DI DAL11010.540 Examining Evidence - Foreign Claims (TN 1 -- 08/2007)

See DI 11010.540

A. General

Medical evidence, i.e., medical evidence of record (MER) and consultative examinations (CEs) for foreign claimants, is usually obtained by disability examiners (DEs) in the Office of International Operations (OIO). The OIO DEs usually request the assistance of the Foreign Service Posts (FSPs) in Consular Offices throughout the world to obtain medical evidence. Frequently, OIO will ask field offices (FOs) on the Mexican border to obtain evidence for residents in Mexico. Assistance from FOs in obtaining medical evidence from foreign claimants can significantly reduce case costs and processing times, thus improving service.

B. Dallas Region Project - Residents Of Mexico

1. Field Offices involved

This procedure applies to all disability claims filed by Mexican residents with the following eight Texas FOs: Harlingen, Brownsville, Eagle Pass, El Paso, El Paso Downtown, Laredo, McAllen, Odessa, and Del Rio.

2. The Disability interview

The FOs above will obtain the same disability applications and forms from Mexican residents as required for all disability applicants (see DI 11005.016). In addition to the routine procedure, the Claims Representative (CR) will explain to the claimant that the FO may assist OIO in obtaining medical evidence to expedite the process, but that the final determination will be made by OIO.

Ask the claimant if he/she can contact his/her medical source(s) to obtain the evidence of record. If it appears he/she is unable to do so, the CR should request the MER from the medical sources. Also explain that if sufficient evidence of record is not available, the FO may ask the claimant to have a special examination conducted by a physician or psychologist in the United States (U.S.).

NOTE: When the interviews are conducted in the FO, generally assume travel to and from Mexico are not a problem. However, if the claimant insists that he/she cannot return to the U.S. for a CE, include the following on a report of contact:

  1. The principal city or town in Mexico closest to the claimant's residence and the name of the state where located;

  2. Approximate distance from the border;

  3. Name of the Foreign Service Post (FSP) serving the claimant's area of residence; and

  4. Any obstacle to travel.

If the claimant insists he/she cannot return to the U.S., request MER as outlined in DI DAL11010.540 B.4.a and transfer the claim to OIO. If OIO determines a CE is necessary, they will arrange for it through the FSP. Because going through the FSP can be a very lengthy process, it should be made clear to the claimant that it is to his/her advantage to provide as much medical evidence as possible and/or agree to return to the U.S. for a CE.

Use judgment when developing non-disability issues. Follow the deferred development procedures in DI 11010.025.

3. Work issues

Refer to DI 10505.025 D for instructions on evaluating work activity outside the U.S. If the work is not SGA, or is no longer SGA, complete an SSA-820 or SSA-821 and continue medical development as outlined below. If the claimant continues to engage in SGA and there is no possibility of a closed period, prepare and sign an SSA-831 for the SGA denial per DI 11010.205. Prepare but do not release the notice and forward the case to OIO following the mailing instructions in DI DAL 11010.540B.6.a.

4. Procedures

a. Obtaining MER

The CR will review the disability material and advise the claimant to request the MER immediately from all medical sources in the U.S. and Mexico. If the claimant is unable to do so, the CR should request the MER for him/her. This will probably be the norm. Use the form in Exhibit 1 (English) or Exhibit 2 (Spanish). Diary the case for 10 calendar days. If the MER is not received in that timeframe, call the medical source to follow-up. Diary the case for 14 days. If the MER is not received in that timeframe, a second follow-up telephone call should be made, if needed. Allow 10 calendar days for reply to the second follow-up.

If the claimant says he/she can obtain the MER, ask him/her to encourage the treating sources to return the evidence to SSA as soon as possible. Provide a request form and a self-addressed mailing label (with the FO address) for each medical source. Use a business reply envelope for treating sources in the U.S. and non-franked reply envelope for treating sources in Mexico. Diary the case for 10 calendar days. If the MER is not received in that timeframe, call the medical source to follow-up. Diary the case for 14 days. If the MER is not received in that timeframe, a second follow-up telephone call should be made, if needed. Allow 10 calendar days for reply to the second follow-up.

b. Forwarding the medical folder to OIO

Currently, all cases that involve Mexican residents and OIO are EDCS exclusions. Paper files must be created when forwarding the case to OIO.

