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What Process Does Social Security Use To Evaluate Disability Claims

To determine whether you will be approved for SSDI or SSI, Social Security uses a 5-Step sequential evaluation process. A decision-maker adjudicates disability claims at every stage. Disability Determination Service (DDS) examiners consulting with DDS physicians decide on applications at the Initial Application and Reconsideration phases. When the hearing phase begins, the Administrative Law Judge makes the final decision, often consulting with a Medical Expert (ME). The adjudicator utilizes the following evaluation at each stage.

Step 1: Non-Medical Criteria

The first and most important thing is that you cannot work above what Social Security calls Substantial Gainful Activity (SGA). The monthly gross income you can earn on a pre-tax basis cannot exceed $1,350. The SGA rule is the most important non-medical criterion, but you must meet other criteria for a claim to qualify for a full medical review in Step 2. Your claim will not advance to Step 2. It will be technically denied if you do not meet the non-medical eligibility requirements, regardless of how severe and debilitating your medical conditions are (even if they are well-supported by years of medical evidence). You can appeal technical denials, but if the facts are correct, your appeal will not succeed.

Step 2: Severe Impairment

During Step 2, you will be asked whether your impairments are severe. The medical evidence is gathered and evaluated to determine whether you are severely impaired. Suppose the adjudicator asks you to complete Activities of Daily Living and Vocational Questionnaires during the process. In that case, you will have the opportunity to explain how your symptoms have affected your ability to function normally. DDS contracts with a doctor to provide medical evaluations on your behalf so that an adjudicator may also schedule a Consultative Examination (CE). The adjudicator reviews the evidence and determines if your symptoms are severe once all the information has been assembled. Severe symptoms must make it impossible for the individual to carry out basic work-like activities. The severity can come in many forms, including physical limitations, such as difficulty walking, standing, lifting, pushing, carrying things, etc. It can also include difficulties speaking, hearing, seeing, concentrating, following simple instructions, or getting along with co-workers. Your claim will proceed to Step 3 if your symptoms are severe; otherwise, it will be denied at Step 2, and you will have the chance to appeal.

Step 3: Medical Listings

A disability listing determines whether your impairment meets a medical "listing." Social Security has divided the human body and mind into fourteen different impairment categories, referred to as the Listing of Impairments. Depending on what type of impairment you have, your claim will be evaluated under the appropriate listing. If the impairment is respiratory-related, it would be evaluated under Listing 3.00 respiratory system, but if it is immune-related, Listing 14.00 immune system disorders would be evaluated. In Step 3 of the disability benefits process, if the adjudicator determines that you are disabled based on your medical records, you are eligible for benefits. If you do not meet one of the medical listings, your claim moves to Step 4.

Step 4: Past Work

Step 4 will determine if you can perform the job you previously performed. A judge does this by determining your Residual Functional Capacity (RFC). Your RFC determines what you can still do with your body and mind based on your medical symptoms. Your RFC will consider all impairments and symptoms, including mental and physical impairments and severe and non-severe impairments. The adjudicator will evaluate your ability to sit, stand, walk, lift, carry, push, pull, reach, handle, crouch, remember, comprehend, etc. Depending on the nature of your job, your RFC may have some limitations, such as not being able to walk and stand for more than 4 hours during an 8-hour workday, not being able to sit for more than 2 hours, not being able to lift and carry more than 10 pounds, not being able to climb ropes or ladders, being unable to maintain concentration, persistence, or pace, etc.

Once they have created your RFC, the adjudicator will list your Past Relevant Work (PRW). This refers to any employment during the 15 years immediately preceding your Alleged Onset Date (AOD). As a general rule, if you performed a job close to full-time within 15 years of your AOD for at least a few months, the job is likely to qualify as Past Relevant Work.

As soon as the adjudicator has completed your list of PRW, they must categorize it. Both exertional effort and skill level will be used to categorize the work you have done in the past. Nursing is considered a skilled position since nurses work at the medium exertional level, while security guards work at the light exertional level and are considered semi-skilled. The adjudicator must then determine if you possess the functional ability to execute any of your previous work after all of your PRW has been classified. If the security guard is incapable of standing and walking, for example, as is required for light exertional jobs, their claim would advance to Step 5 based on the limitations found in the RFC. Alternatively, if the adjudicator finds you capable of performing the functions required by your past work, you will be denied. If you disagree, you can appeal the decision.

Step 5: Other Work

In Step 5, you should determine whether you can perform any other work, regardless of whether you have done it before. Additionally, the adjudicator takes into account your age, education, and work experience, as well as your residual functional capacity (RFC).

Your level of education is classified by Social Security as follows:

  • Illiterate (or unable to communicate in English)
  • Marginal (generally 6th grade or less)
  • Limited (generally 7th through 11th grades)
  • High school (and above)

Depending on your level of education, you might be able to perform different jobs with different skill levels. You would only be able to perform unskilled jobs if you possess only a marginal education. Still, if you possess a high school education, you would be expected to fill semi-skilled and skilled positions.

Work experience is the next factor considered by the adjudicator. It refers to your past work-related skills and abilities. You have now reached Step 5, which means that your past work cannot be performed as determined in Step 4. However, the adjudicator will look at whether the skills you acquired from your previous work can be transferred to a different job. For example, a nurse who previously worked at a medium exertional level and no longer can do that work might have acquired skills that would translate to a position as a medical assistant, a position she would be able to do at a light exertional level.

Age is the final factor the adjudicator will consider. Adults with social security benefits are evaluated based on several age categories:

  • Younger (ages 18-49)
  • Closely approaching advanced age (ages 50-54)
  • Advanced age (ages 55-59)
  • Closely approaching retirement age (ages 60+)

In younger individuals, the burden of proving their incapacity to work is much heavier, but it is lighter in older people. This premise is sometimes referred to as the "Grid Rules" or Medical-Vocational Guidelines because key factors are arranged in a grid with a final column that indicates whether the applicant is disabled or not. Disabled status is more likely to be awarded to older, less educated, and possess less transferrable skills in their past work.

You will be found not disabled and denied if the adjudicator determines that you can perform some other type of work given your age, education, and previous work experience. The denial of your application can be appealed. The adjudicator would determine if you are disabled and eligible for disability benefits if you cannot perform any other kind of work.

Applying for Social Security benefits can be an overwhelming process. If you seek SSDI benefits, check out our article on whether you can get SSI And Social Security Retirement at the same time. To learn more, visit DisabilityHelp.org today!

Cheri Hermanson
Cheri leads our team of writers in producing the best quality content there is regarding society and disability, most especially those that helps ease the quality of life for our differently-abled loved ones.
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