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Social Security & SSI Appeals

Description of the Social Security Appeals Process

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Summary

Social Security appeal issues may include all actions taken against an applicant or a recipient in reference to benefit eligibility, benefit amount, benefit suspension or termination, recoupment, waiver of overpayments, and technical program requirements for Social Security Retirement and Survivors Insurance, Social Security Disability Insurance, and Supplemental Security Income.

There are three levels of administrative appeal: reconsideration, the Administrative Law Judge hearing and Appeals Council review. If an individual is dissatisfied with the Appeals Council decision s/he can request judicial review in federal court.

A consolidated hearing occurs at the ALJ hearing level, where an ALJ will hear more than one case involving the same claimant. In addition, even when a determination or decision has become final it may be reopened and revised by the reviewing local SSA office (for reconsideration), ALJ, or Appeals Council, whichever was the office that issued the final decision.

Finally, when there is a viable constitutional issue, claimants may not need to exhaust all the administrative remedies before requesting judicial review. This procedure is rare and can only be used when the claimant wishes to challenge a part of the law as unconstitutional, not because of a need for a quicker decision.

Note

The regulations governing the appeals procedure on disability determinations for Social Security Disability benefits and Supplemental Security Income are generally identical. Where the matter on appeal is a non-disability, such as alleged overpayment or continuing disability, the regulations governing the appeals procedure for Social Security Retirement and Survivor benefits, Social Security Disability Insurance and SSI are generally the same.

Statutes and Regulations

The formal appeals procedure for Social Security benefits has fewer established procedural guidelines than those governed by Cash Assistance, SNAP or Medicaid. The Social Security programs, including the appeal procedures, are governed by 20 CFR (Code of Federal Regulations). 20 CFR § Part 416 applies to SSI benefits and 20 CFR Part 404 applies to Social Security Insurance benefits. The appeal procedures are specifically found at 20 CFR § 416.1400 et. seq. for SSI and 20 CFR § 404.900 et. seq. for Social Security benefits.

Programs Covered by the Social Security Appeals Process

The following Social Security programs are covered by its appeals process: Social Security Retirement and Survivors Insurance, Social Security Disability Insurance, and Supplemental Security Income.

Social Security appeals issues may include all actions taken against an applicant or a recipient in reference to benefit eligibility, benefit amount, benefit suspension or termination, recoupment, waiver of overpayments, and technical program requirements. There are some issues that SSA has decided are not appealable. They are listed in the following regulation: 20 CFR §§ 404.903; 404.1403.

For appeal procedures for Cash Assistance, SNAP and Medicaid refer to Advocacy, Fair Hearings. For appeal procedures for other benefit programs, including Medicare and Medicare Part D, refer to the respective chapter.

Levels of the Social Security Appeals Process

There are three levels of administrative review: reconsideration, the Administrative Law Judge hearing and the Appeals Council. If a claimant is dissatisfied with the decision at the final level of administrative appeal, s/he can request a judicial review. With only some exceptions, a claimant must exhaust all levels of administrative remedies before proceeding to federal court. See below, Levels of the Social Security Appeals Process for a more thorough description of each level of appeal.

Consolidated Hearings

A consolidated hearing occurs at the ALJ hearing level, where an ALJ will hear more than one case involving the same claimant. With a consolidated hearing, all the claimant’s pending claims do not have to be at the ALJ hearing level. If the ALJ does decide to combine all the claimant’s cases, the ALJ will decide all the issues, even if SSA has not yet made an initial or reconsideration decision on the other claims or appeals. Also, there will be only a single record at the hearing so the evidence introduced in one claim becomes evidence in the other claims.

Criteria that must be met to grant a consolidated hearing include:

  • The claimant has requested a hearing to decide eligibility for benefits for one provision of the Social Security Act and has also requested a hearing to determine his/her rights under another provision administered by the SSA, and
  • One or more of the issues to be considered at the hearing is the same issue that is involved in another claim pending before the SSA.

Consolidated hearings occur most frequently when a claimant files under only one disability program (SSDI or SSI) and then discovers later that s/he might be eligible for the other disability program, and so files a later application for that claim. The first claim is pending for a hearing; the second claim, just filed, can be consolidated with the first even though no initial or reconsideration denial has been made on the later-filed claim.

An individual can request a consolidated hearing by informing the local SSA office of his/her pending hearing at the OHO (Office of Hearings Operations) and asking that the additional claim be sent to OHO for consolidation.

When two claims are consolidated for a hearing the ALJ will decide both claims as one, so if a claimant wishes to appeal the ALJ decision, s/he may continue the administrative review process by appealing to the Appeals Council.

Reopening/Revising Decisions

DEFINITION

Even though a determination or decision has become final it may be reopened and revised by the reviewing local SSA office (for reconsideration), ALJ, or Appeals Council, whichever was the office that issued the final decision. SSA has the right to reopen the claimant’s case either on its own initiative or upon request of the claimant and SSA has the right to deny a reopening. If SSA does reopen the case, it also has the right to revise the determination either to the benefit or detriment of the claimant.

WHEN A DETERMINATION MAY BE REPOPENED

A determination may be reopened:

  • Within 12 months of the date of the notice of the initial determination for any reason, or
  • Within 4 years for SSDI (2 years for SSI) from the date of the notice of the initial determination, if there is good cause, or
  • At any time, if the decision was obtained by fraud or similar fault.

Good cause to reopen the determination will be found when:

  • New material evidence is furnished, or
  • A clerical error was made in figuring the benefit amount, or
  • The evidence that was considered clearly shows an error was made, or
  • In addition, a claimant may show good cause for missing a deadline to appeal a decision if a mental defect prevented the claimant from pursuing such an appeal. Mental defect includes mental, emotional or intellectual impairments, and limitations resulting from age, mental or physical condition, lack of education or lack of facility with the English language. The evidence, however, must relate to the time when an appeal could have been filed and must clearly demonstrate why the claimant was incapable of pursuing the appeal at that time. If SSA denies “good cause” reopening, the decision is generally not appealable.

SSA will not find good cause to reopen the case if the only reason to do so is a change of legal interpretation or administrative ruling upon which the determination was made.

Advocacy Tip

In some cases, it may be worth immediately requesting a reopening of the denial or dismissal of a case rather than filing an appeal. This could be effective in cases where the ALJ decision plainly overlooks a key fact or evidence, or when there is evidence of good cause for missing a hearing. Given the long wait for hearings and Appeals Council review, this strategy could save a great deal of time.

Expedited Appeals Procedure for Constitutional Issues

When there is a viable constitutional issue, claimants might not need to exhaust all the administrative remedies (reconsideration, ALJ hearing, or the Appeals Council) before requesting a judicial review. This procedure can only be used when the claimant wishes to proceed directly to federal court to challenge Social Security law or policy as unconstitutional, not because of a need for a quicker decision.

However, the expedited review process relevant to constitutional claims can only be employed when SSA agrees that the only issue is a constitutional issue and that it would be futile to require a claimant to proceed with the administrative appeals process.

To assert that the only issue is a constitutional issue, the claimant or his/her representative should send a letter to SSA explaining the issue, why it is the sole issue in dispute and request a written decision that expedited appeal to the federal court should be allowed. If SSA fails to respond, follow-up with a phone call. If SSA does not agree that the only issue is a constitutional issue, then be prepared to go ahead with a hearing.

This process is very rare, and appeals are otherwise always required to exhaust administrative remedies. Failure to do so, when required, would result in delay and potential loss of benefits for the claimant who may ultimately succeed through the administrative process. Anyone attempting to use this process should consult an attorney.