Identification Number:
DI 24501 TN 19
Intended Audience:See Transmittal Sheet
Originating Office:ORDP ODP
Title:General - Medical Evaluation
Type:POMS Transmittals
Program:All Programs
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM
Part DI – Disability Insurance
Chapter 245 – Medical Evaluation
Subchapter 01 – General - Medical Evaluation
Transmittal No. 19, 01/04/2021

Audience

PSC: DE, DEC;
OCO-OEIO: CR, ERE, FDE, RECONE;
OCO-ODO: DE, DEC, DS, RECONE;
OCO: ODD;
ODD-DDS: ADJ, DHU;

Originating Component

ODP

Effective Date

Upon Receipt

Background

We are issuing this Program Operations Manual System (POMS) section to provide instructions on corrective action when an individual who did not meet the qualifications of a Medical Consultant (MC) or Psychological Consultant (PC) completed and signed medical assessments and the medical portion of disability determinations.

Summary of Changes

DI 24501.003 Corrective Action When an Unqualified Individual Acted as a Medical Consultant (MC) or Psychological Consultant (PC)

We added this new section.

DI 24501.003 Corrective Action When an Unqualified Individual Acted as a Medical Consultant (MC) or Psychological Consultant (PC)

CITATIONS: Social Security Act - Section 221(h), as amended; 20 CFR Sections - 404.1502(a)(1), 404.1616, 416.902(a)(1), and 416.1016.

A. Overview

MCs and PCs are members of a team that makes disability determinations. The MC completes the medical portion of the case review and medical assessments, including any applicable residual functional capacity (RFC) assessment(s), for all physical impairments in a claim. A PC completes the medical portion of the case review and medical assessments, including any applicable RFC assessment(s), for all mental impairments in a claim. MCs and PCs must meet the relevant qualifications described in DI 24501.001C.

For procedures to ensure an individual meets the relevant MC or PC qualifications, see DI 39569.300C.2.

This section provides instructions for when an individual who did not meet the qualifications of an MC or PC nevertheless completed the medical portion of case reviews and medical assessments in the capacity of an MC or PC.

B. Report and provide status

1. Report the incident

When an unqualified individual completed and signed the medical assessment(s) and the medical portion of the disability determination:

  • The Disability Determination Services (DDS) will immediately report the facts of the incident to the Center for Disability and Program Support (CDPS),

  • Following the DDS report, the CDPS will follow applicable regional procedures to report the incident to the Office of Disability Determinations and Associate Regional Commissioner for Management and Operations Support,

  • The Regional Office (RO) will immediately report the affected cases to the Deputy Commissioner for Hearings Operations and Executive Director of the Office Appellate Operations (OAO), and

  • Following the RO report, the Office of Hearing Operations and OAO will determine the need for action, if any, on cases decided by an administrative law judge or the Appeals Council.

2. Provide status updates

The DDS and the RO will follow any applicable regional procedures to provide periodic updates on the reviews of affected cases.

C. Reassign all cases pending with the unqualified individual

The DDS will immediately reassign all pending cases from the unqualified individual to a qualified MC or PC for review and signature.

The DDS will not assign any new cases requiring MC or PC review to the unqualified individual.

D. Document cases pending in the DDS

When an unqualified individual completed the medical assessment(s), such as the RFC assessment(s), in a case pending in the DDS, take the following actions before closing the case:

  • Document the electronic folder or case worksheet with the following statement, as applicable:

    If the unqualified individual completed the medical assessment(s) at the initial level, and the claim is pending at the reconsideration level:

    “An individual who did not meet the qualifications of a [medical or psychological] consultant completed the medical portion of the case review and medical assessment(s) for the [physical or mental] impairments in the prior determination dated [MM/DD/YY].”

    If the case is pending at the initial or reconsideration level and an unqualified individual completed a medical assessment(s) at the current level:

    “An individual who did not meet the qualifications of a [medical or psychological] consultant completed a medical assessment(s) for the [physical or mental] impairments on [MM/DD/YY]. That medical assessment is included in the record, but is not part of the [initial or reconsideration] determination.”

  • Refer the case to a qualified MC or PC for review, and

  • Process the case with the qualified MC or PC medical assessment(s).

NOTE: 

Retain any assessment that an unqualified individual signed in the file. When determining whether an individual is an acceptable medical source for evidence, see DI 22505.003.

E. Identify final determinations that need a medical review

If an individual who did not meet the MC or PC qualifications completed and signed the medical assessment(s) and the medical portion of the disability determination, and the determination has become administratively final, the DDS must determine whether the case is within:

  • the 1-year unrestricted reopening period,

  • the 2-year period for reopening a title XVI determination based on good cause (unless fraud or similar fault is involved), or

  • the 4-year period for reopening a title II determination based on good cause (unless fraud or similar fault is involved).

For cases within the 1-year unrestricted reopening period or the applicable period for reopening based on good cause, the DDS must ensure that a qualified MC or PC, as appropriate, completes a medical review following the below instructions in DI 24501.003F.

For more information about the time limits for reopening, see DI 27505.001.

For additional reopening considerations, see the below instructions in DI 24501.003G.

