20 C.F.R. Subpart A—Introduction, General Description, and Definitions
Title 20 - Employees' Benefits
(a) General. This part explains our procedures for adjudicating the disability portion of initial claims for entitlement to benefits based on disability under title II of the Social Security Act or for eligibility for supplemental security income payments based on disability or blindness under title XVI of the Act. All adjudicators derive their authority from the Commissioner and have the authority to find facts and, if appropriate, to conduct a fair and impartial hearing in accordance with section 205(b) of the Act. (b) Explanation of the administrative review process. Generally, the administrative review process consists of several steps, which must be requested within certain time periods. The administrative review process steps are: (1) Initial determination. When you claim disability benefits and a period of disability under title II of the Act or eligibility for disability or blindness payments under title XVI of the Act, we will make an initial determination on your claim. See §§404.902–.903 and 416.1402–.1403 of this chapter for a description of what is and what is not an initial determination. (2) Review of initial determination. If you are dissatisfied with our initial determination, you may request review by a Federal reviewing official. (3) Hearing before an administrative law judge. If you are dissatisfied with a decision made by the Federal reviewing official, you may request a hearing before an administrative law judge. The administrative law judge's decision becomes our final decision, unless your claim is referred to the Decision Review Board. (4) Decision Review Board. When the Decision Review Board reviews your claim and issues a decision, that decision is our final decision. (5) Federal court review. If you are dissatisfied with our final decision as described in paragraphs (b)(3) and (4) of this section, you may request judicial review by filing an action in Federal district court. (c) Nature of the administrative review process. (1) Non-adversarial proceeding. In making a determination or decision on your claim, we conduct the administrative review process in a non-adversarial manner. (2) Evidence considered and right to representation. Subject to the provisions of §§405.331 and 405.430, you may present and we will consider information in support of your claim. We also will consider any relevant information that we have in our records. To help you present your claim to us, you may have someone represent you, including an attorney. (3) Evidentiary standards applied. When we make a determination or decision on your disability claim, we will apply a preponderance of the evidence standard, except that the Decision Review Board will review findings of fact under the substantial evidence standard. (4) Clarity of determination or decision. When we adjudicate your claim, the notice of our determination or decision will explain in clear and understandable language the specific reasons for allowing or denying your claim. (5) Consequences of failing to timely follow this administrative appeals process. If you do not seek timely review at the next step required by these procedures, you will lose your right to further administrative review and your right to judicial review, unless you can show good cause under §405.20 for your failure to request timely review. (d) Expedited appeals process. You may use the expedited appeals process if you have no dispute with our findings of fact and our application and interpretation of the controlling law, but you believe that a part of that law is unconstitutional. This process permits you to seek our agreement to allow you to go directly to a Federal district court so that the constitutional issue(s) may be resolved. As used in this part: Act means the Social Security Act, as amended. Administrative appeals judge means an official, other than an administrative law judge, appointed by the Commissioner to serve on the Decision Review Board. Administrative law judge means an administrative law judge appointed pursuant to the provisions of 5 U.S.C. 3105 who is employed by the Social Security Administration. Board means Decision Review Board. Commissioner means the Commissioner of Social Security, or his or her designee. Date you receive notice means five days after the date on the notice, unless you show us that you did not receive it within the five-day period. Day means calendar day, unless otherwise indicated. Decision means the decision made by a Federal reviewing official, an administrative law judge, or the Decision Review Board. Decision Review Board means the body comprised of administrative law judges and administrative appeals judges that reviews decisions and dismissal orders by administrative law judges. Disability claim or claim means: (1) An application for benefits that is based on whether you are disabled under title II of the Act, or (2) An application for supplemental security income payments that is based on whether you are disabled or blind under title XVI of the Act. (3) For purposes of this part, the terms “disability claim” or “claim” do not include a continuing disability review or age-18 redetermination. Document includes books, records, correspondence, papers, as well as forms of electronic media such as video tapes, CDs, and