Targeted Denial Reviews by SSA

June 28, 2017

SSA is required to review at least half of the favorable disability determinations issued by state agencies. However, SSA also reviews a smaller number of unfavorable decisions prior to effectuation. This “Targeted Denial Review” (TDR) process keeps several thousand cases a year from being appealed to ALJs, and thus potentially reduces the hearings backlog and provides faster service for those claimants. SSA uses a predictive model to select cases for TDR, with the goal of locating the denials that are most likely to be reversed at the hearing level. In Fiscal Year (FY) 2016, SSA’s Office of Quality Review (OQR) performed 43,643 TDRs. The FY 2017 goal is 50,000 TDRs.

 

About two thirds of the claims returned to state agencies after a TDR result in the adjudicating component issuing a favorable decision. The “reversal rate” of returned claims has ranged from 63.5% to 68.3% in recent years. In FY 2016, adjudicating components issued favorable decisions on 66.4% of the cases returned to them after a TDR.

 

3,376 claims were reversed after in FY 2016. Since Fiscal Year 2012, more than 17,000 DDS-level denials were reversed through TDRs.

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