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Find answers to frequently asked questions.

Question:
How long does a medical provider have to provide information to a patient? Is it a federal mandate or do individual states have a different timeline?

HIPAA requires medical providers to release the patient's records within 30 days after the request is received (https://www.hhs.gov/hipaa/for-professionals/privacy/guidance/access/ind…). Some states have laws that require the release of medical records in fewer than 30 days.

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Question:
If an applicant is approved for SSI/SSDI, will they lose their medicaid and be placed on medicare? If they can have both, which would be their primary insurance?

If a person is approved for both SSI and SSDI they will maintain Medicaid because SSI benefits include Medicaid. However, some states require a separate Medicaid application, (https://www.ssa.gov/disabilityresearch/wi/medicaid.htm).

Medicaid coverage for services varies from state to state. Here is a link that will take you to your state's Medicaid agency: https://www.medicaid.gov/about-us/contact-us/contact-state-page.html.

SSDI benefits include Medicare, but there is typically a 24 month waiting period before the SSDI beneficiary can begin to have Medicare coverage (see Page 12 at https://www.ssa.gov/pubs/EN-05-10029.pdf).

Once the beneficiary has both Medicaid and Medicare, Medicare is typically the primary insurance.

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Question:
Should I actually include information from the Listings and Grids in the MSR, or should I wait until the applicant is denied?

The SAMHSA SOAR TA Center recommends that you don’t cite the Listing and Grid numbers, e.g.) Ms. Jones meets Listing 12.04, and the alternative Grid rule 203.03. Rather, at the DDS level (initial and reconsideration) we suggest providing a description of how the applicant meets a particular Listing(s) or Grid rule through specific examples from the medical records, applicant quotes, and other collateral sources.

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Question:
Should I file a SSI/SSDI claim when there are no medical records available?

Yes, you should file a SOAR-assisted application because even if you don’t have access to the medical evidence, DDS will request directly from prior treating sources and/or schedule appropriate Consultative Examinations (CE) to obtain diagnoses. Remember, SSA needs a diagnosis to make a disability determination. Remember, to write in the “Remarks Section” on SSA forms, about your efforts to obtain medical information so that DDS will know what they need to do to medically develop the claim.

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Question:
How do we find out why a client was previously denied?

You can obtain valuable insight into the reason an applicant was previously denied by reviewing the applicant’s electronic folder, or at minimum, obtaining the “Disability Determination Explanation” or denial notice. Most likely, you will have easy access to the denial notice from the applicant or, if you are the authorized representative, SSA should have mailed a copy to you. You can also request reason for denial by contacting your local SSA office. Learn more at Reviewing Denial Notices.

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Question:
My client's SOAR case has been denied and I would like to ask for another representative to review the case. How do I ask for reconsideration and which forms do I use to request this?
The first level of appeal is the reconsideration. It is an opportunity to have the application reviewed by different staff at DDS and to add new or additional information.
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Question:
Is there any guidance or training on assisting with the appeal process?

Yes, we have a number of resources on the SOAR website to help provide information and guidance through the appeals process. They can all be found in the SOAR Library. I recommend starting with the article About Appeals and then checking out the Appeals Toolkit.

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Question:
If someone has a pending claim for SSDI under appeal with an attorney involved, should/can a SOAR application be submitted?

SSA does not allow an applicant to have multiple applications pending at the same time.  If the applicant chooses to have a new initial SOAR-assisted application for SSDI benefits submitted, then the applicant would need to withdraw their current application.  It is important that the applicant understands that the new application would create a new application date which may result in the loss of retroactive 'back' benefits based on withdrawing the current pending application.

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Question:
I was told there was a list of questions that was good to use during an ALJ appeal hearing.

"Questions for Direct Examination at SSA Administrative Law Judge (ALJ) Hearing," along with other helpful resources, can be accessed on the webinar "Hearing Tips for SOAR Practitioners."

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Question:
Are medical providers required to respond to your request for medical records once you provide a copy of the SSA 827 to them? Is eliciting cooperation from them generally an issue for case managers?

Generally speaking, medical providers are not legally bound to provide records to a third party. They are not required to provide records to DDS, either. However, HIPAA regulations require healthcare providers to provide individuals copies of their own records: 

"The Privacy Rule generally requires HIPAA covered entities (health plans and most health care providers) to provide individuals, upon request, with access to the protected health information (PHI) about them in one or more “designated record sets” maintained by or for the covered entity.

We hear from most SOAR providers that they are able to get medical records from most sources. Some states have special laws that cover access to records for disability applications. We also do our best to build relationships with commonly used providers and the medical records departments to try to improve those relationships, and clarify and expedite processes.

 

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