Using SOAR in the Appeals Process

1. Using SOAR in the Appeals Process Will Connelly SAMHSA SOAR TA Center September 13, 2011

2. 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

3. Webinar Instructions • Recording availability • Q&A segment and chat function • Muting

4. 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

5. 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

6. 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

7. Reconsideration Paul Berry, Ph.D.

8. 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

9. 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

10. 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

11. 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.

12. 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

13. 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

14. 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

15. Contact Information Paul Berry Email: plb.maine@gmail.com Office: 952 432 1091 Cell: 952 412 0794

16. On-The-Record Favorable Decision Vicki Dunham Eckman/Freeman and Associates

17. 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

18. 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

19. 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

20. 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

21. Dire Need • Submit proof of homelessness • Other dire need situations • Terminal illness • Eviction/foreclosure • Suicidal/homicidal tendencies

22. 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

23. 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

24. 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

25. 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

26. Contact Information Vicki Dunham, CDMS Eckman/Freeman and Associates Social Security Disability Services Email:VDunham@eckmanfreeman.com Phone (615) 889-1221 Fax (615) 889-4206

27. SOAR Appeals & Hearings William A. DoubGenesee County Community Mental Health

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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.

36. Contact Information William A. Doub, MAUPCommunity Housing SupervisorGenesee County Community Mental Health WDoub@gencmh.org Phone: (810) 257-3662 Fax (810) 257-3665