HA 01250.020 Consultative Examinations

A consultative examination (CE) is a physical or mental examination or test purchased for a claimant at the Social Security Administration's request and expense from a treating source or another medical source, including a pediatrician when appropriate (20 CFR 404.1519 and 416.919).

If the claimant does not provide adequate evidence about their impairment(s) for the Administrative Law Judge (ALJ) to determine whether the claimant is disabled or blind, and the ALJ or the hearing office (HO) staff is unable to obtain adequate evidence from the claimant's medical source(s), the ALJ may request a CE through the Disability Determination Services (DDS). See Program Operations Manual System (POMS) DI 22510.005 and DI 22510.006 for additional guidance on when a CE should and should not be purchased.

A. Requesting a CE

When requesting a CE, the HO will prepare an assistance request (AR) for a CE to be sent to the DDS following the instructions in Standard Hearings Operations Procedure (SHOP) section 3.3.5. The HO staff will place a copy of the CE request in the claim(s) file and will add a development action to the Case Processing and Management System (CPMS) record or a Case Note in Hearings and Appeals Case Processing System (HACPS).

The ALJ or HO staff should provide the DDS with the following:

1.
A “Request for DDS Assistance in Obtaining Consultative Examination(s) and Other Medical Evidence as Indicated” [HA-4489];
2.
A signed and dated Form SSA-827, Authorization to Disclose Information to the Social Security Administration (SSA) (for eligible claim types, Form SSA-827 may be completed electronically or via attestation under DI 11005.056D);

NOTE:

If there is no signed and dated Form SSA-827 in the claim file, or if there is one but the 12-month period has expired or will expire within 30 calendar days, annotate the Specific Information Requested section of the “Request for DDS Assistance” (Form HA-4489) with “Updated SSA-827 Needed”. This action will alert the DDS to take steps to have the claimant provide a new authorization.
3.
A medical exhibits folder which contains evidence relating to the type of examination ordered with instructions for the DDS to send the folder to the CE provider for review (see HALLEX HA 01250.022, Medical Exhibits Folder);
4.
A medical source statement form (i.e., HA-1151, Medical Assessment of Ability to Do Work-Related Activities (Physical), or HA-1152, Medical Assessment of Ability to do Work-Related Activities (Mental), but only if directed by the ALJ (SHOP section 3.3.5); and
5.
The name, email address, and telephone number of a person in the HO that the DDS may contact.

B. Requesting Specific Tests

If an ALJ decides that they need the results of a specific medical test(s) to make a decision, the ALJ may request the DDS to arrange for the test(s) to be performed either in conjunction with an examination or alone. Whenever possible, the ALJ should indicate that an equivalent test(s) may be substituted for the specific test(s) requested.

NOTE 1:

An ALJ should request only the specific examination(s) or test(s) that they need to make a decision. For example, an ALJ should not request a complete medical examination if the only evidence needed is a special test (such as an x-ray, blood study, or electrocardiogram) or if the CE source has already performed an examination and the only evidence needed is a medical source statement of the claimant's ability to do work-related activities.

NOTE 2:

Some diagnostic tests or procedures, such as treadmill exercise testing, may involve significant risk to the claimant. The DDS medical consultant will review the evidence and determine whether a requested diagnostic test or procedure involves significant risk. (see HALLEX HA 01250.026, State Agency Physician Determines that Requested Tests Would Involve Significant Risk.)

When requesting the DDS to have a specific medical test(s) performed in conjunction with a CE or alone, the ALJ or HO staff should provide the DDS with the information described above in subsection A and describe the specific medical test(s) in section 3 (Specific Information Requested) of the HA-4489.

The HO staff will place a copy of the request in the claim(s) file and will add a development action to CPMS or a Case Note in HACPS.

NOTE 3:

See HALLEX HA 01250.014 E, Medical Test Data, which discusses requesting background medical test data (e.g., X-ray films and “raw” psychological test data, such as answer sheets or drawings). Because CE sources are, by regulation, subject to special oversight provisions, as described in 20 CFR 404.1519p through 404.1519t and 416.919p through 416.919t, it should not be necessary to request background medical test data from them.