When the MER is received, or after the diaries above have expired, forward the case via express mail to OIO for a determination. (See DI DAL11010.540 B.6.c for dealing with evidence in Spanish.) Document all unsuccessful requests for MER so OIO will not duplicate the FO's efforts.

The folder will be prepared as if it were going to the Texas DDS, except that an SSA-831 will be required. Prepare the SSA-831 as shown in DI 11010.205. The DDS code for item 2 will be V22. If MER is received after the medical folder has been sent to OIO, express mail the evidence to the same address for sending the folder.

c. Flagging Texas border cases

For cases with paper folders, the FO will attach the new Texas Border Case flag (Exhibit 11) on the outside of the claims folder to assist in expediting these claims once they are received in OIO. Click here for a Microsoft Publisher Version and here for a web version.

d. Arranging for a CE

Follow the instructions below at any point OIO determines a CE is needed.

If no MER is received at the end of the diary period or the claimant alleges no medical sources during the interview, fax the SSA-3368 to the OIO Disability Determinations Services. Query DOORS to obtain the current telephone or fax number for the appropriate Module. Ask the examiner to review the SSA-3368 and call the CR with advice on how to proceed (obtain CE, etc.). The FO should be sure to include a contact name and telephone number. We also encourage the CR to call the disability examiners in OIO for advice on TERI cases or other special needs situations during the interview. The FO may be asked to fax material in such cases. If OIO determines a CE is necessary, call the Supervisor of Unit #80 of the Texas DDS at telephone (512) 437-8753. Ask for the name of the CE provider to perform the examination(s) requested by OIO. The DDS will provide the approved fee for that CE source.

Schedule the CE as soon as possible. Contact the CE provider by telephone to schedule an appointment. Then send the authorization form in Exhibit 3 (instructions are in Exhibit 3b) as soon as possible. The form should be signed by the FO manager.

Along with the authorization form, send any background material to the CE provider. Background material includes photocopies of the SSA-3368/3820, supplemental medical forms (e.g., pain questionnaires) and any other information that would be helpful to the CE provider in performing the examination.

e. Requesting the claimant to attend the CE

Send the claimant or representative payee one of the letters in Exhibit 4 through 7 as shown below. Use FO letterhead.

Exhibit 4 (English) - to the claimant who has not requested Spanish notices.

Exhibit 5 (Spanish) - to the claimant who has requested Spanish notices.

Exhibit 6 (English) - to a representative payee applicant if Spanish notices have not been requested.

Exhibit 7 (Spanish) - to a representative payee applicant if Spanish notices have been requested.

Also include with the above notice a Claimant Response form as indicated below (and a self-addressed, non-franked reply envelope):

Exhibit 8 (English) - if Spanish notices have not been requested.

Exhibit 9 (Spanish) - if Spanish notices have been requested.

Place a copy of all notices in the file.

f. Claimant fails to keep CE appointment

Failure to appear for a CE will result in making a determination based on the evidence in file (see exception below if a mental impairment is involved).

Documentation:

If no mental impairment is alleged or indicated - The CR should prepare a report of contact stating that the claimant failed to appear. Forward the case to OIO via express mail.

If a mental impairment is alleged or indicated - Contact the claimant, or applicant, to ascertain the reason for not attending the CE. Make two telephone attempts at different times on different days (a busy signal is not an attempt). If a telephone contact is not possible, send the claimant a call-in letter to contact the CR. If the claimant has not called within 10 calendar days of the date of the letter, send the case to OIO via express mail. If contact is made with a claimant and a mental impairment is involved, explain that the examination is for evaluation purposes only and that no treatment will be required. If the claimant agrees to attend the CE, give the claimant one additional opportunity to attend the CE; i.e., reschedule the CE. Identify the appointment letter as a rescheduled CE. If the claimant fails to appear at the rescheduled CE, document the fact on a report of contact and send the case to OIO via express mail.

g. Reviewing the CE report

CRs will not review the report for medical accuracy, but should check the report to determine if it contains all the reports requested. Also check to ensure that the CE provider signed the form. A rubber stamped signature or a signature by someone else (e.g., a nurse) is not acceptable. An annotation on the report "not proofed" or "dictated but not read" is also not acceptable. See DI DAL11010.540B.6.c for Spanish language evidence.

h. Followup on the CE report

If necessary, call the CE provider 10 calendar days after the date of the CE appointment. If a second follow-up is needed, call again 14 calendar days after the first followup call was made. Allow additional time for mail to and from Mexico.

