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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.

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using soar in the appeals process

Using SOAR in the Appeals Process

Will Connelly

SAMHSA SOAR TA Center

September 13, 2011

welcome
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
Webinar Instructions
  • Recording availability
  • Q&A segment and chat function
  • Muting
agenda
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
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
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

Reconsideration

Paul Berry, Ph.D.

overview
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
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
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
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
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
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
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
contact information
Contact Information

Paul Berry

Email: [email protected]

Office: 952 432 1091

Cell: 952 412 0794

on the record favorable decision

On-The-Record Favorable Decision

Vicki Dunham

Eckman/Freeman and Associates

the steps
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
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 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
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
Dire Need
  • Submit proof of homelessness
  • Other dire need situations
    • Terminal illness
    • Eviction/foreclosure
    • Suicidal/homicidal tendencies
common issues
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
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
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
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 information26
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

SOAR Appeals & Hearings

William A. DoubGenesee County Community Mental Health

before the hearing
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
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
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
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
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
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
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
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 information36
Contact Information

William A. Doub, MAUPCommunity Housing SupervisorGenesee County Community Mental Health

[email protected]

Phone: (810) 257-3662

Fax (810) 257-3665

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