TN 2 (03-10)

DI 44001.120 Developing Medical Evidence

If the available evidence is insufficient to adjudicate the claim, the Great Lakes Program Service Center-Disability Processing Branch (GLPSC-DPB) disability processing specialist (DPS) should develop medical evidence of record (MER) for claims processing.

A. Obtaining MER from Railroad Retirement Board (RRB)

RRB and SSA have agreed to provide each other with copies of medical evidence received in connection with disability claims to avoid duplication of development. For processing RRB requests to GLPSC-DPB for medical evidence, including RR-5 requests see DI 44001.125.

1. Upon receipt of a new dual eligibility disability claim

Contact RRB to find out if the claimant filed a claim for a disability annuity with RRB. If so, ask for copies of any medical or vocational evidence, medical consultant assessment, and disability determination, if available.

NOTE: If RRB has medical evidence from a current or recent claim, wait to review the RRB evidence before initiating additional medical development in DPB. Do not delay the development of medical evidence from the claimant’s current medical sources if it appears the RRB evidence is more than one year old or unrelated to the current alleged impairment(s) per DI 44001.120B in this section.

Phone or e-mail the RRB examiner who has jurisdiction of the claim. (RRB divides its casework into initial claims and post-entitlement cases, and periodically sends DPB a list of RRB supervisors and examiner names and phone numbers organized by terminal digits).

2. If the RRB examiner does not reply to a phone or e-mail request within two workdays

Send a follow up e-mail to the RRB Group mailbox address, to the attention of the RR examiner responsible for those terminal digits. (RRB Group mailbox address is available on the DPB shared drive in the Railroad Cases folder).

3. If the RRB examiner does not reply to the follow-up e-mail request within five workdays

  • Contact your supervisor. Your supervisor will phone a RRB supervisor and ask for assistance in obtaining the requested information.

  • Document all contacts (and attempted contacts) with RRB; cite the name of the RRB examiner, the date, and the result of the contact, use either an SSA 415 (Notice of Disability Determination) or an SSA 5002 (Report of Contact). Sign and date the report.

    NOTE: Use the same form to record all contacts with RRB whenever possible. However, always use Form SSA-415 to coordinate the final determination with RRB.

  • Set a 20-calendar day tickle, from the date of the initial contact with RRB to follow-up if you have not received the medical evidence.

  • If the initial follow up is unsuccessful, set a 10-calendar day tickle for receipt of evidence from RRB.

  • If RRB has not furnished the requested evidence after 30 calendar days from the initial contact, refer the case to a DPB manager to request expedited handling by RRB.

B. RRB evidence insufficient – development of MER

If RRB does not have a disability claim, or if the evidence furnished by RRB is not sufficient to make a determination,

  • Assist the claimant in obtaining medical reports from all pertinent medical sources, using the disability determination services (DDS) guidelines per DI 22505.001.

  • Initiate and control all MER requests following the guidelines established in the MIDAS legacy system. Consider all evidence in the claimant’s case record when making the determination.

  • Authorize payment as appropriate to the MER sources upon receipt of requested medical evidence, and

  • Refer the MER invoices to the MIDAS disability assistants for payment.

C. Obtaining consultative examinations (CEs)

After a review of all available evidence, if the DPS and medical consultant/psychological consultant (MC/PC) agree that a CE is necessary to reach a determination, request the DDS in the state of residence to obtain the necessary CE(s) per DI 20101.040A.

1. CE requests for electronic claims using MIDAS Legacy System

  • Prepare an SSA-883-U3 (Request for Evidence or Assistance (Disability Case)) in MIDAS and send to the electronic folder (EF). BE VERY SPECIFIC ABOUT THE TYPE OF CE NEEDED AND ABOUT ANY SPECIAL REQUIREMENTS REQUESTED BY THE MC/PC. Remember to include the claimant’s alleged impairments that are related to the type of CE requested.

  • Clearly identify the claim as “Career Railroad – GLPSC-DPB Jurisdiction”. Advise the DDS that DPB will make the disability determination and retain jurisdiction of the case upon receipt of the CE report.

  • Show your name, phone number, date of request on the SSA-883-U3, and ask the DDS to phone you if they have any questions or problems with your request.

  • Categorize all pertinent evidence, including an SSA-827 (Authorization to Disclose Information to the Social Security Administration (SSA)). Pages categorized as “Physical,” “Mental,” or “Mental and Physical” generate with the CE material and are sent to the CE provider as background material by the DDS per DI 81020.095D.

  • Ask the DDS to scan or download to the EF all pertinent CE documents, (e.g. such as the notice to the claimant with the CE appointment information), as received.

  • Go to the “Case Maintenance” screen when the SSA-883-U3 is in the EF, and create an assistance request – select “D”.

  • Show the appropriate DDS site code. Enter a follow-up date of 14 days in the future. In the Notes section, type: “GLPSC-DPB railroad case – Please obtain a CE per DI 20101.040A. See SSA-883-U3 in file.”

  • Telephone the DDS after 14 days to verify that someone is working on the CE request if the EF does not show that a CE has been scheduled. Ask the DDS to scan the CE appointment notice into the EF when received, or to notify you by phone/e-mail when the exam has been scheduled.

When the tickle matures:

  • Check the EF to see if the CE information has been scheduled

  • Set another 14-day tickle date for the next follow-up once the CE is scheduled.

  • Advise the DDS examiner that they need to scan the CE report or any “failure to attend” letters into the EF upon receipt. Document all contacts with the DDS in the claims folder.

2. CE requests for paper claims

  • Follow the same CE request and follow-up guidelines for electronic claims when possible (per DI 44001.120C.1. in this section) making adjustments as necessary for paper folder processing.

  • Prepare an SSA-883-U3 (using either MIDAS or eForms).

  • Prepare a paper CE request package for transmittal to the DDS of residence. The package should include an SSA-883-U3, an SSA-827, and copies of all medical evidence pertinent to the CE request.

  • Telephone the DDS and ask to speak to the disability examiner who will handle the claim. Advise the DDS examiner that a CE is needed for a career railroad claim per DI 20101.040.

  • Advise the examiner to follow regular DDS guidelines in requesting the CE, including rescheduling missed appointments, or handling failure to appear for a CE cases per DI 23007.010.

  • Explain that DPB will make the disability determination and retain jurisdiction of the case upon receipt of the CE report from the DDS.

  • Fax the CE request material to the DDS to the attention of the DDS examiner handling the CE request.

  • Ask the DDS examiner to fax a copy of the CE report to your attention to GLPSC-DPB at 312-575-4701 and to mail the original signed CE report to:

    GLPSC-DPB – 9th Floor
    P.O. BOX 87755
    CHICAGO, IL 60680-0955

    “Do Not Open in Mailroom”

3. Review of CE report and Referral of CE report to treating source

Follow the usual DDS guidelines for reviewing CE reports and for referral of reports to the claimant’s treating source if the CE examination discloses new diagnostic information or test results which reveal potentially life-threatening situations per DI 22510.020B.4.a.

4. Referral of CE report to RRB

Send a copy of the CE report to the RRB as appropriate. For instructions see, Coordination of Dual Eligibility Cases with Railroad Retirement Board (RRB) DI 44001.125.


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http://policy.ssa.gov/poms.nsf/lnx/0444001120
DI 44001.120 - Developing Medical Evidence - 09/22/2016
Batch run: 09/22/2016
Rev:09/22/2016