Identification Number:
DI 22510 TN 19
Intended Audience:See Transmittal Sheet
Originating Office:ORDP ODP
Title:Development of Consultative Examinations (CE)
Type:POMS Transmittals
Program:All Programs
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM
Part DI – Disability Insurance
Chapter 225 – Case Development Procedures
Subchapter 10 – Development of Consultative Examinations (CE)
Transmittal No. 19, 09/24/2019

Audience

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

Originating Component

ODP

Effective Date

01/06/2020

Background

We are updating our POMS to provide clarified guidance about how to notify and confirm a scheduled consultative examination (CE) appointment. This updated guidance is the result of a workgroup that we convened to gather suggestions on clarifying and improving these procedures.

Summary of Changes

DI 22510.016 Claimant Consultative Examination (CE) Notice and Confirmation Procedures

We updated instructions regarding who should receive a CE appointment notice, how to make a reasonable effort to confirm the CE appointment, including special handling cases.

We revised the title of this section to reflect the content.

We relocated information about special handling to DI 23007.001.

We relocated information about involving a third party to DI 23007.015.

We clarified when an adjudicator may discontinue attempts to get a claimant to attend a CE appointment and how to proceed with development and determinations for such cases.

We addressed alternative and special CE scheduling procedures.

We standardized the time required for the claimant to return our call to 10 calendar days from the date of the message when making a reasonable effort to confirm CE attendance via telephone.

We clarified that a call-in letter must be sent when there is no telephone number or you are unable to leave a message.

DI 22510.017 Consultative Examination (CE) Appointment Notice

We simplified the instructions for notifying the CE source of scheduled appointments and emphasized the importance of sending collateral information with the request for the CE.

DI 22510.019 Consultative Examination (CE) Appointment Notice Follow Up and Reminder

We clarified instructions for following up when the claimant does not confirm the CE appointment.

We clarified procedures for follow ups when special handing is involved.

We replaced the scripted language used for telephone CE appointment reminders with guidelines of the details the adjudicator needs to include in the reminder to permit flexibility in messaging.

Conversion Table
Old POMS ReferenceNew POMS Reference
DI 22510.016DI 22510.016
DI 22510.017DI 22510.017
DI 22510.019DI 22510.019

DI 22510.016 Claimant Consultative Examination (CE) Notice and Confirmation Procedures

CITATIONS:

20 CFR 404.1516 through 404.1519t , and 416.916 through 416.919t

A. When to schedule a CE appointment

Follow DI 22510.005 and DI 22510.006 for when and when not to schedule a CE appointment.

NOTE: Do not schedule a CE appointment for a claimant who has not cooperated with the initial, written request or the follow up request for evidence or action, see DI 22505.014. For Claimants who require special handling, you must first make a reasonable effort to identify and involve a third party.

  • For claimants who require special handling, see DI 23007.001A.

  • For how to make a reasonable effort to identify and involve a third party, see DI 23007.010.

B. Written notice of CE appointment

Send the written notice of the scheduled CE appointment to the appropriate individuals in accordance with DI 23007.005.

Use either the Model 1 CE appointment notice or your own CE appointment notice.

1. Model 1 CE appointment notice

Use the example provided in NL 00705.745A.

2. Your own CE appointment notice

When you use your own CE appointment notice, it must include the following:

  • The date, time, and type of CE appointment,

  • The name, address, and telephone number of the CE provider,

NOTE: Provide your telephone number when the CE provider refuses to share his or her telephone number with the claimant.

  • A reminder to bring current, government-issued identification (preferably photo identification),

  • A reminder to bring all medications in their original containers and any other medical aids (e.g., eyeglasses, hearing aids, etc.),

  • Instructions on how to respond to your notice,

NOTE: Require the claimant to confirm CE attendance with you and to respond immediately when he or she cannot attend the CE appointment for any reason.

  • An explanation on payment of travel expenses, see DI 39525.005,

  • A request to notify you when an interpreter is needed, see DI 23040.001,

  • Why you need the CE (and additional tests, if applicable),

  • An explanation that SSA will pay for the CE,

  • An explanation that you will send a copy of the CE report to the claimant's medical source when the claimant provides written authorization,

  • The following closeout language, "If you do not attend your appointment, we may make a determination based on the evidence in your file. This means we may find that you are not disabled," and

  • SSA Publication No. 05-10087A Special Examination Is Needed for Your Disability Claim.

NOTE: You may find the Publication here by typing 05-10087 into the search bar at the top, center of the webpage.

C. Confirming the CE appointment

How you confirm the CE appointment depends on whether the CE appointment is more than 10 days or 10 days or less from the date of the written notice.

For the appropriate individuals to contact to confirm a CE, see DI 23007.005.

