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Understanding the Social Security Appeals Process: Explained by Marken Law Group

SSA Appeals: What Are They and When to Request One

SSA stands for the Social Security Administration, a federal agency in the United States that manages social security benefits programs.

SSA appeals are a process through which a person who has been denied social security benefits or is unhappy with the amount of benefits received can request a review of their case. The appeals process can result in the original decision being overturned or modified.

What is a Social Security Determination?

A determination is a decision that SSA makes for a claim. If you disagree with the SSA’s determination for your claim, you can make an appeal. If you submit a claim for your SSI payment, SSA will give you the amount they determined you are eligible for. If you think that the payment is too low, you can make an appeal.

Are there Eligibility Requirements to Appeal to a Determination?

Everyone is eligible to appeal SSA’s determination for their initial claims. Simply file an application for SSI within the proper deadlines. We will then mail you your first notice of “initial determination.” 

If you want to appeal the initial determination, the deadline is within 60 days of the date you received your “initial determination.” By doing so, you will receive another notice instructing you how to appeal and if you are entitled to continued benefits.

Suppose you file for an appeal for the initial determination regarding the amount of your SSI payment. The deadline is the same. You will then receive the same amount until SSA decides on your appeal.

But what if your medical disability benefits are to be discontinued? You must appeal for your eligibility within ten days of receiving such notice. While SSA determines your appeal, your SSI benefits will continue with the same amount.

The Social Security Administration (SSA) Appeals Process: Step-by-Step

The stages of SSA appeals are: 1.) Reconsideration, 2.) Hearing by an administrative law judge (ALJ), 3.) Appeals Council Review, and 4.) Federal Court. The SSA appeals process comes in stages and timelines so that if you disagree with the second determination, you move higher up to take your case to a person of a higher position. Each stage may need you to meet requirements within 60 days to proceed. You can also have a hearing with an ALJ to discuss your case. 

Tips for Preparing for a Hearing for an SSA Appeal

When you are in a hearing, the judge will have to explain why your case has been determined as such and ask you and your representative questions about your case. You may bring a witness to answer the judge’s questions under oath. The judge may also call an expert if needed to testify.

Therefore, you can do the following for your hearing preparation:

1. Review all evidence in your case file. Submit new evidence, if available, to strengthen your case. The new evidence must be submitted within five days before the hearing. If you have less than five days before the hearing, you can appeal for a time extension to review the new evidence.

2. If you have any evidence you want the ALJ to consider, submit them as soon as possible. You can send electronic evidence through a special fax number and bar code provided by the hearing office through the Electronic Records Express (ERE).

The Reconsideration Stage: How to Request Another Review

At the reconsideration stage, a different SSA claims examiner reviews the original decision to ensure all evidence is considered and the correct decision is made. You must fill out the following forms based on your SSA appeal. Once the request is received and reviewed, the SSA will send a notice of reconsideration determination. 

During this stage, we recommend adding any additional evidence that you have available. 

Here are the ways to request reconsideration:

  • Disability Claim or Non-medical Issue

Appeal a Decision online, or send a “Request for Reconsideration (SSA-561-U2)” form to your local SSI fax number and address (see Social Security Office Locator to find a branch near you). Deadline is up to 60 days after receiving your notice.

  • Medical Disability Cessation

Send “SSA-789 (Request for Reconsideration Disability Cessation)” form within 60 days after the date of receiving your notice. To continue receiving payments until a new determination is made, send the form within ten days after receiving your notice.

  • Non-Medical Initial Determination

Send a form “SSA-263 (Waiver of Supplemental Security Income Payment Continuation).” If the form is sent within ten days after receiving your notice, the payment amount will continue until reconsideration. However, if the form is sent within 11-60 days after receiving your notice, the payment amount will lessen until reconsideration.

The Hearing Stage: What to Expect and How to Prepare

If the reconsideration decision is unfavorable, the next stage of the SSA appeal is a hearing before an Administrative Law Judge (ALJ). The ALJ will listen to the individual’s case and any new evidence presented and make a new decision based on the evidence.

The following are ways to request a hearing:

What if My Disability or Situation Prevents Me from Being Present at My Hearing?

