MEDICAL EXPERT HANDBOOK - Social Security Administration
MEDICAL EXPERT August 2017 HANDBOOK
Social Security Administration Office of Hearings Operations Office of the Chief Administrative Law Judge
MEDICAL EXPERT HANDBOOK
Social Security Administration
Office of Hearings Operations Office of the Chief Administrative Law Judge
Preface
Thank you for becoming a medical expert (ME) for the Office of Hearings Operations (OHO). This handbook provides the basic information you will need when you participate in administrative law judge (ALJ) hearings. The handbook explains Social Security's disability programs, the appeals process we use, your role and responsibilities, and technical information you must know. We hope that you will find this handbook interesting and useful. If you have any comments or questions about it, please write or call:
Social Security Administration Office of Hearings Operations Office of the Chief Administrative Law Judge 5107 Leesburg Pike, Suite 1608
Falls Church, VA 22041 (703) 605-8500
OHO.OCALJ.ME.VE.Program@
i
Table of Contents
In General-Disability Overview, Medical Experts,
and the Social Security Appeals Process
1
What are Social Security's Disability Programs?
1
Where Do You Fit In?
1
What is an "ME"?
3
What is an ALJ?
3
What is "Disability" for Social Security Programs?
3
What Happens at the ALJ Hearing?
5
What is the Appeals Council?
6
What are Federal Court Appeals?
7
Role of the ME
8
Responsibilities of the ME
8
Conduct of the ME
10
Pre-Hearing Preparation
10
Protecting Personally Identifiable Information (PII)
11
Determining Disability
13
Detailed Definitions of Disability
13
Determining Initial Disability for All Title II and Adult
Title XVI Cases
15
The Sequential Evaluation Process
15
Step 1
16
Step 2
16
Step 3
18
Residual Functional Capacity (RFC)
21
Step 4
22
Step 5
23
Determining Initial Disability under Title XVI for Individuals
under Age 18 (Title XVI (SSI) Childhood Cases)
24
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__________ii____ __Medical Expert Handbook
Determining Continuing Disability
28
Continuing Disability Reviews (CDRs) and Medical Improvement 28
Age-18 Redeterminations
30
Interrogatories
31
Other Medical Considerations
33
Mental Impairments in Adults
33
Symptom Evaluation
34
Onset of Disability
35
Duration of Disability
35
Failure to Follow Prescribed Treatment
36
List of References
38
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__________iii____ __Medical Expert Handbook
In General-Disability Overview, Medical Experts, and the Social Security Appeals Process
What are Social Security's Disability Programs?
The Social Security Administration (SSA or agency) administers several programs that pay disability benefits to individuals. Under Title II of the Social Security Act (Act), 1 disability benefits may be paid to people who work in "covered" employment or self-employment and who pay sufficient Social Security taxes2 to become "insured" for disability benefits. There are also disability benefits that may be paid to the disabled adult children of insured workers who retire, die, or are themselves disabled, and disability benefits that may be paid to certain disabled widows and widowers of insured workers. We often refer to these benefits as "Title II" disability benefits in reference to the title of the Act that provides for these benefits.
We administer another disability program under Title XVI of the Act. Title XVI provides payments of Supplemental Security Income (SSI) to individuals who are age 65 or older, or blind or disabled, and who have limited income and resources. Title XVI (SSI) payments are funded from general tax revenues and not from Social Security taxes, because eligibility for Title XVI programs is not based on payment of Social Security taxes.
Where Do You Fit In?
We use medical experts (ME) to provide evidence at hearings before an administrative law judge (ALJ).3 At this level of our administrative review process people ask for a de novo hearing before an ALJ regarding a prior determination on their claim for benefits under the Social Security disability program.
The administrative review process is our term for a multi-step process of application (or other initial determination) and appeals.
1 The Social Security Act, 42 U.S.C. 301 et seq., is the federal law governing Social Security Benefits. 2 Federal Insurance Contributions Act (FICA) or Self-Employment Contributions Act (SECA) taxes. 3 Hearing office staff select MEs in rotation, subject to the ME's availability and based upon a request from the ALJ for a particular medical specialty. HALLEX I-2-5-36.
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