1. The CE appointment is more than 10 days from the written notice

When you do not receive confirmation within 10 calendar days from the date of the initial written notice, make a reasonable effort to confirm that the claimant will attend the CE appointment. When you do not make a reasonable effort to confirm, and the claimant misses the CE appointment, you must make a reasonable effort to find out why the claimant missed it. When the claimant, applicant, appointed representative, or third party provides a good reason for missing the CE appointment, reschedule the CE.

a. Who may confirm or refuse the CE appointment

When the claimant does not require special handling, the claimant, applicant, or appointed representative can confirm or refuse the CE appointment. When the claimant requires special handling, and you cannot obtain confirmation or refusal from the claimant, make a reasonable effort to identify and involve a third party. In addition to confirming or refusing the CE appointment, a third party may also ask you to reschedule the CE appointment when there is good reason to do so.

For the claimants who require special handling, see DI 23007.001A.

For how to make a reasonable effort to identify and involve a third party, see DI 23007.010.

REMEMBER: An adult claimant who has an applicant (someone who can sign the claimant's application) or appointed representative does not require special handling even when the claimant falls into one of the special handling categories.

b. Attendance is confirmed

When the claimant confirms the CE appointment within calendar 10 days, document confirmation on an SSA-5002 Report of Contact, the claims communication section in eCAT, or the DDS worksheet. For details on what to document when a claimant confirms a CE, see DI 22510.019B.

NOTE: When the claimant confirms the CE appointment in writing, add the confirmation to the file. There is no need to document elsewhere.

c. Attendance is not confirmed

When the claimant does not confirm the CE appointment within 10 calendar days, attempt one telephone contact to ask for confirmation. For claims requiring special handling, you must also attempt one telephone contact to identify and involve a third party. When you are unable to speak to the claimant, applicant, appointed representative, or third party, and you cannot leave a message, send a call in letter. For additional details on what to do when a claimant does not confirm a CE, see DI 22510.019D.

NOTE: When the claimant, applicant, or appointed representative does not respond to your telephone contact or call in letter to confirm attendance, cancel the CE appointment unless the claimant requires special handling. When the claimant requires special handling, cancel the CE appointment only when the claimant and third party (when you are able to identify and involve a third party) does not respond to your telephone contact or call in letter to confirm attendance.

1. You speak to the claimant, applicant, appointed representative, or third party by telephone

Do the following:

  • Confirm the claimant's attendance at the CE appointment, or reschedule the CE appointment when there is a request to do so and a good reason is provided, and

  • Provide a reminder that failure to attend the CE appointment may result in you making a determination based on the evidence in file, which means that you may find the claimant not disabled.

Document the date, content of your conversation, and with whom you spoke, on an SSA-5002 Report of Contact, the claims communication section in eCAT, or the DDS worksheet.

2. You leave a message

You may leave a message on the voicemail recording system of a telephone number in the claim file that is attributable to the claimant or his or her applicant, appointed representative, or third party. You may also leave a message with an adult who answers a telephone number in the claim file that is attributable to the claimant or his or her applicant, appointed representative, or third party (e.g., the claimant’s spouse or an appointed representative’s assistant).

Include the following information:

  • Your name, title, telephone number and date that you called. Do not disclose any unnecessary personal information about the claimant, see GN 03316.005D,

  • The date, time, and location of the CE appointment,

  • A request that the claimant, applicant, appointed representative, or third party return your call to confirm the CE appointment within 10 calendar days from the date of your message. Explain that failure to do so will cause you to cancel the appointment, and

  • A reminder that failure to attend the CE appointment may result in you making a determination based on the evidence in file, which means that you may find the claimant not disabled.

Document the date, content of your message, and with whom you left it, on an SSA-5002 Report of Contact , the claims communication section in eCAT, or the DDS worksheet.

3. You send a call-in letter

Include the following information:

  • Your name, title, telephone number and date of your letter,

  • The date, time, and location of the CE appointment,

  • A request that the claimant, applicant, appointed representative, or third party call you to confirm the CE appointment within 10 calendar days from the date of the letter, and

  • A reminder that failure to confirm the CE appointment will cause you to cancel it and may result in you making a determination based on the evidence in file, which means that you may find the claimant not disabled.

2. The CE appointment is 10 days or less from the written notice (i.e., alternative scheduling)

Alternative scheduling is recommended only when you have difficulty locating the claimant after the passage of time (e.g., a homeless claimant).

a. The claimant does not require special handling

Take the following steps:

  • Use the procedures in DI 22510.016C for confirming the CE appointment.

  • When the claimant misses the CE appointment for a good reason or the claimant calls prior to the CE appointment and agrees to attend a rescheduled CE, reschedule the CE.