If the CE report is not received after the follow-up diaries have expired, document fully all attempts to obtain the report(s) and express mail the information to OIO at the address in DI DAL11010.540B.6.a.

5. Payment for MER and CEs

The FO will use the third party draft to pay for MER and CE reports. Since the OIO CAN and SOC are used, the funds are not charged against the FO's local budget.

The CR must ensure the draft is documented with:

  1. For MER, a copy of the request for MER over the manager's signature (only managers have procurement authority). A photocopy of a completed letter from Exhibit 1 or 2 will suffice.

  2. For CEs, a copy of the letter to the CE provider authorizing the CE (Exhibit 3).

  3. For MER and CEs use the CAN and SOC for OIO - CAN=4005113; SOC=2533.

  4. For MER/CEs, provide a statement by an SSA employee that the evidence was received.

MER/CE invoices should be paid promptly to maintain a good ongoing relationship with MER/CE providers.

6. Forwarding the claim and/or evidence to OIO

a. Mailing the folder

The claims folder with any MER or CEs obtained by the FO should be sent via express mail to the following address:

OIO/DDS
P O Box 17775
Baltimore, MD. 21235

b. Systems input

When a disability claim is outside of MCS, show folder movement on the 1418 to V22 (do NOT use PC8). V22 is the OIO DDS code.

The FO can SPORT a non-medical completion for an EC case, if possible, just as on a domestic disability case. If the SPORT/non-medical completion is successful, OIO's input of the decision to the National DDS System will complete systems processing.

c. Spanish language medical reports

OIO has translators to translate Spanish language medical evidence. However, the FO can expedite the process by recording on a report of contact that review of the file indicates that the medical source will not or cannot provide the records.

d. Trailer material

Trailer material, such as MER or CEs that come in after the folder has been shipped, should be sent to the OIO address. Using the special address ensures the material is routed expeditiously to the disability branch in OIO. No systems inputs are required when trailer material is forwarded.

7. Adjudication

Once OIO has made a disability determination, the medical folder will be returned to the FO. For awards, complete all non-medical development such as auxiliary applications. Mail the allowance to PC8. If the case was a denial, file the case for the appeals period.

If FO action is needed to complete adjudication of the case, process through EC if possible. If not, prepare an SSA-101 for an allowance or an SSA-3428 for a denial. On manual actions, input a 1418 to show folder movement to PC8 (do not use the V22 DDS code).

8. Reconsiderations

The above process is for initial claims only. Handle reconsiderations filed by residents of Mexico as follows:

  • Obtain the usual reconsideration forms and send via express and follow the mailing instructions shown in DI DAL11010.540B.6.a. The FO will not initiate any medical development unless contacted by OIO to do so.

  • Folder movement will be made to V22.

Exhibit 1a

Request to Medical Source for Medical Evidence of Record (MER)

(English Version)

(1)        Patient: (4)         

         SSN: (5)

          DOB: (6)

         Sex: (7)            

Patient/Clinic No.: (8)       

______________ (2) _______________

_____________________________

_____________________________

Dear (3) :

Your patient has applied for disability benefits through the Social Security Administration. The Office of International Operations, Baltimore, Maryland, is responsible for determining whether the claimant is eligible for benefits. We are assisting the claimant in obtaining available medical evidence.

Disability is alleged because of (9) .

This is not a request that studies be performed if they have not been performed already. Please furnish a narrative report and/or copies of your records for the period (10) to (11) , to include the following: __________(12)_________________________________________

_____________________________

We would also like to have a statement, based on your medical findings, of the claimant's ability to perform work-related physical activities such as sitting, standing, walking, lifting, carrying, handling objects, hearing, speaking, and traveling. When there is a mental impairment, please indicate your opinion regarding understanding and memory, sustained concentration and persistence, social interaction and adaptation.

