Reviewing Denial Notices and the Electronic Folder

About the Disability File

The first step when preparing to appeal a denial is to review the Electronic Disability File, so you understand SSA’s rationale for denying disability benefits. This should be done as soon as possible. You should assess whether SSA made any errors in the decision or if any medical documentation is missing from the file. You can help by correcting these issues on appeal.

• The disability file includes the SSA-831: Disability Determination and Transmittal, SSA-4268: Explanation of Determination, unexhibited medical documentation, and various SSA/DDS communications.
• Even if you filed the applicant’s initial application or reconsideration complete with medical records and other documents, other contents of the disability file are important to review. 

Requesting the Disability File

• Applicants and authorized representatives with a filed SSA-1696 can obtain relevant application information.
• Request the file by faxing a signed SSA-3288: Consent to Release Information to the attention of your local SSA field office.
• SSA keeps all new disability files in electronic format; paper files are no longer generated. 
• The local SSA field office will provide one CD-ROM copy of the applicant’s file for free if the request is for “program purposes” (e.g., in connection with a claim for benefits).

Opening the CD-ROM

• No additional software is necessary to read the information on the encrypted CD.
• The CD will be labeled with claimant’s last name and first 4 numbers of SSN.
• See instructions for opening and decrypting the CD-ROM.

Reviewing the File

Form SSA-831: Disability Determination and Transmittal

Overview

• The SSA-831: Disability Determination and Transmittal is the official disability determination document used by DDS to record the decision.
• This form is helpful, especially when the denial notice is unclear. The form should contain the name of the DDS disability examiner and the DDS medical consultant who worked on the claim.
• Most of the information on the form are SSA codes; several key codes are highlighted below

Important SSA Codes

• Item 19: States that the applicant is not disabled through the date of the determination (or other pertinent dates, such as expiration of insured status)
• Item 22: Citation to the Sequential Evaluation regulation under which a claim is denied
  • Common denial basis codes:
    • H1 - The individual has a severe impairment(s) but is found not disabled because he/she has the functional and vocational capacity to engage in substantial gainful activity in relevant past work (Step 4)
    • J1 - Ability to do other work (Step 5)
    • K1 - Failure to follow prescribed treatment
    • L1 - Refusal to appear for a consultative exam (CE)
    • M5 - Failure to cooperate in submitting evidence of disability
    • N1 - Engaging in Substantial Gainful Activity (SGA)
    • Z1 - DAA (Drug Addiction and Alcoholism) is material to the determination of disability
• Item 32B - This includes the specialty code for the doctor who signed the form.

Form SSA-4268: Explanation of Determination

Overview

• The SSA-4268: Explanation of Determination states the “Disability Determination Rationale.” This is also known as the technical rationale. It is the step-by-step reasoning that SSA and DDS used to make the disability determination.
• Although it may contain SSA technical language that is difficult to understand, it is in your best interest to look it over as it contains more detailed information than the denial notice.
• See a sample SSA-4268 (PDF)

Elements of the Technical Rational

• Symptoms and test results
• Whether the impairment(s) meet the requirements of a listing
• The applicant’s Residual Functional Capacity (RFC)
• The exertional level and skills the applicant’s past jobs required
• Whether the applicant can do past work, given current limitations
• Whether a medical-vocational rule says that, with vocational factors (age, education, and experience), the applicant should be able to do other work, and if so, what type of other work exists that is suitable.