Deep knowledge of the Social Security Administration's disability determination business process and enterprise architecture for architects designing solutions that must align with SSA's operational and policy framework. Use this skill whenever someone asks about: SSA disability determination workflow, sequential evaluation, Listings of Impairments, Residual Functional Capacity (RFC), DDS operations, medical evidence evaluation, consultative examinations, SSA adjudicative levels, disability claim processing, SSA POMS policy, DDS quality assurance, or how SSA makes disability decisions. Also use when an architect needs to understand the business process context before designing a solution — especially for AI/ML, clinical decision support, health IT, or case processing modernization targeting SSA. This skill pairs with ssa-hit-architect, which covers the technical HIT integration layer. Use this skill first to understand the business problem; use ssa-hit-architect for integration specifics.
This skill provides the business process and policy foundation that any architect must understand before designing solutions for SSA's disability determination program. It covers how SSA decides whether someone is disabled, what evidence is required at each step, how that evidence is evaluated, and what systems and people are involved.
Companion skill: ssa-hit-architect covers the Health IT technical integration
layer — record collection channels, MEGAHIT, EDCS, CEF, eHEX protocol.
Use this skill first. Use ssa-hit-architect when you reach integration specifics.
For detailed policy on each topic, read the relevant reference file:
references/sequential-evaluation.md — five steps, RFC, Grid Rules, onset, CDRreferences/evidence-framework.md — evidence categories, MER policy, CE, representationreferences/listings-structure.md — Listings body systems, meeting vs. equaling, AI opportunityreferences/adjudicative-levels.md — DDS/OHO/AC workflow, system touchpoints, MEGAHIT gaps by levelSSA administers two disability programs under the Social Security Act:
Title II — Social Security Disability Insurance (SSDI)
Title XVI — Supplemental Security Income (SSI)
Scale:
Definition of disability (statutory): Unable to engage in any Substantial Gainful Activity (SGA) due to a medically determinable physical or mental impairment expected to last at least 12 months or result in death. SSA does not award temporary or partial disability.
SSA uses a five-step sequential evaluation process for adult initial claims. Each step is evaluated in order. If a determination can be made at any step, evaluation stops — the subsequent steps are not considered.
Citation: 20 CFR 404.1520 and 416.920 | DI 22001.001 (June 2024)
Question: Is the claimant currently working at SGA level?
SGA thresholds are set annually. Work activity is evaluated by earnings and nature of work. SGA does not apply to Age 18 redeterminations.
Question: Does the claimant have a severe medically determinable impairment (MDI) or combination of MDIs that meets the duration requirement?
An impairment is severe if it significantly limits basic work activities. Must be established by objective medical evidence from an acceptable medical source. Claimant's statements alone cannot establish an MDI — clinical signs, laboratory findings, or diagnostic reports required.
Question: Does the impairment meet or medically equal a listing in Appendix 1 and meet the duration requirement?
The Listings describe conditions severe enough to prevent any gainful activity. Meeting a listing = automatic disability finding without vocational analysis. RFC assessment occurs between Steps 3 and 4 regardless of Step 3 outcome.
Question: Does the claimant's RFC allow them to perform any past relevant work as actually performed, or as generally performed in the national economy?
Past relevant work = substantial gainful activity within the past 15 years, lasting long enough to learn the job.
Question: Can the claimant make a vocational adjustment to any other work in the national economy, given RFC, age, education, and work experience?
Medical-Vocational Guidelines (Grid Rules) apply at Step 5. Burden shifts to SSA at Step 5 — SSA must show other work exists.
Every AI/ML or decision support solution targeting SSA must map to this framework. A solution that surfaces clinical evidence without connecting it to these five questions provides limited examiner value. The highest-value intelligence layer maps clinical findings to: (1) MDI establishment, (2) Listing criteria, (3) RFC limitations. That is the business logic of disability determination.
SSA must make "every reasonable effort" to obtain:
12-month development period is the baseline. Evidence outside this period may be needed for: potential onset dating, severity/duration, longitudinal history.