C. Selecting a Medical Source to Conduct the CE or Test(s)

Generally, the ALJ should not specify a particular medical source to conduct a CE or test. The DDS will select a medical source who is qualified, available, and willing to perform the CE for the amount allowed under its fee payment schedule. The claimant's own medical source(s) is generally the preferred CE source (see POMS DI 22510.010D). ALJs should be aware that the DDS may be unable to schedule CEs with every type of medical specialist, as certain specific medical specialties are not contracted and/or widely available to the DDS.

An ALJ may request that the DDS use a particular medical source to conduct a CE only if the Appeals Council or a court has so ordered.

An ALJ may request that the DDS not use a particular medical source to conduct a CE if they have a good reason. For example, a good reason could include circumstances where the claimant is related to the CE source or where there is an unavoidable conflict of interest. If an ALJ requests that the DDS use or not use a particular medical source to conduct a CE or test, the ALJ must:

•
provide the medical source's name, address, and telephone number,
•
explain the reason(s) for the special request, and
•
place a copy of the special request in the CF.

The DDS may decline to use a particular medical source to conduct a CE if it has a good reason, e.g., the medical source has a history of not providing timely or complete reports. When the DDS declines to use a particular medical source, the reason should be provided in writing to the ALJ or HO.

NOTE:

A claimant or their representative may object to being examined by a particular medical source (See 20 CFR 404.1519j and 416.919j). If an ALJ receives an objection to using a particular source, the objection should be forwarded to the DDS for resolution per POMS DI 22510.010E. The DDS will determine whether there is a good reason for the objection and, if there is, reschedule the examination with another medical source (See DI 22510.010E). Where the claimant or their representative object because they allege that the CE source lacks objectivity, the DDS will document the case file with all actions taken in response to the objection and the reasons for the actions (See DI 22510.010E.3). If the case file is not documented with the DDS's response to the objection, HO staff should follow the procedures in subsection E below.

D. Follow-up Procedures

If the DDS does not provide the requested evidence by the end of the diary period, the HO staff should follow the procedures in HALLEX HA 01250.014 D.2.

E. Problems with the DDS's Response

1. CE Report is Inadequate or Incomplete

If the DDS does not provide a CE report or provides a CE report that is inadequate or incomplete (see 20 CFR 404.1519n, 404.1519p, 416.919n, and 416.919p), the HO staff should follow the procedures in HALLEX HA 01250.014 D.3.

2. CE Report is Unsigned or Improperly Signed

If the DDS provides a CE report that is unsigned or improperly signed, or if the claim(s) file contains such a CE report, which would otherwise be proposed as an exhibit, the HO staff should ask the DDS to obtain a properly signed CE report, and then follow the procedures in E.3., or E.4., below. Acceptable signatures include original handwritten signatures, signed in ink, on the original paper copy of the CE report; eFax or analog fax of the CE report with the original handwritten signature(s); or electronic signatures applied in and submitted through the Electronic Records Express attestation process (see DI 22510.015C).

NOTE:

A CE source's signature on a report annotated “not proofed” or “dictated but not read” is not acceptable. A rubber stamp signature or a signature entered by another person is also not acceptable.

3. Decision Fully Favorable

The ALJ should not delay issuing a fully favorable disability decision pending receipt of a properly signed CE report. The ALJ should issue the fully favorable decision, and the HO staff should send the decision and claim(s) file to the appropriate component for effectuation.

4. Decision Less Than Fully Favorable

The ALJ should not use an unsigned or improperly signed CE report as basis for a decision that is less than fully favorable. If the ALJ needs a CE report to issue a decision, but the CE report is unsigned or improperly signed, and the DDS cannot obtain the proper signature on the report, the ALJ should not use the report, but rather should request the DDS to arrange for another CE with a different CE source.

F. Telehealth Consultative Examination(s) (THCE)

1. THCE Definition

a.
A THCE is a CE that:
1. i.
  Uses audio and video technology to allow remote interaction between a CE source and a claimant (in this context, a claimant will be defined as including the claimant and the parent or legal guardian of a minor child),
2. ii.
  Requires the claimant to participate using a personal device at their home or other private location, and
3. iii.
  Requires the claimant to participate using a platform selected by the CE source.
b.
Types of THCEs permitted:
1. i.
  Psychiatric CEs
2. ii.
  Psychological CEs without standardized testing
3. iii.
  Speech and language CEs
  
  NOTE:
  
  Claimants below age five cannot participate in a THCE.