DVDs. Evidence means evidence as defined under §§404.1512 and 416.912 of this chapter. Initial determination means the determination by the State agency. Medical expert means a medical professional who has the qualifications required by the Commissioner and who provides expertise to disability adjudicators at the initial, Federal reviewing official, and administrative law judge levels of the administrative review process. Medical and Vocational Expert System means the body comprised of medical, psychological, and vocational experts, who have qualifications required by the Commissioner. It provides expertise to disability adjudicators at the initial, Federal reviewing official, and administrative law judge levels of the administrative review process. Medical and Vocational Expert Unit means the body within the Medical and Vocational Expert System that is responsible, in part, for overseeing the national network of medical, psychological, and vocational experts. National network means those medical, psychological, and vocational experts, which may include such experts employed by or under contract with the State agencies, who have the qualifications required by the Commissioner and who, under agreement with the Medical and Vocational Expert Unit, may provide advice within their areas of expertise to adjudicators at all levels of the administrative review process. Preponderance of the evidence means such relevant evidence that as a whole shows that the existence of the fact to be proven is more likely than not. Psychological expert means a psychological professional who has the qualifications required by the Commissioner and who provides expertise to disability adjudicators at the initial, Federal reviewing official, and administrative law judge levels of the administrative review process. Quick disability determination means an initial determination on a claim that we have identified as one that reflects a high degree of probability that you will be found disabled and where we expect that your allegations will be easily and quickly verified. Quick Disability Determination Unit means the component of the State agency that is authorized to make quick disability determinations. Federal reviewing official means a Federal official who reviews the initial determination. State agency means the agency of a State that has been designated by the State to carry out the disability determination function. It also means the Federal disability determination services and agencies that carry out the disability determination function in Puerto Rico, Guam, and the District of Columbia. Substantial evidence means such relevant evidence as a reasonable mind might accept as adequate to support a conclusion. Vacate means to set aside a previous action. Vocational expert means a vocational professional who has the qualifications required by the Commissioner and who provides expertise to disability adjudicators at the initial, Federal reviewing official, and administrative law judge levels of the administrative review process. Waive means to give up a right knowingly and voluntarily. We, us, or our refers to the Social Security Administration. You or your refers to the person who has filed a disability claim and, where appropriate, his or her authorized representative. (a) General. The Medical and Vocational Expert System is comprised of the Medical and Vocational Expert Unit and a national network of qualified medical, psychological, and vocational experts, which is overseen by the Medical and Vocational Expert Unit. These experts from the national network will assist Federal reviewing officials and administrative law judges in deciding claims. Medical and psychological experts from the national network may assist a State agency in determining disability when the State agency does not have the necessary expertise available to it. The Medical and Vocational Expert Unit also will maintain a national registry of vocational experts having qualifications required by the Commissioner who could provide vocational evidence at the initial level. (b) Network of medical, psychological, and vocational experts. From time to time, the Commissioner may establish qualifications that medical, psychological, and vocational experts must meet in order to join the network. Any medical, psychological, or vocational experts meeting those qualifications, including State agency medical or psychological consultants, may become part of the network. (1) Use of medical and psychological experts at the State level. (i) If a State agency requests assistance from us, the Medical and Vocational Expert Unit may assign, to the extent practicable, a network expert to a claim. (ii) If a State agency is unable to obtain expertise that the Commissioner requires to adjudicate claims involving particular impairments, the Medical and Vocational Expert Unit will assign a network expert to a claim. (iii) The medical or psychological expert so assigned will serve on the State agency's adjudication team as a medical or psychological consultant and will be deemed qualified as such under §§404.1616 and 416.1016 of this chapter. (2) Use of network experts at Federal level. Both Federal reviewing officials and administrative law judges may request evidence from a claimant's treating source, including requesting a treating physician to conduct a consultative