NOTE: 

It is not necessary to obtain a medical review of, or otherwise take further action on, an initial determination signed by an unqualified individual if a different, qualified MC or PC signed the reconsideration determination and the claimant did not seek further administrative review. Further action is not necessary because a qualified MC or PC completed the medical portion of the case review and made the medical assessments for the final determination on the claim(s).

F. Review the final determination

1. Apply the preponderance of evidence standard

The DDS must have a qualified MC or PC, as appropriate, determine whether the evidence in file supports the prior medical assessment(s) by the individual who did not meet the MC or PC qualifications. When evaluating whether the evidence in file supports the prior medical assessment(s), the reviewing MC or PC must apply the preponderance of evidence standard as described in GN 04440.003G.

2. Qualified MC or PC agrees with the prior medical assessment(s)

If the qualified MC or PC determines that a preponderance of the evidence supports the prior medical assessment(s), take no action to reopen or revise the prior determination.

The qualified MC or PC will complete and sign an SSA-416 (Medical Evaluation) or electronic equivalent with the following statement: “An individual who did not meet the qualifications of a [medical or psychological] consultant completed the medical portion of the case review and medical assessment(s) for the [physical or mental] impairments in the determination dated [MM/DD/YY]. I reviewed all the evidence in file and I agree with the medical portion of the case review and medical assessments by [unqualified individual’s name] in the determination dated [MM/DD/YY]. Therefore, no further action is required.”

Retain the statement in the file.

3. Qualified MC or PC disagrees with the prior medical assessment(s)

In some circumstances, the qualified MC or PC may be able to determine, based on his or her new medical review alone, whether the outcome of the final determination should change. When the new medical assessment would not change the outcome of the final determination, take no action to reopen or revise the determination.

EXAMPLE: 

The qualified MC may disagree with a step two finding that the claimant’s fibromyalgia and carpal tunnel syndrome are non-severe, but may agree with the step three finding that the claimant is disabled because the claimant’s spine impairment meets Listing 1.04. In that circumstance, the qualified MC would be able to determine, based on his or her new medical assessment alone, that the outcome of the final determination should not change.

a. Qualified MC's or PC's new medical assessment would not change the outcome of the final determination

If the qualified MC or PC is able to determine, based on his or her new medical review alone, that the outcome of the determination should not change, the qualified MC or PC will complete and sign an SSA-416 or electronic equivalent with the following statement: “An individual who did not meet the qualifications of a [medical or psychological] consultant completed the medical portion of the case review and medical assessment(s) for the [physical or mental] impairment(s) in the determination dated [MM/DD/YY]. I reviewed all the evidence in file and, based on my review, I do not believe the outcome of the determination should change. Therefore, no further action is required.”

The qualified MC’s or PC’s statement must also include an explanation of any disagreement with the prior medical assessment(s) so that the disability examiner may confirm the outcome of the final determination would not change. Retain the statement in the file.

If the DDS cannot confirm that the outcome of the final determination would not change, follow the below instructions in DI 24501.003F.3.b.

b. All other cases

The disability examiner will prepare a request for medical advice and refer the case to the reviewing qualified MC or PC to complete a thorough medical evaluation and complete new medical assessment forms.

If the new medical assessment does not change the outcome of the final determination, document the electronic folder or case worksheet with the following statement: "An individual who did not meet the qualifications of a [medical or psychological] consultant completed the medical portion of the case review and medical assessment(s) for the [physical or mental] impairment(s) in the determination dated [MM/DD/YY]. A new medical assessment(s), including a medical review by a qualified [medical or psychological] consultant, did not reverse the determination dated [MM/DD/YY]; therefore, no further action is required."

If the new medical assessment will change the outcome of the final determination, pursue reopening and revising the determination following the below instructions in DI 24501.003G and DI 24501.003H.

G. Consider reopening and revising the prior final determination

The discovery that an individual who did not meet the MC or PC qualifications completed the medical portion of the case review and medical assessment(s) for the physical or mental impairments in a case may constitute new and material evidence that provides good cause for reopening. For identifying good cause to reopen a determination that has become administratively final, see DI 27505.010.

We can reopen any determination within 1 year of the notice of the initial determination for any reason following DI 27505.001A.1.

We can reopen a title II determination within 4 years, or can reopen a title XVI determination within 2 years, of the notice of the initial determination for good cause, such as when we receive new and material evidence. For title XVI reopening rules, see DI 27505.001A.2. For title II reopening rules, see DI 27505.001A.3.

We can reopen a determination at any time for fraud or similar fault following DI 27505.001A.4.

NOTE: 

Evidence that the individual did not meet all of the applicable MC or PC qualifications would be "new" if it was not part of the claim file when the final determination was made. The evidence would be "material" if the unqualified individual's medical assessment(s) caused the determination to be incorrect, i.e., not supported by a preponderance of evidence.

H. Reopen and revise the incorrect prior final determination

The DDS will follow normal procedures to reopen and revise a determination as described in DI 27501.005.

For example, if the corrective action results in a revision from allowance to denial, prepare an Adverse Reopening Revision of Allowance to Denial notice. An overpayment may result. The examiner will prepare a due process decision notice for the medical adverse reopening following DI 27525.001.

NOTE: 

The DDS does not need to issue a pre-determination notice prior to processing the SSA-831 or SSA-833 because the adverse reopening is due to a medical determination.


DI 24501 TN 19 - General - Medical Evaluation - 1/04/2021