If there is a charge for this service, please enclose an itemized statement with the records. The Social Security Administration is authorized to pay up to $18.00 for copies of medical records and/or narrative report.

Thank you for your prompt attention to this request. If you have any questions, please call
   (13)    at (14) .

Sincerely yours,

District Manager

Enclosure (15)

Exhibit 1b

Fill-ins for Request for MER (Exhibit 1a)

1. Date.

2. Name and address of treating source.

3. Salutation.

4. Claimant's name.

5. Claimant's Social Security number.

6. Claimant's date of birth.

7. Claimant's sex.

8. Patient or clinic number assigned by the treating source, if any.

9. Impairment(s) alleged by claimant.

10. Earliest date for which medical evidence is requested as determined below:

Show the later of:

a. 12 months prior to the application date or

b. Alleged date that impairment first bothered the claimant (item 1 of the SSA-3368 or item 38 of the SSA-3820).

11. Latest date for which medical evidence is requested as determined below:

Show the earlier date of:

a. Date insured status or prescribed period expired or

b. The current date.

12. If the SSA-3368/3820 indicates any tests were performed by this treating source, enter them here. If no tests are alleged, show "no tests specified at this time."

13. CR's name.

14. Telephone number for CR.

15. Enclose a self-addressed mailing label to return records to the FO. If the treating source is in the U.S., use a business reply envelope; if in Mexico, use a non-franked reply envelope.

Exhibit 2a

Letter to Medical Source Requesting Medical Evidence of Record (MER)

(Spanish Version)

(1) . Paciente: (3)

Dirección: (4)

SSN: (5)

Fecha de Nacimiento: (6)

Sexo: (7)

(2)

_____________________________

_____________________________

_____________________________

Estimado Doctor:

Su paciente ha solicitado beneficios del Seguro Social de los Estados Unidos por incapacidad para trabajar. Esta agencia está encargada de obtener información médica para determinar si tiene derecho a recibir beneficios. El paciente indica que está incapacitado por padecer (8) .

Favor de preparar un resumen clínico y/o enviar copias de sus expedientes médicos correspodientes al período de (9) a (10) .

Solicitamos únicamente información ya existente. No queremos que se efectúen estudios especiales para el informe ya que el paciente tendrá que pagarlos.

Favor de incluir los datos:

___________ (11) __________________

_____________________________

Si se cobra para el servicio de copiar, tenga la bondad de incluir la cuenta detallada con las pruebas de archivo. La Administración del Seguro Social de EE.UU. pagará hasta 15 dólares por copias de archivos medicales o de reportes narrativos del médico.

Le agradecería su pronto atención a esta petición. Si tiene cualquier preguntas, llame por
(12) a (13) , por favor.

Atentamente,

Gerente de Distrito/Ramo

Adjunto (14)

Exhibit 2b

Fill-ins for Request for MER (Exhibit 2a)

1. Date.

2. Name and address of treating source.

3. Claimant's name.

4. Claimant's address.

5. Claimant's Social Security number.

6. Claimant's date of birth.

7. Claimant's sex.

8. Impairment(s) alleged by claimant.

9. Earliest date for which medical evidence is requested as determined below:

Show the later of:

a. 12 months prior to the application date or

b. Alleged date that impairment first bothered the claimant (item 1 of the SSA-3368 or item 38 of the SSA-3820).

10. Latest date for which medical evidence is requested as determined below:

Show the earlier date of:

a. Date insured status or prescribed period expired or

b. The current date.

11. If the SSA-3368/3820 indicates any tests were performed by this medical source, enter them here. If no tests are alleged, show "No necesitamos ningun otro examen ahora" (We do not need any other exam now).

12. CR's name.

13. CR's telephone number.

14. Enclose a self-addressed mailing label to return records to the FO. If the medical source is in the U.S., use a business reply envelope; if in Mexico, use a non-franked reply envelope.

Exhibit 3a

Authorization for Consultative Exam (CE)

To: (1) .
______________________
______________________

SSN: _____ (4) _____________

Name: _ __ (5) __________

If you have any questions, please call our office at: (6) .

From: Social Security Administration
__________ (2) ________________
______________________________
______________________________

* Receiving report:* _________(7)_______
*                                  (SSA Manager)

Claims Representative
Signature (3) .

