The Disability Determination Process

The disability determination process has to be very structured, disciplined, and consistent in order to be successful, fair, and timely. UMass Medical School’s Disability Evaluation Services uses two structured review processes in making disability determinations for our clients.

Once our disability reviewers have gathered all relevant medical data for a specific case, it undergoes the five-step sequential analysis specified by federal and state regulations. When a Medicaid redetermination is necessary, the cases go through an eight-step sequential review.

We constantly evaluate our disability determination process and decision-making for quality assurance, measuring the accuracy of our decisions against Social Security benchmarks. Disability reviewers and managers use case management metrics to monitor timeliness. In cases where there is a serious traumatic injury or other significant diagnosis, our case alert system flags those applications that require faster review.

Five-Step Review

1. Evaluation of an applicant's substantial gainful activity—can he or she work enough hours for self-support?
2. Documentation of the severity and duration of the disability—does the applicant's disability cause work-related functional restrictions? How long are these restrictions expected to last?
3. Evaluation of medical listings (which, in Massachusetts, includes three sets of listings, specified by state and/or federal regulation, depending on the program the client has applied for).
4. Determination of whether the applicant can perform past work, based on assessment of his or her residual functional capacity, which is the maximum work-related abilities the applicant retains in spite of their physical and mental problems.
5. Determination of whether the applicant can perform other work that is within his or her remaining physical and mental capacities.

At the end of the review, Disability Evaluation Services makes a determination and notifies the applicant of the decision according to a plan agreed upon with the customer agency.

Eight-Step Review

1. Evaluation of an applicant's substantial gainful activity—can he or she work enough hours for self-support?
2. Do current impairment(s) meet or equal a Social Security Insurance Listing—evaluate using the current federal listings.
3. Has Medical Improvement occurred? Has the client shown significant improvement in signs, symptoms, and/or laboratory findings?
4. Is Medical Improvement related to the ability to work? Evaluate whether the prior listing is still met/equaled (if the client previously met/equaled a listing) or evaluate the prior and current residual functional capacity (if the client was previously vocationally approved).
5. Are there exceptions to Medical Improvement? Were there any exceptions that occurred that demonstrate the client should no longer be considered disabled or never should have been considered disabled?
6. Are the client’s impairment(s) severe? Does the applicant's disability cause work-related functional restrictions?
7. Determination of whether the applicant can perform past work, based on assessment of their residual functional capacity, which is the maximum work-related abilities the applicant retains in spite of his or her physical and mental health problems.
8. Determination of whether the applicant can perform other work that is within his or her remaining physical and mental health capacities.

Again, at the end of the review, Disability Evaluation Services makes a determination and notifies the applicant of the decision according to a plan agreed upon with the customer agency.