TN 7 (03-17)

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

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 Symptoms, Medically Determinable Physical and Mental Impairments, and Exertional and Nonexertional Limitations (Social Security Ruling (SSR) 96-4p) in DI 24515.065).

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 Sequential Evaluation of Title II and Title XVI Adult Disability Claims in DI 22001.001).

Reconsideration affirmation

See Affirmation of a Prior Disability Determination in DI 27021.010.

Continuing disability review (CDR) medical evaluation

See Comparison of Symptoms, Signs, and Laboratory Findings in DI 28010.015.

IMPORTANT: You can only compare symptoms, signs, and laboratory findings in an SSA-416-UF when there is no medical improvement.

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,

  • MA,

  • Single decision maker (SDM), or

  • Disability examiner (DE) with authority to issue fully favorable determinations in claims adjudicated under the compassionate allowance (CAL) and quick disability determination (QDD) initiatives.

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

For an explanation of SDM authority, see DI 12015.100.

For an explanation of DE authority for CAL and QDD cases, see DI 23023.001.

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.

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:

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.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0424501006
DI 24501.006 - Form SSA-416 (Medical Evaluation) - 04/15/2015
Batch run: 03/30/2017
Rev:03/30/2017