* Accounting Classification:

* CAN = 4005113 SOC = 2533

Doctor: Please perform the listed services below which are hereby authorized. Complete the bottom half of this form, sign it, and attach the form to your report(s) and mail them to the SSA office shown above. This exam will be paid for by the Federal government based on a set fee schedule. ________________________________________________________________

Service Description & Approved Fee Amounts

                                                             (8)

===================================================

Date of Service Description of Service Amount

______________________________________________________________

Pay this Amount $ (10) .

Certification

I, (11) , do hereby certify that I am a (12) . and that I am duly authorized to make this certification for and on behalf of (13) (patient). I further certify that the attached invoice is correct and that it corresponds in every particular with the services contracted for and does not exceed my usual customary fee. I further certify that the amount is true, correct and unpaid. As vendor, I certify there has been no discrimination on the grounds of race, color, national origin or handicap in the performance of this contract..

(14)

Signature

Exhibit 3b

Completion Procedures for CE Authorization Forms (Exhibit 3a)

FO completes these blocks:

1. CE provider's name and address.

2. FO's address.

3. CR's signature (print name below signature).

4. Claimant's SSN.

5. Claimant's name.

6. FO telephone number.

7. Manager's or designee's signature (show "by manager's designee").

8. Description of services requested and DDS approved amounts.

CE provider completes these blocks:

9. Date, description of services performed and fee requested.

10. Total amount of fees charged.

11. Name of person certifying the CE (e.g., Dr. Miguel Adams).

12. Title of person certifying the CE (e.g., M.D.).

13. Name of the claimant.

14. Signature of CE provider (must be original).

After receipt of the CE authorization and the vendor's invoice, prepare a third party draft to cover all requested fees that do not exceed the approved amount(s). Be sure to use the OIO CAN and SOC on the third party draft.

Exhibit 4

Letter to Claimant Requesting Attendance at CE

(English Version)

(Claimant's Name and Address)

Your application for Social Security disability benefits has been received by this agency for consideration. Additional current medical information is needed and a special examination can best provide this information. In order to save time, we have authorized an examination(s) for you by:

( ) You should call the above office(s) for an appointment as soon as possible.

( ) We have made an appointment for you on ________________________ at _____________________________ a.m./p.m.

( ) Type of examination or test: _____________________________.

The examination(s) will be performed at Federal government expense and at no cost to you.

If you fail to make/keep the appointment at the established time, and if you do not notify us of the reason you are unable to appear for the examination(s) by 24 hours before the examination time, we may make a determination based on the medical information we currently have on file (if any). The lack of complete information about your medical condition could cause us to determine you are not disabled or blind.

Be sure to return the enclosed Claimant Response Form before the appointment day. If you have any questions, please call us immediately at ______________.

Sincerely yours,

District/Branch Manager

Enclosures (2)

Exhibit 5

Letter to Claimant Requesting Attendance at a CE

(Spanish Version)

(Name and Address of Claimant)

Su solicitud de beneficios del Seguro Social por incapacidad ha sido recíbido por esta agencia para evaluación. Será necesario conseguir más evidencia médica y la mejor manera de conseguirla es mediante un examen especial. Para ahorrar tiempo, hemos autorizado que sea examinado por:

( ) Deberá llamar a la oficina de este doctor(es) inmediatemente para hacer una cita.

( ) Le hemos hecho una cita para el día ______________________________.

El examen(es) será pagado por el Gobierno Federal y usted no tendrá que pagar nada.

Si no hace su cita o si no acude en la fecha indicada y no nos avisa la razón por la cual no podrá acudir 24 horas antes de la hora de su examen, haremos nuestra decisión basándonos solamente en la información contenida actualmente en su expediente. Es probable que ésto no demuestre que está usted incapacitado o ciego.

POR FAVOR asegúrese de regresar la carta adjunta antes de la fecha ahí indicada para acusar recibo de esta carta. Si tiene preguntas sobre el examen, por favor comuníquese de inmediato con nosotros por telefono al numero _____________________________.

