SSA - POMS: DI 24501.006 - SSA-416-UF Medical Evaluation

A. When to use the SSA-416-UF (Medical Evaluation)

1. Medical Consultants (MC) and Psychological Consultants (PC) Medical Evaluation

Process the medical evaluation eForm(s) through the Disability Determination Services (DDS) case processing system, see DI 81020.110. MCs and PCs use the SSA-416-UF (Medical Evaluation) to document medical evaluation of any of the following medical findings for adult claims:

Medical Findings:	Reference to Policy Information:
No medically determinable physical impairment	See Evidence of a Medically Determinable Impairment, DI 25205.005.
Non-severe physical impairment(s)	See Sequential Evaluation of Title II and Title XVI Adult Disability Claims in DI 22001.001.
Insufficient evidence for physical impairment(s)	See Disability Case Development for Medical and Other Evidence in DI 22501.001.
Impairment meets or medically equals a physical listing	See The Steps of Adult Sequential Evaluation of Disability(DI 22001.001D).
Reconsideration affirmation	See Adoption of Initial Level RFC Assessment (DI 24510.066B).
Continuing disability review (CDR) medical evaluation	See Comparison of Symptoms, Signs, and Laboratory Findings in DI 28010.015.

For more information about when to use the SSA-416 in medical CDRs, see DI 28010.050.

2. Using the SSA-416-UF for a Medical Advisor’s (MA) analysis

The MA will use an SSA-416–UF to enter his or her full claim analysis. The MA must use the Claim Communication page in eCAT to provide his or her analysis for both adult and child claims. Select the Claim Communication source titled “Medical Advisor (416).” For additional information on the role of the MA see DI 24501.001.

B. Who signs Form SSA-416-UF

The signer may be an:

•

MC,
•

PC, or
•

MA.

For a detailed explanation of MC, PC, and MA roles, see DI 24501.001.

C. How to complete form SSA-416-UF

When processing:

•

paper claims, you can access the SSA-416-UF via the InForm website; and
•

electronic claims, you can access the SSA-416-UF eform via the form selector application.

NOTE: The disability examiner (DE) may complete or assist in completing the SSA-416-UF but only the MC, PC, or MA may sign the form. The DE cannot edit a medical evaluation form that the MC, PC, or MA has signed.

The following chart provides instructions on how to complete the SSA-416-UF:

Form section	Action
1. Heading	Fill in the claimant’s name and SSN.
2. Period Covered	Indicate the assessment period covered in the evaluation: • Current evaluation - Onset date through present and the duration requirement has been met, or when the onset is within 12 months of adjudication and the impairment does not preclude substantial gainful activity (SGA) at the time of the assessment. • Date last insured (DLI) - For Title II cases only, when DLI has expired in the past. Enter the DLI “(Date)” in the space provided. • 12 months after onset - When duration is an issue, enter the “(Date)” to which you are projecting in the space provided. • Other period(s) - For any situation not covered by the other three blocks (multiple assessments or closed periods).
3. Subject	Identify which type of medical finding you are documenting. There may be more than one subject for each SSA-416-UF.
4. Assessment	Document the medical evaluation in this section. As appropriate, address the following: • onset (See DI 25501.200 through DI 25501.470), • duration (See DI 25505.025 through DI 25505.040), • Drug Addiction and Alcoholism (DAA) materiality analysis (See Evaluating Cases Involving Drug Addiction and Alcoholism (DAA) SSR 13-2p in DI 90070.041), • symptom evaluation (See DI 24501.021), and • closed period (See DI 25510.001 through DI 25510.015).
5. Signoff block “THESE FINDINGS COMPLETE THE MEDICAL PORTION OF THE DISABILITY DETERMINATION”	• MC/PC: If an MC or PC is completing this form, check this box when the evaluation is complete. • MA: Do not check this box. The Social Security Act (42 U.S.C. 421(h)) authorizes only an MC or PC to complete the medical portion of the case review and any applicable residual functional capacity (RFC) assessment. • Do not check this block. This block is for MC/PC completion only.
6. Signer’s Role	Check the appropriate box corresponding with your role in the disability determination.
7. Signature instructions	• In all claims, sign your name, enter your office number, print or type your name, identify the page numbers, and date the form. • MC/PC/MA Specialty Code: Only an MC, PC, or MA will complete this field. Enter the appropriate specialty code found in DI 24501.004.
8. MC/PC/MA Specialty Code	Only an MC, PC, or MA will complete this field. Enter the appropriate specialty code found in DI 24501.004.

IMPORTANT: Alternatively, an MA may print the form and sign in ink; identify the signer as “Medical Advisor,” and scan the document into the EF. For guidance on completing the SSA-416-UF in eCAT, see the most recent eCAT User Guide.

D. How MAs add their evidence to a claim

The MA with take one of the following actions to add his or her analysis to a claim:

Kind of claim	Action
An electronic claim completed in eCAT	Complete a “Medical Advisor (416)” Claim Communication. For guidance on adding a Medical Advisor (416) Claim Communication in eCAT, see the most recent eCAT User Guide.
A paper claim	Complete, print, and add Form SSA-416 to the paper Modular Disability Folder (MDF). For further information about the MDF, see DI 70005.005.

Social Security

Program Operations Manual System (POMS)

DI 24501.006 SSA-416-UF Medical Evaluation