DI 39518.065 Administrative Provisions for Assuring that Mental Impairment Cases are Evaluated by Qualified Professionals

Citations:

Social Security Disability Benefits Reform Act of 1984;

Regulations 20 CFR 404.1624 and 416.1024

A. Policy principle

SSA must make every reasonable effortto ensure that a qualified psychiatrist or psychologist completes the medical portion of the case review and any needed assessment of residual functional capacity in initial mental impairmentcases before an unfavorable decision is made.

B. Background

1. CO responsibilities

CO is responsible for monitoring national compliancewith the statutory requirements and intent of Congress by:

  1. identifying problemsrequiring new or revised instructions, guides or regulations;

  2. developing mental caseload estimates,where necessary;

  3. budgetingfor program costs;

  4. providing clarificationon a case-by-case basis of what circumstances warrant a finding that “every reasonable effort” has been made to obtain necessary specialist staff; and

  5. issuing guidelineson the nature and extent of Federal resources that may be applied in securing specialist services.

NOTE: Use of Federal resources,including contracting out for psychiatrist and psychological services, will be considered only where the States are unable, despite every reasonable effort, to obtain the specialist services required.

2. RO responsibilities

The RO is responsible for assuring every reasonable effortis made to obtain specialist reviews by:

  1. providingState agency with caseload estimates and other information for use in determining the extent of staff needed;

  2. workingwith the State agency to develop strategies for meeting the required effort, and/or undertaking actions needed to eliminate impedimentsto the State's obtaining and maintaining the required staff;

  3. budgetingfor approved acquisitionof additional staff or for increases in payment rates for professionals;

  4. monitoringState agency performance in completing plans and providing the necessary reviews;

  5. determiningfor the State agency:

    • the circumstancesunder which the State may release mental impairment cases that have not been reviewedby a specialist,

    • the number and types of cases that may be released,and

    • the period of timethat such releases may continue;

  6. determining when alternative Federal resources,including contracting out, are needed and how these resources will be provided;

  7. obtaining the necessary Federal resourcesand coordinating these resources within the State agency, RO and CO structure; and

  8. requesting CO assistanceas needed.

C. Operating policy

1. Specialist review

SSA's goalis to have specialist,i.e., qualified psychiatrists or psychologists, review all mental impairment cases.

2. Every reasonable effort

The responsibility to ensure that every reasonable effortis made to obtain specialist reviewsin mental impairment cases is the responsibility of all State agencies and regional and central offices.

D. Operating procedures

1. Staff levels

Determinewhether the current staff is sufficient to provide specialist reviews.

2. Less than full time

Develop a plan to overcome less than fulland continuous coverage. Include:

  1. The delays, caseload and/or anticipated number of days, specialist case reviews are pending;

  2. Planned recruitmentinitiatives and contacts to be made.

    EXAMPLE:The following actions can be taken:

    • Increaseexisting staff hours;

    • Contactother State agencies for qualified staff willing to participate or for other recruitment leads;

    • Contactmedical schools/universities;

    • ContactState/national specialist societies and associations; and

    • Advertisein professional publications.

3. Fee