1. Objective medical evidence Signs, laboratory findings from a medical source. Does NOT include symptoms, diagnoses, or opinions. Required to establish a Medically Determinable Impairment.
2. Medical opinion Statement about what a claimant can still do despite impairments — functional abilities and limitations. Under current rules (post-March 2017):
3. Prior administrative medical findings RFC assessments or findings from prior SSA adjudications. Not binding on subsequent adjudicators but must be considered.
4. Evidence from nonmedical sources Claimant, family, caregivers, employers, teachers. Cannot establish MDI alone but relevant to symptom evaluation and functional limitations.
5. Other evidence Statements about pain/symptoms, educational records, work history.
Licensed healthcare workers practicing within scope of state/federal law. Certified speech-language pathologists and school psychologists. Note: Medical sources who are NOT acceptable medical sources can provide evidence relevant to severity and functional limitations — but cannot establish an MDI.
When existing evidence is insufficient, SSA purchases a CE from an independent medical source. CE is SSA's tool of last resort for evidence gaps. CEs are expensive (typically $200-500+) and add weeks to processing time. Reducing CE rates is a documented SSA efficiency goal. Architect implication: Solutions that improve completeness of treating source records directly reduce CE costs and processing time.
Every disability determination must contain a medical evaluation unless no medical evidence exists. Must address:
Medical evaluation is documented on formal assessment forms in DCPS:
All signed electronically in DCPS. Paper versions require wet signature + scan to CEF.
RFC = what a claimant can still do despite impairments. Required at all levels when: severe impairment exists AND listing not met AND SGA determination required.
RFC describes functional limitations in:
RFC is an administrative determination — not a medical opinion. MC/PC informs the RFC; examiner makes the final administrative finding. New independent RFC required at each adjudicative level.
Architect implication: RFC is the output that drives Steps 4 and 5. An AI system that extracts functional limitations from clinical records and maps them to RFC work categories addresses the highest-value determina- tion step — where most non-Listing cases are decided.
Location: POMS DI 34000 series | 20 CFR Part 404, Subpart P, Appendix 1 Purpose: Describe impairments severe enough to prevent any gainful activity. Meeting a listing = automatic disability — no vocational analysis required.
Part A — Adults (18+). Also applied to children when disease process similar. Part B — Children under 18 only. Applied first; Part A used if Part B doesn't apply.
Each body system section contains:
SSA does not find a listing met solely because a diagnosis label matches. Clinical findings must satisfy all specified criteria.
| Listing | Body System | Last Major Update |
|---|---|---|
| 1.00 | Musculoskeletal Disorders | February 2025 |
| 2.00 | Special Senses and Speech | — |
| 3.00 | Respiratory Disorders | — |
| 4.00 | Cardiovascular System | — |
| 5.00 | Digestive System | — |
| 6.00 | Genitourinary Disorders | — |
| 7.00 | Hematological Disorders | — |
| 8.00 | Skin Disorders | — |
| 9.00 | Endocrine Disorders | — |
| 10.00 | Congenital Disorders (children) | — |
| 11.00 | Neurological Disorders | — |
| 12.00 | Mental Disorders | — |
| 13.00 | Cancer (Malignant Neoplastic Diseases) | — |
| 14.00 | Immune System Disorders | — |
Mental Disorders (12.00) is particularly significant — largest single category of disability claims. Includes: neurocognitive, schizophrenia, depressive/bipolar, intellectual disorder, anxiety, somatic symptom, personality/impulse control, autism, neurodevelopmental, eating disorders, trauma/stressor-related.
Meets (DI 24508.005): Impairment satisfies ALL criteria in the listing including introductory text AND duration requirement.
Medically equals (DI 24508.010): Three pathways:
Medical equivalence requires sign-off from a Medical Consultant or Psychological Consultant — examiner alone cannot find medical equivalence.