For more information about THCEs, see DI 22510.013 and DI 22510.014.

2. THCE Business Process

HO staff will use the following procedure to obtain agreement to the claimant's participation in a THCE:

a.
Determine Who Must Agree to the Claimant's Participation in a THCE
The HO may only request a THCE if the appropriate party agrees in advance to the claimant's participation in a THCE.
1. i.
  Obtaining agreement in cases with an appointed representative
  1.
  An appointed representative may not agree to the claimant's participation in a THCE on the claimant's behalf.
  2.
  If the claimant has an appointed representative, the HO staff must obtain the appointed representative's consent to contact the individual(s) who must agree to the claimant's participation in a THCE before making direct contact that individual, unless the HO already has permission to contact that individual directly. If the representative refuses to permit direct contact, the HO staff will request an in-person CE.
2. ii.
  Who Must Agree to the Claimant's Participation in a THCE
  1.
  If the claimant is an adult who does not have a legal guardian, the claimant must agree to participate in a THCE.
  2.
  If the claimant is an adult who has a legal guardian, the legal guardian must agree to the claimant's participation in a THCE.
  3.
  If claimant is a child under age 12, the claimant's parent or legal guardian must agree to the claimant's participation in a THCE.
  4.
  If the claimant is a child aged 12 until attainment of age 18, both the claimant and the claimant's parent or legal guardian must agree to the claimant's participation in a THCE.
b.
Obtain and Document Agreement to the Claimant's Participation in a THCE
Prior to requesting a THCE, the HO staff will contact the individual(s) identified in subsection F.2.a.ii above by telephone to obtain their agreement to the claimant's participation in a THCE. The HO staff must then document such agreement or non-agreement in the claim(s) file.
1. i.
  During the telephone call, the HO staff must:
  1.
  Verify the individual's identity consistent with existing policy for disclosure and identity (see DI 22510.014C.1, DI 39567.210, and GN 00203.020),
  2.
  Advise the individual that they will collect personal information during the telephone call,
  3.
  Confirm the individual is in a private location in which no one can overhear the conversation, and
  4.
  Read the appropriate call script at DI 22510.014C.1, which provides required information for the individual to determine their willingness and ability to have the claimant participate in a THCE and solicits their agreement to proceed with scheduling a THCE.
2. ii.
  To obtain agreement, the HO staff must:
  1.
  Explain the need for a CE,
  2.
  Explain the option to attend a THCE,
  3.
  Explain the claimant requirements for a THCE (see DI 22510.013D),
  4.
  Explain the need for an email address to participate in a THCE, and
  5.
  Ask whether the individual:
  a.
  Understands the requirements for attending a THCE, and
  b.
  Agrees to the claimant's participation in a THCE.
  
  NOTE:
  
  The call scripts at DI 22510.014C.1 address each of these requirements.
3. iii.
  To document agreement or non-agreement, the HO staff will upload a completed Form SSA-5002, Report of Contact to the claim(s) file with the following information from the telephone call:
  1.
  The date and time of the conversation,
  2.
  The responses to the preliminaries in subsection F.2.b.i above,
  3.
  A copy of the THCE call script used, and
  4.
  All responses to the THCE call script questions, including agreement to the claimant's participation in a THCE.
c.
Submit the Completed AR to the Appropriate DDS Office.
After the HO staff obtains and documents the agreement or non-agreement to the claimant's participation in a THCE, they will submit an AR to the DDS following the procedure in subsection A above. If the individual agreed to the claimant's participation in a THCE, the HO staff will ensure that the AR meets the following requirements:
1. i.
  The type of THCE is permitted (see subsection F.1.b),
2. ii.
  The requesting office has contacted the individual(s) who must agree to the claimant's participation in a THCE and has obtained their agreement (see subsections F.2.a and F.2.b), and
3. iii.
  The requesting office has documented the agreement to participate in a THCE (see subsection F.2.b.iii).
If the AR does not meet all the requirements, DDS may reject the AR.

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HA 01250.020 - Consultative Examinations (I-2-5-20) - 03/28/2024
Batch run: 04/20/2025
Rev:03/28/2024