TN 6 (11-16)
DI 24501.001 The Disability Determination Services (DDS) Disability Examiner (DE), Medical Consultant (MC), and Psychological Consultant (PC) Team, and the Role of the Medical Advisor (MA)
A. Introduction to the roles and responsibilities of the DE, MC, PC, and MA
A disability determination requires the DE, MC, and PC to collaborate as the adjudicative team. Not all team members participate in the development and evaluation of all claims, as outlined in DI 24501.001B in this section. All team members have training in the disability process. MAs are not part of the adjudicative team but can provide analysis of medical issues.
B. Adjudicative roles and responsibilities of the DE, MC, PC, and MA
1. Role of the DE
The following provides information about the DE’s role in the adjudicative process:
The DE’s role in the determination process includes, but is not limited to:
Identifying sources of evidence from claim folder information;
Sending and following up on requests for evidence from medical sources, entities that maintain medical sources’ evidence, and nonmedical sources;
Contacting claimants, applicants, claimant representatives, and other appropriate parties for additional information;
Preparing cases for MC, PC, and MA review including highlighting relevant periods for consideration such as date last insured or prior adjudicated periods;
Initiating requests for consultative examinations (CE) when medical evidence of record (MER) is not sufficient to make a determination of disability and following up to obtain CE reports when necessary;
Consulting with MCs, PCs, and other staff members to resolve problems in getting evidence from medical sources, entities that maintain medical sources’ evidence, and nonmedical sources;
Consulting with MCs, PCs, and MAs to resolve medical issues and evidence interpretations;
Making every reasonable effort (to ensure that the following sources have completed the medical portion of the case review and have completed any applicable RFC assessment:
a qualified physician (where a physical impairment is alleged),
a psychiatrist or psychologist (where the claimant alleges a mental impairment), or
both (where the claimant alleges both a physical impairment and a mental impairment); and
Determining whether an individual can perform past relevant work given his or her RFC at step 4 of the sequential evaluation process;
Determining whether an individual can adjust to other work given the individual’s RFC, age, education, and work experience at step 5 of the sequential evaluation process; and
Preparing determinations, including Forms SSA-831 (Disability Determination and Transmittal) or Title XVI SSA-832 and Title II SSA-833 (Cessation or Continuance of Disability or Blindness Determination and Transmittal), determination rationales, and disability determination notices.
NOTE: See DI 39518.065 for a definition of “reasonable effort.”
The DE alone may make the disability determination in the following situations:
No medical evidence exists in the current file or in any prior files and (despite making every reasonable effort) the DDS is unable to obtain any medical evidence that may exist and one or more of the following situations exists:
the claimant refuses or fails, without a good reason, to attend a CE as explained in DI 23007.009 and DI 23007.010;
the DDS curtails CE development after establishing the claimant’s failure or refusal to cooperate as explained in DI 23007.004E and DI 23007.005H; or
the date last insured or other technical factor is in the past, and there is no possibility of setting an onset prior to the end of the entitlement period. (For additional information about technical factors in the past see DI 25510.006G.)
The DE has single decision maker (SDM) authority in a prototype or SDM II DDS and the claim meets SDM requirements as explained in DI 12015.100B.1.
The DE has the authority to use the procedures for quick disability determinations (QDD) and compassionate allowance initiative (CAL) determinations as explained in DI 23023.001.
NOTE: Due to the Bipartisan Budget Act of 2015 Section 832, we plan to phase out SDM authority nationwide by the end of 2018.