The Listings are the clinical criteria backbone of SSA disability determination. An AI intelligence layer that maps incoming clinical evidence to Listing criteria by body system is the highest-value analytical capability SSA could deploy. Currently this mapping is done entirely by human MCs and PCs reading images.
SSA disability claims move through up to four administrative levels before federal court. Each level is an independent determination — prior findings are not binding but must be considered.
Who: Disability Examiner (DE) + Medical Consultant (MC) or Psychological Consultant (PC) System: DCPS (case management) + eView (evidence review) + CEF (record folder) Timeline: ~219 days average (FY2023) Evidence: MEGAHIT automated request fires at FO→DDS transfer
Who: Different DE than initial — independent review System: Same as initial — DCPS, eView, CEF Evidence: MEGAHIT does NOT auto-fire at reconsideration if no initial HIT request was made — DDS must create User Trigger manually Note: Some states use a single decision-maker process — no reconsideration
Who: Administrative Law Judge (ALJ), independent of DDS System: DCPS, separate OHO case management Evidence: Claimant may submit new evidence; representatives can request HIT via ERE through hearing office (cannot trigger directly) New 827 required: Cannot reuse DDS-level authorization Timeline: 12-24+ months backlog typical
Who: Appeals Council, Falls Church VA Evidence: Existing record travels on CD/CEF — NO new HIT requests can be triggered. Most complex cases have least ability to supplement record. Outcome: AC can affirm, reverse, remand to ALJ, or dismiss
Outside SSA administrative process. Record is fixed at AC level.
DDS Administrator designs QA function suited to agency needs.
QA roles:
QA reviews:
SSA conducts its own Quality Assurance reviews of DDS determinations. Error rates are tracked and DDS agencies with high error rates receive additional oversight and corrective action plans.
Any AI decision support tool must be designed with QA accountability in mind. Examiners remain legally responsible for determinations — AI assists, does not decide. Output must be auditable, explainable, and traceable to source evidence. "Black box" recommendations are incompatible with QA and legal defensibility requirements.
SSA built a sophisticated electronic collection pipeline and then immediately destroys the value of what it collected — converting structured records to images, presenting them to examiners with no analytical support, and requiring manual mapping to a complex five-step legal framework with detailed clinical criteria.
The business process has not changed since the paper era. Electronic records are bolted on top of a paper workflow.
1. RFC functional limitation extraction (highest) Map clinical language → physical/mental RFC work categories. This is what MCs and PCs spend most of their time doing. Directly accelerates Steps 4 and 5 determinations for the majority of cases.
2. Listings criteria mapping (very high) Map clinical findings → Listing body system criteria. Step 3 determinations = automatic disability — no vocational analysis needed. Currently 100% manual MC/PC review.
3. MDI establishment support (high) Identify objective medical evidence (signs, labs) vs. symptoms vs. opinions. Help examiners distinguish what can establish an MDI from what cannot.
4. Longitudinal timeline construction (high) Assemble evidence across providers, time periods, and channels into coherent chronological narrative aligned to POD through adjudication date. Currently done manually — no system does this.
5. CE reduction (significant) Better completeness from treating sources → fewer consultative exams. Each CE avoided saves $200-500 and weeks of processing time.
6. Identity resolution (significant) 15% of HIT requests fail due to identity mismatch. Probabilistic matching before MEGAHIT fires saves the entire downstream failure.
Examiners decide — AI assists. The DE makes the determination. MC/PC signs medical assessments. AI must support, not replace, this accountability.
Audit trail is non-negotiable. Every AI output must be traceable to source evidence in CEF. Examiners annotate findings in DCPS case notes.
Policy is the constraint. POMS governs what examiners can consider and how. A technically correct AI output that contradicts POMS policy will be rejected.
QA will review AI-assisted determinations. Design for explainability — QA reviewers need to understand why a recommendation was made.
Each level is independent. Don't design for "the claim" — design for the determination at a specific adjudicative level with its specific evidence record and its specific examiner accountability.
The policy constraints that technology cannot override:
Knowledge current as of April 2026. Companion skill: ssa-hit-architect