BASIC (09-06)

DI 39545.150 CE/MER Evidence

A. Policy

The DDS is responsible for determining claimants’ disabilities and ensuring that adequate evidence is available to support its determination. When existing medical evidence is insufficient, not available or cannot be obtained, DDSs are authorized to purchase CEs.

References:

  • Development of Consultative Examinations (CEs), DI 22510.000

  • Development of Medical Evidence of Record (MER), DI 22505.001

B. Procedure – CEs

DDSs should review policies and practices for purchasing CEs to ensure close attention is given to the specific evaluation issues involved in each case. These policies and practices should consist of the following activities:

  • Establish controls to ensure only required examinations and tests are authorized and no open-ended authorizations are issued.

  • Limit additional tests or studies requested by the medical provider to what is specifically needed for adjudication.

  • Perform ongoing and/or special management studies on the quality of CEs purchased from medical sources. Share the results of the studies with appropriate DDS management and internal components.

  • Ensure CEs are scheduled only with medical sources that are properly licensed or certified and have the equipment required to develop an adequate assessment and record of the level of severity of the claimant's alleged impairments and the functional limitations caused by the impairment(s).

  • Establish procedures to verify that CE sources are paid the lower of the usual and customary amount they bill for each service or the maximum allowable under the DDS fee schedule.

  • Make maximum use of the SSA’s Electronic Records Express (ERE) website or other SSA approved secure electronic communications methods, fax, and telephone contacts where possible to obtain existing reports, records, and supplemental objective medical evidence to document the severity of any alleged impairments prior to consideration of the purchase of a CE. Similarly, this same technique could be used to obtain reports and clarify the results of CEs.

C. Procedure - MER

DDS should carefully review all MER policies and practices to ensure every reasonable effort is made to obtain sufficient, accurate, and timely documentation from the claimant's treating and other medical sources prior to purchasing a CE. These policies and practices should include the following activities:

  • Schedule contacts on a priority basis with medical sources who are extremely slow or uncooperative in reporting or whose reports generally lack necessary objective data and other components of a complete report to educate them regarding program needs.

  • Make arrangements for receipt of MER via the ERE website or other SSA approved secure electronic communication methods through fax, or teledictation, unless US mail is the only option.

  • Review development practices, questionnaires, and form letters used to request MER to ensure the wording of each request will elicit all available pertinent clinical and laboratory findings and opinions needed for adjudication.

  • Make maximum use of telephone contacts to obtain supplemental objective treating source medical evidence and to document the severity of any alleged impairments prior to consideration of the purchase of a CE. Similarly, this technique could be used to clarify the results of CEs.

  • Review all procedures and practices in approving payments for MER to ascertain that all requirements are met before payment is made.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0439545150
DI 39545.150 - CE/MER Evidence - 06/15/2007
Batch run: 01/27/2009
Rev:06/15/2007