                                                 Muy atentamente,

                                                      Director

Adjunto: 2 formas

Exhibit 6

Letter to Representative Payee Applicant Requesting Claimant Attend a CE

(English Version)

(Rep payee's name and address)

This letter is about the application for Social Security disability benefits you have filed on behalf of _____________________________. Additional current medical information is needed and a special examination can best provide this information. In order to save time, we have authorized an examination(s) for the person for whom you have filed an application by the following doctor(s):

( )You should call the above office(s) for an appointment as soon as possible.

( )We have made an appointment for the claimant on ______________________ at ______________________ a.m./p.m.

( ) Type of examination or test: ____________________________________.

The examination(s) will be performed at Federal government expense and at no cost to you or the claimant.

If the appointment is not kept at the established time, and if you do not notify us of the reason the claimant is unable to appear for the examination(s) by 24 hours before the examination time, we may make a determination based on the medical information we currently have on file (if any) for the claimant. The lack of complete medical information could cause us to determine that _____________________________ is not disabled or blind.

Be sure to return the enclosed Claimant Response Form before the appointment day. If you have any questions, please call us immediately at _____________.

Sincerely yours,

District/Branch Manager

Enclosures (2)

Exhibit 7

Letter to Representative Payee Applicant Requesting Claimant to Attend CE

(Spanish Version)

(Rep Payee's Name and Address)

Esta carta se refiere a la solicitud de beneficios del Seguro Social por incapacidad que usted hizo a nombre de ________________________________. Será necesario conseguir más evidencia médica y la mejor manera de conseguirla es mediante un examen especial. Para ahorrar tiempo, hemos autorizado que sea examinado por:

( ) Deberá llamar a la oficina de este doctor(es) inmediatemente para hacer una cita.

( ) Le hemos hecho una cita para el día ________________________________.

El examen(es) será pagado por el Gobierno Federal y usted no tendrá que pagar nada.

Si no hace su cita o si no acude en la fecha indicada y no nos avisa la razón por la cual no podrá acudir 24 horas antes de la hora de su examen, haremos nuestra decisión basándonos solamente en la información contenida actualmente en su expediente. Es probable que ésto no demuestre que está incapacitado o ciego.

POR FAVOR asegúrese de regresar la carta adjunta antes de la fecha ahí indicada para acusar recibo de esta carta. Si tiene preguntas sobre el examen, por favor comuníquese de inmediato con nosotros por telefono al numero _____________________________.

Muy atentamente,

Director

Adjunto: 2 formas

Exhibit 8

Claimant Response Form
(English Version)

Claimant: _____________________

SSN: _____________________

Please check the proper box below to let us know whether you will keep the examination or test scheduled for you on         (day, date) at       (time) .

______ I will keep the appointment.

______ I cannot keep the appointment because ___________________ __________________________________________________________ __________________________________________________________

IMPORTANT: Sign, date and mail this form immediately, using the pre- addressed envelope provided or telephone ____________ at ______________.

                         (Claims Representative) (Telephone #)

______________________ _____________________

Your signature Date

Exhibit 9

Claimant Response Form

(Spanish Version)

Reclamante: _______________________

Numero De Reclamación: _______________________

Favor de marcár la caja debajo para informarnos de haber recíbido la noticia de examanación médica para el día ___________, fecha ____________________a las _____________________________.

____ Atenderé la cita

____ No atenderé la cita porque ___________________________________ _______________________________________________________________

IMPORTANTE: Firme, ponga la fecha, y envié por correo inmediatemente, usando el sobre con la direción proporcionada, o llame por telefono al numero _______________________.

_____________________________ ____________________________

Su firma Fecha

Exhibit 10

Foreign Claims

Report of Expenditures via Third Party Draft

ATTN: Management and Program Analyst

FAX: 410-966-3196

Reporting Period:______________________

FO:_________________________________

Charged to:

SOC: 2533

CAN: 4005113

Draft Date Claimant’s Name       SSN      Paid To       Amount

_______________________________________________________

_______________________________________________________

_______________________________________________________

Fax the above report to OIO by the 15th of the month following the end of each calendar quarter. For example, the report of October – December quarter should be faxed by January 15th.

Exhibit 11

Click here for a Microsoft Publisher Version and here for a web version.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0411010540DAL
DI DAL11010.540 - Examining Evidence - Foreign Claims (TN 1 -- 08/2007) - 09/18/2012
Batch run: 09/18/2012
Rev:09/18/2012