TN 4 (05-19)

DI 39545.525 Exhibit 1 – Suggested Protocol for DDS Onsite Reviews of Consultative Examination (CE) Providers

Date _________________

1. A. 

   Name and address of facility/provider

2. B. 

   Other office locations

3. C. 

   Types of examinations conducted

4. D. 

   Provider has performed consultative examinations (CEs) for DDS since

5. E. 

   Provider contact name and phone number

6. F. 

   Provider classification

   Key provider or top five CE provider by dollar volume

   Yes_______ No________

7. G. 

   Reason for visit

8. H. 

   Facilities

   1. 1. 

      Building

      1. a. 

         Identifiability

      2. b. 

         Cleanliness

      3. c. 

         Safe location for claimants to travel

      4. d. 

         Handicap Accessibility

      5. e. 

         Public Transportation and Parking

      6. f. 

         Emergency Exit Signs

      7. g. 

         Rest Rooms

      8. h. 

         Secure location for medical records and computer records

   2. 2. 

      Equipment/Laboratory Tests

      1. a. 

         Onsite

      2. b. 

         Offsite

9. I. 

   Staff

   1. 1. 

      Professionalism

   2. 2. 

      Claimants greeted timely

   3. 3. 

      Current Licensing:

      1. a. 

         Displayed

      2. b. 

         On file at DDS

   4. 4. 

      Does medical source speak any language other than English?
      If so, which language?

10. J. 

    Scheduling

    1. 1. 

       What is maximum number of CEs scheduled per medical source per day per specialty?

    2. 2. 

       What are minimum interval times that the CE provider schedules for an exam?

    3. 3. 

       What is actual length of time for exams to be completed per visit?

11. K. 

    Procedures

    1. 1. 

       Privacy and confidentiality of claimant information

    2. 2. 

       How and from who is the claimant’s medical/psychological history obtained?

    3. 3. 

       How much time does the medical source spend face-to-face with the claimant?

    4. 4. 

       Does the source certify that assistants meet the appropriate licensing or certification requirements of the State?

12. L. 

    Laboratories

    1. 1. 

       Diagnostic and lab tests: Performed by (if by a non-physician, state performer’s qualifications)

    2. 2. 

       Interpreted by (if by a non-physician, state the interpreter’s qualifications).

    3. 3. 

       Turnaround timeliness, including both the results of the tests and interpretations.

13. M. 

    Exit Interviews of Claimants

14. N. 

    Does provider transmit CE report electronically? If so, fax, website, C:D, etc.

References:

• •

  PM 00233.005 Regional Office (RO) Consultative Examination (CE) Oversight Procedures

• •

  PM 00233.900 Regional Office (RO) Guide for Evaluating Disability Determination Service (DDS) Management of the Consultative Examination (CE) Process