.D., St. Paul, MN
Review on Record– Vicki Dunham, Eckman/Freeman & Associates, Nashville, TN
Administrative Law Judge (ALJ) Hearings Bill Doub, Genesee County Community Mental Health, Flint, MI
Levels of Appeal Reconsideration
– Note: 10 States do not have this level– AL, AK, CA (Los Angeles North and West areas), CO, LA, MI, MS, NH, NY (Brooklyn and Albany), and PA
Review on Record Hearing before an Administrative
Law Judge (ALJ) Appeals Council Federal Court
Useful Information
SSA website information on appeals http://www.ssa.gov/pubs/10041.html#Reconsideration
Tips on Appeals http://www.prainc.com/SOAR/training/pdfs/TipsforPendingAppsandAppeals.pdf
Reconsideration
Paul Berry, Ph.D.
Overview
File within 60 days of SSA denial If possible allege
– Worsening condition and/or– New evidence and/or– New impairment
Case is reviewed at DDS by different examiner than original claim
Overview con’t
Nationally 15% are reversed on recon
Many case managers file recon as quickly as possible to move to ODAR
Consider carefully before filing a recon for a partially favorable SSDI decision
Reconsider Recon!
There are opportunities at recon level Steps
– Obtain and READ the decision from DDS thoroughly
– Gather information that will counter DDS’s original denial
– Become familiar with Process Unification regulations
Timing Is Everything
Become familiar with your state’s guidelines on waiting period before reconfirming denial
Make DDS aware that there may be some delay in providing new evidence.
Don’t be afraid to ask them to wait.
Timing con’t
Know how long DDS must wait for new medical evidence. In MN it’s 30 days
Wait period may be different for non-medical/ADL data. In MN it’s 10 days
Delay Filing for Recon
If you know you have new evidence, consider delaying filing the application – until you have the new data
Ensure that your new information arrives prior to the deadline
Amended MSR
Submit a revised Medical Summary Report (MSR) on recon
Be sure to address the issues raised by DDS in the denial
Make sure that the new evidence is easy for the new adjudicator to find
On-The-Record Favorable Decision
Vicki Dunham
Eckman/Freeman and Associates
The Steps Know the reason for denial File the appeal with supporting rationale on SSA Form
501 Prehearing Review based on advanced age and Dire
Need Processing Identify and Resolve Issue Obtain additional supporting evidence Research and identify corresponding Impairment Listing,
Medical-Vocational Rule, and/or Social Security Ruling(s)
Request an On-the-Record Favorable Decision
Know the Denial Reason(s)
Request the electronic folder from the Social Security office or ODAR
Review the CD to ascertain evidence on file and rationale for denial
Review earnings record to make sure there are no SGA earnings
Make note of errors,omissions, and plan your strategy
File a Hearing Request
File online within 60 days of decision
Cite supporting rationale on Form HA-501-U5
State that you have additional evidence
Plan to attend the hearing
Pre-Hearing Based on Age
If claimant is 55 or over– Generally flagged by ODAR for pre-
hearing review– If unfairly denied by DDS, can be
approved here Submit new evidence immediately Follow up on status
Dire Need
Submit proof of homelessness
Other dire need situations– Terminal illness– Eviction/foreclosure– Suicidal/homicidal tendencies
Common Issues
Wages on the earnings record after disability onset
Alleged disability onset date does not match the evidence
Substance abuse...material vs. non-material
Suggested Strategies
Contact past employers for clarification of earnings, special conditions, etc.
Consider amending alleged disability onset date to a date where the proof is clear
Compare functioning during periods of use and abstinence
Clarifying letter from treatment provider
Creating the OTR Request
Summarize the evidence, cite proof, and propose consideration of an on-the-record decision
Submit the brief with a bar code or through Electronic Records Express
Follow up with ODAR to be sure the case is pulled for prehearing review
Resources Medical-Vocational Guidelines: 20 CFR Appendix 2 to
Subpart P of Part 404
SSR 96-2p: Policy Interpretation Ruling Titles II and XVI: Giving Controlling Weight to Treating Source Opinions
SSR 96-9p: Policy Interpretation Ruling Titles II and XVI: Determining Capability To Do Other Work
SSR 06-03p: Titles II and XVI: Considering Opinions and Other Evidence from Sources Who Are Not “Acceptable Medical Sources” in Disability Claims
Contact Information
Vicki Dunham, CDMS
Eckman/Freeman and Associates
Social Security Disability Services
Email:[email protected]
Phone (615) 889-1221
Fax (615) 889-4206
SOAR Appeals & Hearings
William A. DoubGenesee County Community Mental Health
Before the Hearing
Find out when the hearing is scheduled
Begin to prepare your client for what’s likely to happen
Determine who is going to be conducting the hearing on behalf of the claimant
Preparing for the Hearing
Request a copy of the Client’s Record Disc from the Hearing Office
Review the claim, including the evidence used to deny the claim
Submit new evidence if applicable Use SSA Disability Criteria and
apply the evidence
Hearing Mechanics
Respond immediately to hearing announcement
Find out the location for the hearing
Contact the judge’s office for the timetable to introduce evidence
Other People at Hearing
A Hearing Monitor and a Vocational Expert are assigned to be present
Pay close attention to the testimony given by the Vocational Expert
What the ALJ Looks For Is all the evidence in the file,
including any new evidence
Does your Medical Summary Report reflect any new evidence
Judges will look at your MSR and consider it a legal framework to review the claim
Evidence During the Hearing
Be prepared to make an opening statement showing how claim meets Listings with new evidence
Judge wants you to present your client’s case and not give testimony
You may be asked to question your client about his/her conditions causing them to be disabled
Closing Statements
You may be asked to provide a closing statement, summarizing key points
Be ready to ‘connect the dots’ and make your client’s case
The ALJ may ask for your recommendations for the client
Final Comments
Don’t panic! There are trainers who can help you get ready for the hearing
Get your client ready for the hearing by meeting with him/her frequently
Be supportive and a source of encouragement.
Contact Information
William A. Doub, MAUPCommunity Housing Supervisor
Genesee County Community Mental Health
Phone: (810) 257-3662
Fax (810) 257-3665