If you cannot or do not want to be present in your hearing due to your disability, you must let them know upon requesting a hearing. Contact your ALJ, explain your reasons, and mention the evidence based on your file. The ALJ can give you a copy of the hearing’s recording. 

What if I cannot Go to My Hearing?

While the person needs to attend their own hearing, there can be reasons why you cannot come, such as a family emergency. If so, you must contact the ALJ before the hearing as soon as possible. Explain why and if it is a good reason, the AJL will reschedule the hearing. If the ALJ thinks the reason is not good enough, your request for a hearing can be dismissed.

How to Present Your Case and Answer the Questions

The AJL will be there to know more about your case straight from the source: you and your representative. Here are the topics that you may have to answer in the hearing process:

  • Your medical conditions that cause your disability and symptoms
  • Limitations caused by your disability in your activities of daily living
  • Your education, training, and work experience
  • Work history

Presenting your case can put you in a lot of pressure, especially when answering questions. Therefore, to present your case in the hearing stage, you can do the following:

  • Provide updated medical records
  • Create a cheat sheet to refer to for all the important details about your case or disability.
  • Get a written doctor’s statement regarding your medical condition if needed.
  • Get an attorney to navigate the disability law and represent your case.

Appeals Council Review: The Final Administrative Step

If the ALJ decision is not satisfactory, the next stage of appeal is to request a review to the SSA Appeals Council. The Appeals Council may review the case and make a new decision or send the case back to the ALJ for further review.

Here are ways on how to request a review:

The Appeals Council can either grant, deny or dismiss your case upon examination. Therefore, you must have new evidence on or before the hearing decision. If there is reasonable cause to believe that said evidence would change the outcome, the Appeals Council will review your case. 

Upon reviewing your case, they can return it to the ALJ for another hearing. If they choose to decide your case, it can go two ways. 

  1. If they make a less favorable decision to you, you will be sent a notice before issuing the decision. This way, you or your representative can respond appropriately. 
  1. However, if the decision puts you in a more favorable end, they will enact it and send you a notice afterward. 

Either way, you get a copy of the review process and the reasons behind the decision-making.

Appealing to Federal Court: What You Need to Know

If the Appeals Council decision is unfavorable, the final stage of appeal is a federal court appeal. 

In this stage, you must file an action in the US District Court. The deadline will be up to 60 days after receiving your notice of the Appeals Council’s action. You are expected to receive the notice five days after the date of the notice.

The US District Court will process the presenting case and determine the final Agency decision. You can expect the court to:

  1. Send the case back to SSA for a new hearing and issue a new decision
  2. Order the SSA to award the benefits
  3. Dismiss the case.

Social Security Disability Claims: Understanding the Decision Process 

Before disability claims are appealed, they have to go through a decision process, medical and non-medical criteria, to determine the claimants’ eligibility for disability profits. To avoid jumping hoops of appealing claims, it is recommended to meet all requirements firsthand through the decision process of social security.

Review of Applications

SSA receives applications for disability benefits in person, by fax, by mail, or online. The application form inquires for a description of the claimant’s impairments from the alleged disability and its treatment sources.

The SSA Field Office (FO) verifies the non-medical eligibility requirements of the claimants. These requirements include age, marital status, employment status, or Social Security coverage information.

H3: Medical Records Review

After reviewing the applications, they are sent to the DDS to evaluate for disability. The DDS reviews the medical documentation of the claimants.

Consultative Examination

If the files are insufficient, they will do a consultative examination to have more additional information. They can contact the healthcare providers of the claimants or obtain information from an independent source.

Disability Determination

Lastly, the DDS determines disability, computes the benefit amount, and pays the benefits. If the claims are denied, they are stored in case claimants want to appeal them. 

Why You Need a Representative to Help with Your Appeal

Appealing claims can take a lot of time and energy that you can use for your other priorities. A representative experienced with the SSA appeals process can help increase the likelihood of a successful appeal. They can help you get your benefits by navigating the complex appeals process and qualifications. 

Many qualified non-attorney representatives work on a contingency fee basis, which means they only get paid if you win your appeal. This can be a helpful option for individuals who cannot afford legal fees upfront.

Here at Marken Law, we know how valuable your time and effort are. Schedule a consultation to get successful appeals today.