BASIC (10-16)

DI 23060.020 Identifying Excluded Medical Sources of Evidence

Citations:

Soc. Sec. Act as amended in 2015, Secs. 223(d)(5)(C), 1614(a)(3)(H)(i), 42 U.S.C. §§ 423(d)(5)(C), 1382c(a)(3)(H)(i); P.L. 114-74, § 812; 20 CFR §§ 404.1503b, 416.903b

A. Excluded medical sources of evidence must provide a written statement of exclusion

Excluded medical sources of evidence must provide a written statement of exclusion each time they furnish evidence to us directly or indirectly through a representative, claimant, or other individual or entity.

Adjudicators have no duty to identify excluded medical sources of evidence on their own. However, if there is no written statement of exclusion, and an adjudicator receives clear documentation that a source is an excluded medical source of evidence, the adjudicator must exclude the source’s evidence (unless there is sufficient information to apply a good cause exception(s)).

Additionally, if there is no written statement of exclusion, and an adjudicator receives clear documentation that a source is an excluded medical source of evidence, the adjudicator should refer the source to the Social Security Administration’s Office of the Inspector General (SSA’s OIG). See DI 23060.040 for how to refer an excluded medical source of evidence to SSA’s OIG.

An example of clear documentation is an email from an administrator or professional relations officer to all staff stating that John Doe, M.D., is an excluded medical source of evidence because he was convicted of a felony under section 208 of the Social Security Act (Act) on November 2, 2016.

B. Contents and placement of the written statement of exclusion

1. Contents of the written statement of exclusion

All written statements of exclusion must include the following:

  1. The heading, “WRITTEN STATEMENT REGARDING SECTION 223(d)(5)(C) OF THE SOCIAL SECURITY ACT – DO NOT REMOVE;”

  2. The name and title of the excluded medical source of evidence; and

  3. The reason we cannot consider the evidence furnished by the excluded medical source of evidence – i.e., that the medical source was:

    • Convicted of a felony under section 208 or 1632 of the Act;

    • Excluded from participating in any Federal health care program under section 1128 of the Act; or

    • Imposed with a civil monetary penalty (CMP), assessment, or both, for submitting false evidence under section 1129 of the Act.

As applicable, all written statements of exclusion must also include:

  • The date of the felony conviction under section 208 or 1632 of the Act;

  • The reason, effective date, and expected length of exclusion under section 1128 of the Act, and whether the Office of Inspector General of the Department of Health and Human Services (HHS’ OIG) has waived the exclusion; and

  • The date of the CMP, assessment, or both, for submitting false evidence under section 1129 of the Act.

2. Placement of the written statement of exclusion

Excluded medical sources of evidence should place the written statement of exclusion after the barcode page, but before the first page of evidence.

If a written statement of exclusion is placed somewhere else in the evidence, adjudicators do not have to move it.

C. Unclear or incomplete written statements of exclusion

If a written statement of exclusion does not include information that allows an adjudicator to determine whether a good cause exception(s) may apply, the adjudicator should contact the excluded medical source of evidence for clarification or additional information. See DI 22505.008 for instructions on developing supplemental evidence.