examination. However, if they need additional medical, psychological, or vocational documentary or testimonial evidence to adjudicate a claim, they must use the Medical and Vocational Expert System. (3) Experts who provide evidence at your request. Experts whom you ask to provide evidence on your claim are not required to be affiliated with the network or meet the qualifications that we establish. (c) National registry of vocational experts. Vocational experts having the qualifications established by the Commissioner may be included in a registry that we will maintain. The registry will be maintained for and made available to State agencies. (a) If you wish us to extend the deadline to request a review under §405.210, a hearing under §405.310, action by the Decision Review Board under §405.427(a), or judicial review under §§405.501–.505, you must establish that there is good cause for missing the deadline. To establish good cause, you must show us that— (1) Our action misled you; (2) You had a physical, mental, educational, or linguistic limitation(s) that prevented you from filing a timely request; or (3) Some other unusual, unexpected, or unavoidable circumstance beyond your control prevented you from filing a timely request. (b) Examples of circumstances that, if documented, may establish good cause include, but are not limited to, the following: (1) You were seriously ill, and your illness prevented you from contacting us in person, in writing, or through a friend, relative, or other person; (2) There was a death or serious illness in your immediate family; (3) Important records were destroyed or damaged by fire or other accidental cause; (4) You were trying very hard to find necessary information to support your claim but did not find the information within the stated time period; (5) Within the time limit for requesting further review, you asked us for additional information explaining our action, and within 60 days of receiving the explanation, you requested a review; (6) We gave you incorrect or incomplete information about when and how to request administrative review or to file a civil suit; (7) You did not receive notice of the determination or decision; or (8) You sent the request to another Government agency in good faith within the time limit, and the request did not reach us until after the time period had expired. Adjudicators at all levels of the administrative review process recognize the need for fair and impartial consideration of the merits of your claim. Any adjudicator who has any personal or financial interest in the matter pending for determination or decision will withdraw from conducting any proceeding with respect to your disability claim. If the adjudicator so withdraws, we will assign your claim to another adjudicator for a determination or decision. At all levels of the administrative review process, we do not give inappropriate consideration to your race, color, national origin, age, sex, religion, or nature of your impairment(s). If you believe that an adjudicator has improperly discriminated against you, you may file a discrimination complaint with us. You must file any such complaint within 180 days of the date upon which you became aware that you may have been discriminated against. (a) What is this Appendix for? This appendix lists the type of claims that will be handled under the procedures in this part, and in which States we will apply these procedures. If you meet the criteria in paragraphs (b) and (c) of this appendix, we will apply the procedures in this part when we decide your disability claim. (b) What claims will be handled under the procedures in this part? (1) We will apply the procedures in this part if you file a disability claim (as defined in §405.5) in one of the States listed in paragraph (c) of this appendix. (2) If you move from one State to another after your disability claim has been filed, adjudicators at subsequent levels of review will apply the regulations that initially applied to the disability claim. For example, if you file a claim in a State in a region in which we have implemented the procedures in this part, the procedures in this part will apply to the disability claim at subsequent levels of review, even if you move to a State in a region where we have not yet implemented these procedures. Conversely, if you file a claim in a State in a region where we have not yet implemented the procedures in this part, we will adjudicate the claim using the procedures in part 404 or 416 of this chapter, as appropriate, even if you subsequently move to a State where we have implemented the procedures in this part. (c) Which States are using the procedures in this part? The procedures in this part apply in Maine, New Hampshire, Vermont, Massachusetts, Rhode Island, and Connecticut. (d) Section 405.835 will be effective one year from the effective date of this rule.
Title 20: Employees' Benefits
PART 405—ADMINISTRATIVE REVIEW PROCESS FOR ADJUDICATING INITIAL DISABILITY CLAIMS
Subpart A—Introduction, General Description, and Definitions
§ 405.1 Introduction.
§ 405.5 Definitions.
§ 405.10 Medical and Vocational Expert System.
§ 405.20 Good cause for extending deadlines.
§ 405.25 Disqualification of disability adjudicators.
§ 405.30 Discrimination complaints.
Appendix to Subpart A of Part 405—Claims That Will Be Handled Under the Procedures in This Part
