TN 56 (07-20)

GN 00502.040 Developing Medical Evidence of Capability

A. Medical evidence of capability

Medical evidence of capability is evidence of a medical nature that sheds light on a beneficiary’s ability to manage or direct the management of benefits. When a beneficiary’s capability is questionable, you must develop for medical evidence following the instructions in this section. You must scan all medical evidence used in the capability determination into the Non-Disability Repository for Evidentiary Documents (NDRed) under the beneficiary's claim number or eView under the Beneficiary's Own Account Number (BOAN).

Although a major factor, medical evidence is not the definitive, determining factor of capability. You must evaluate medical evidence, along with lay evidence (see GN 00502.030), in order to make a sound capability determination.

1. Types of medical evidence

Medical evidence is a statement offered by a physician, psychologist, or other qualified medical practitioner (medical source), based on their evaluation, examination, or treatment of the beneficiary, which provides a meaningful assessment on the beneficiary’s ability to manage or direct the management of benefits. All medical evidence used for making the capability decision must be signed by a medical source who conducted the examination or a person authorized to sign such certifications (e.g., a medical records librarian).

The SSA-787, Medical Source Opinion of Patient’s Capability to Manage Benefits, is the preferred vehicle for obtaining medical evidence of capability. However, you may use other forms and summary reports from the medical source instead of the SSA-787, if:

  • It is signed and dated from the medical source (physician, psychologist or other qualified medical practitioner);

  • The medical source noted in the other form or summary report that they have knowledge of the claimant's medical condition as it relates to the beneficiary's ability to manage or direct the management of funds; and

  • Includes a basis for their assessment, e.g., observations, medical records, diagnostic tests, patient self-report, family member's report.

For instructions for medical evidence that is less than one year old, follow GN 00502.040A.2.a.

For instructions for medical evidence that is over one year old medical evidence, follow GN 00502.040A.2.b

For instructions when there is no medical evidence, follow GN 00502.040B.

NOTE: For information on using the disability listing 12.05A as medical evidence, see GN 00502.040A.9.

2. Age of medical evidence

a. Medical evidence less than one year old

In every case when capability is questionable, you must develop for the most up-to date medical evidence based on an evaluation, examination, or treatment that occurred within the last year by following GN 00502.040A.3.

b. Medical evidence over one year old

If the beneficiary has not had an evaluation, examination, or treatment by a medical source within the past year, and there is an SSA-787, other form, or summary report that is over one year old and already in Social Security Administration (SSA) records, use this as medical evidence in your capability determination, per GN 00502.040A.11.

IMPORTANT: If an SSA-787, other form, or summary report over one year old is used, it must meet the criteria listed in GN 00502.040A.1.

3. Obtaining medical evidence less than one year old

If the beneficiary had an evaluation, examination, or treatment by a medical source within the past year, you must obtain a signed and dated SSA-827 Authorization to Disclose Information to the Social Security Administration. You must send the SSA-787 and SSA-827 directly to the medical source to obtain medical evidence that is less than one year old. Follow instructions for completing the SSA-827 in DI 11005.055.

The beneficiary or representative (someone who can act under State law, in making decisions related to beneficiary health care) must sign the SSA-827, or an alternative Health Insurance Portability and Accountability Act (HIPAA)-compliant authorization form, to disclose medical information. If the beneficiary refuses to sign the form, and has no representative, and there is no older evidence in SSA records, per GN 00502.040A.2.b, you must develop capability using other evidence, per GN 00502.040B.

If the beneficiary decides to undergo an evaluation, examination, or obtain treatment on their own volition, ask the beneficiary to notify SSA after the examination. Then mail a SSA-787, and signed and dated SSA-827, to the medical source. If the beneficiary is unwilling to undergo an evaluation, examination, or treatment, do not compel them to do so solely to obtain medical evidence of capability.

If the medical source does not mail a completed and signed SSA-787 directly to SSA, follow GN 00502.040A.4.