2. Role of the MC or PC
The following provides information about the MC or PC role in the disability process:
MC or PC role in the determination process
The MC or PC role in the determination process includes but is not limited to:
Fully evaluating the evidence in the case to determine its adequacy for completing the medical portion of the case review;
Making the medical portion of the disability determination;
Assessing the existence and severity of impairments at step 2 of the sequential evaluation process;
Determining whether an impairment meets or equals the requirements of a listing in the Listing of Impairments (Listings) at step 3 of the sequential evaluation process;
In childhood disability claims, determining functioning and whether a claimant’s impairment(s) functionally equals the Listings at step 3 of the sequential evaluation process;
Assessing and determining RFC in adult disability determinations;
Participating in making other specific medical determinations in a claim, as appropriate;
Resolving problems in obtaining MER through discussions with DEs and other staff members;
Reviewing requests for CEs in specific claims to ensure they are necessary and will resolve the issues as intended;
Providing alternatives to the purchase of a CE;
Reviewing CE reports for deficiencies in content and recommending ways to avoid deficient reports;
Evaluating and responding to medical questions;
Recommending improvements in letters and other forms of communication designed to obtain evidence;
Improving relations with the medical community, enlarging consultative examiner panels, and minimizing CE processing time by working closely with staff members and CE providers;
Improving DE understanding and use of medical evidence by working with training staff;
Reviewing determinations to ensure their integrity; and
Handling conflicts of interest
If a DDS MC or PC furnishes any of the MER, he or she will not participate in the disability determination of that claim. If that MC or PC provides evidence to the MC or PC who is participating in the determination, he or she should submit it in writing so that it becomes part of the case record.
For instructions on when a DDS Adjudicative Team Member Furnishes Evidence, see DI 22505.027.
For instructions on Conflict of Interest, see DI 39569.100.
3. Role of the MA
The MA’s role in the determination process includes:
helping DEs, MCs, and PCs understand specialized issues or evidence in claims; and
providing analysis about medical issues related to impairments for which they are qualified to evaluate, as described in DI 22505.003A. For example, a speech-language pathologist (SLP) may provide advice in a claim about an issue or evidence related to a speech or language impairment.
Adjudicators must consider this MA analysis as evidence from an acceptable medical source. The statute prohibits MAs from signing or otherwise taking responsibility for the medical portion of the determination.
MAs must use Form SSA-416 (Medical Evaluation) to provide their analysis. We will use the analysis as evidence in the claim. For specific business process instructions, see DDSAL 960 “Medical Advisors—Bipartisan Budget Act (BBA) Section 832—INFORMATION.”
C. Qualifications for MC, PC, and MA
An MC is a licensed physician (medical or osteopathic) who is a member of a DDS or Social Security Administration (SSA) team that makes disability determinations.
A PC is a licensed psychiatrist or a psychologist who:
is licensed or certified as a psychologist at the independent practice level of psychology by the State in which he or she practices;
possesses a doctorate degree in psychology from a program in clinical psychology of an educational institution accredited by an organization recognized by the Council for Higher Education Accreditation, formerly the Council on Post-Secondary Accreditation; or
is in a national register of health service providers in psychology which the Commissioner of Social Security deems appropriate; and
possesses two years of clinical experience as a psychologist, at least one year of which is post masters degree, and who is a member of a DDS or SSA team that makes disability determinations.
A medical advisor is an acceptable medical source who is not an MC or PC. Currently, this includes:
Licensed optometrists, for impairments of visual disorders only (except, in the United States Virgin Islands, licensed optometrists, for the measurement of visual acuity and visual fields only).
Licensed podiatrists, for impairments of the foot, or the foot and ankle only, depending on whether the State in which the podiatrist practices permits the practice of podiatry on the foot only, or the foot and ankle.
Qualified speech-language pathologists, for impairments of speech or language only.
For more information about acceptable medical sources, see Evidence from an Acceptable Medical Source (AMS) per DI 22505.003A.
D. MC and PC responsibility for the medical portion of the determination
An MC who is a physician takes responsibility for the medical portion of the determination, except in cases where a PC may perform this function.
A PC may perform this function when:
a mental impairment is the only impairment in the claim; or
when there is a combination of a mental impairment with a physical impairment, but the mental impairment alone would justify a finding of disability.
The MC or PC who is taking responsibility for the medical portion of the determination, signs the disability determination forms and any supporting documents relevant to the determination that require a signature.
In cases where there is evidence of mental and physical impairment(s), and a PC reviews the case, the PC evaluates only the mental impairment(s) and the MC evaluates the physical impairment(s).
In cases where the combination of physical and mental impairments may be equivalent to a medical listing, the MC and PC will confer, and both will sign the rationale supporting the equivalence.