If you receive the SSA-787, but you question the authenticity, follow GN 00502.040A.5.

For an unsigned SSA-787, other form, or summary report, follow GN 00502.040A.6.

IMPORTANT: If you receive a completed and signed other form or summary report back from the medical source, i.e., not the SSA-787, you can accept it, but only if it fits the criteria in GN 00502.040A.1.

4. Medical source does not mail the less than one year old medical evidence directly to SSA

If the medical source does not mail the completed and signed (wet signature or a rubber stamp signature) SSA-787, other form, or summary report, directly back to SSA, you may accept the completed and signed SSA-787, other form, or summary report, if the medical source:

  • Directly mailed or gave the completed SSA-787, other form, or summary report with a wet signature or a rubber stamp signature to the beneficiary instead of SSA;

  • Faxed the completed SSA-787, other form, or summary report directly to SSA; or

  • Provided a completed photocopy of the SSA-787, other form, or summary report directly to SSA.

IMPORTANT: If you question the authenticity of the SSA-787, other form, or summary report, follow GN 00502.040A.5.

REMINDER: If the medical evidence is not the SSA-787, but an other form or summary report, you can only accept it if it also fits the criteria in GN 00502.040A.1.

For an unsigned SSA-787, other form, or summary report, you must follow GN 00502.040A.6.

5. Authenticity of the less than one year old SSA-787, other form, or summary report questioned

If you question the authenticity of the SSA-787, other form, or summary report, you must contact the medical source, or medical source’s representative, to confirm its authenticity and verify the contents; including confirmation the medical source signed it. You must document the details of contacts with medical sources as follows:

a. Case established in the electronic Representative Payee System (eRPS)

A representative payee (payee) application is taken or will be taken, whether the application is denied or approved or there is an established beneficiary’s case in eRPS:

On the Beneficiary Details page, using the “Add Report of Contact” link, complete the RPOC. In the “Subject” section, write “MEDICAL EVIDENCE CONFIRMATION” before adding your details in the “Report” section, see MS 07416.002.

b. Case not established in eRPS

Follow these procedures for all beneficiary cases not established in eRPS.

EXAMPLE: The state Disability Determination Services (DDS) suggested there may be a possibility the beneficiary needs a payee. However, you do capability development and determine the beneficiary is capable (therefore, there is no payee application) or the payee does not have an SSN and the beneficiary has no established case in eRPS:

  • Title II or Concurrent--Complete the Report of Contact (RPOC). In the “Report” section, write “MEDICAL EVIDENCE CONFIRMATION” before adding your details (see MS 03508.007).

  • Title XVI--Complete the Report of Contact (DROC). In the “Report Text” section write “MEDICAL EVIDENCE CONFIRMATION” before adding your details (see MS 04422.010).

NOTE: If you are unable to establish a RPOC in MCS or DROC in MSSICS, use the paper Form SSA-5002 (Report of Contact) for your documentation and scan into NDRed or eView.

You must:

  • Scan a copy of the SSA-5002 into the Non-Disability Repository for Evidentiary Documents (NDRed) under the beneficiary's claim number or eView under the Beneficiary's Own Account Number (BOAN); and

  • Note in your “Report of Contact” in eRPS, MCS, or MSSICS, that you scanned the medical evidence and any other paper medical evidence used in your capability determination, into NDRed or eView.

6. Unsigned less than one year old medical evidence

If you receive an unsigned SSA-787, other form, or summary report, directly from a medical source, contact the medical source of the evidence for confirmation. If the medical source confirms providing the unsigned evidence, treat it as signed and document all pertinent facts. The confirmation may be from the medical source who provided the SSA-787, other form, or summary report, or the medical source’s representative.

If the medical source cannot confirm providing the evidence, redevelop by sending an SSA-787 and SSA-827 to this medical source.

You must document the details of your contact with the medical source, per GN 00502.040.A.5.

7. SSA is asked to pay for medical evidence

SSA does not pay for medical evidence used solely to decide capability. If the medical source requests payment for medical evidence of capability, do not honor the request. Explain that since we will not use the evidence in deciding entitlement, SSA cannot pay for it. If the medical source refuses to provide the evidence without payment and there is no other medical evidence available per GN 00502.040A, develop capability using other evidence, per GN 00502.040B.

8. DDS provides an opinion regarding a beneficiary’s capability

In disability cases, DDS often gives an opinion regarding the beneficiary’s capability. DDS is not responsible for making capability determinations.

DDS opinion is lay evidence of capability; it is NOT a determination on capability.

DDS is responsible for providing an opinion regarding a claimant’s capability to manage their disability benefits when the field office (FO) identifies a case where it is likely that a claimant may be incapable or where DDS medical development indicates the claimant may be incapable, per DI 23001.001. While the DDS provide an opinion regarding the evidence of capability, the FO is responsible for the final determination of capability. DDS does not complete medical development solely to resolve an issue of capability, per DI 23001.005.

If you are referring your case to the DDS for a disability determination, you can request DDS assistance in obtaining medical evidence of capability by following the instructions in:

  • DI 11055.215 Resolving Representative Payee Issues;

  • DI 11005.045 Completing the SSA-3367;

  • DI 23001.001 Disability Determination Services (DDS) Capability Opinion; and

  • DI 23001.005 Disability Services (DDS) Procedures for Developing Capability.

In cases where DDS initiates capability development, the DDS enters its opinion in the remarks section of the Forms SSA-831-U3 (Disability Determination and Transmittal), SSA-832-U3 (Cessation or Continuance of Disability or Blindness Determination and Transmittal) for Title XVI, or the SSA-833-U3 (Cessation or Continuance of Disability or Blindness Determination and Transmittal) for Title II.

If the file contains a completed SSA-831-U3, SSA-832-U3, or SSA 833-U3 from the DDS with no opinion on capability, do not seek a DDS opinion on capability even if you have doubts about the beneficiary’s capability. Develop capability using other information.

If you do not need a disability determination, or if the DDS indicates on the Form SSA-831-U3 (Disability Determination and Transmittal) that capability is unresolved, contact the medical source for medical evidence of capability.

9. Disability listings and medical evidence

Disability listings appear on the SSA-831-U3, in item 23. They may be referred to in Administrative Law Judge or Appeals Council decisions. A disability allowance under disability listing 12.05A is medical evidence only of incapability and you must consider the medical evidence along with lay evidence to conduct a full capability determination. For more information on DDS procedures for developing capability, see DI 23001.005.

10. Obtaining medical evidence from the Department of Veterans Affairs (VA)

If the medical source works at a VA facility, include a signed and dated SSA-827 with your request (e.g., your request may be the SSA-787).

11. Weighing the medical evidence obtained in a capability determination

It is important to use good judgment to weigh the value of the medical evidence before you make a capability determination based on it. For example, a medical statement of capability from a consultative examiner or another medical source based on limited contact with the beneficiary is less convincing than a statement from the beneficiary’s own medical source.

Likewise, a medical statement based on an evaluation, examination, or treatment of more than one year ago is not as valuable as medical evidence that is less than one year ago. To arrive at a sound and well-reasoned capability determination, you must carefully evaluate the medical evidence obtained for each case, along with all other evidence (namely, lay evidence, see GN 00502.030.)

B. No medical evidence

When there is no medical evidence, document your attempt(s) to obtain medical evidence. Use the same documentation instructions as described in GN 00502.040A.5 to document your attempt(s) to secure medical evidence; however in your report, write “MEDICAL EVIDENCE ATTEMPTS” before adding your details. If there is no medical evidence, you still must develop other evidence of capability, see GN 00502.001 through GN 00502.075.


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GN 00502.040 - Developing Medical Evidence of Capability - 06/19/2017
Batch run: 07/16/2020
Rev:06/19/2017