NOTE: Do not use alternative scheduling for the rescheduled CE unless the claimant, applicant, or appointed representative requests it.

b. The claimant requires special handling

Take the following steps:

  • When the claimant misses an alternatively scheduled CE appointment, send a call in letter to the claimant and third party(ies) asking them to call you within 10 calendar days from the date of the letter.

  • When the claimant or third party responds to the call in letter, discuss how to ensure the claimant will attend the rescheduled CE.

NOTE: Do not use alternative scheduling for the rescheduled CE when the claimant or third party asks for more time to confirm attendance.

  • When the claimant or third party(ies) fail to call you within 10 calendar days from the date of the letter, stop attempts to get the claimant to attend a CE.

For claimants who require special handling, see DI 23007.001A.

For how to make a reasonable effort to identify and involve a third party, see DI 23007.010.

D. The claimant misses or refuses to attend the CE appointment

Document the missed or refused CE appointment on an SSA-5002 Report of Contact , the claims communication section in eCAT, the DDS worksheet, or when the DDS has a missed CE notice, include a copy of that notice.

1. The claimant does not require special handling

When you attempted to confirm the claimant’s attendance at the CE appointment in accordance with DI 22510.016C and the claimant misses or refuses to attend the CE appointment, do not reschedule the CE unless:

  • The claimant, applicant, or appointed representative calls you prior to case finalization, and

  • Provides a good reason for the claimant missing or refusing to attend the CE appointment.

When the above does not occur, do not reschedule the CE and stop attempts to get the claimant to attend the CE.

When you did not attempt to confirm the claimant attendance at the CE appointment in accordance with DI 22510.016C:

  • Contact the claimant, applicant, or appointed representative by telephone to ask why the claimant missed or refused to attend the CE appointment, see DI 23007.005.

  • Reschedule the CE when the claimant has a good reason for missing or refusing to attend the CE appointment. Otherwise, do not reschedule the CE and stop attempts to get the claimant to attend the CE.

2. The claimant requires special handling

When the claimant requires special handling, make a reasonable effort to identify and involve a third party. After you have done so, only reschedule the CE when the claimant or third party calls you prior to case finalization and provides a good reason for the claimant missing or refusing to attend the CE. If this does not occur, do not reschedule the CE and stop attempts o get the claimant to attend the CE.

For claimants who require special handling, see DI 23007.001A.2.

For how to make a reasonable effort to identify and involve a third party, see DI 23007.010.

Document the date, time and content of your conversation with the claimant or third part(ies), and with whom you spoke, on SSA-5002 Report of Contact , the claims communication in eCAT, or the DDS worksheet.

E. Unusual CE appointment scheduling Procedures

These procedures apply to situations when it is difficult to schedule a CE, such as incarcerated claimants who do not have access to a CE in their immediate area, and claimants who allege an inability to travel to a CE due to health risks or hospitalizations.

Document your attempt to schedule a CE appointment using these procedures on an SSA-5002 Report of Contact, the claims communication section in eCAT, or the DDS worksheet.

1. The claimant is incarcerated

Determine if one of the following scheduling options are available:

  • The facility's staff medical source (or an outside CE source selected by you) can perform the CE at the facility, or

  • The facility will permit the claimant to attend the CE at an outside facility selected by you.

Try to accommodate the facility’s preferred date, time, and conditions. When you cannot schedule a CE using these procedures, stop attempts to get the claimant to attend a CE.

2. There is no CE in the claimant's immediate area

Schedule the CE appointment at the most convenient location for the claimant.

For how to purchase a CE in a neighboring state, see DI 39545.225.

For guidelines on travel reimbursement, see DI 39525.005

3. The claimant alleges an inability to travel due to health risk

When possible, confer with the claimant’s medical source to determine whether the claimant can travel to the CE. When the medical source advises against it, or the claimant refuses to go due to the alleged health risk, schedule the CE appointment at the claimant’s residence. When the claimant refuses the CE appointment, or you cannot obtain it at the claimant’s residence, stop attempts to get the claimant to attend a CE.

Document your efforts on an SSA-5002 Report of Contact , the claims communication section in eCAT, or the DDS worksheet.

F. The effect of stopping your attempts to get a claimant to attend a CE appointment

When, in accordance with the requirements of DI 22510.016A through E of this section, you stop attempts to get the claimant to attend a CE appointment, you no longer need to pursue further evidence that requires the claimant’s cooperation.

NOTE 1: This does not apply to claimants who are in situations described in subsection DI 22510.016E above. In those instances, you must still pursue all other evidence that requires the claimant’s cooperation.

NOTE 2: No longer needing to pursue further evidence applies only to evidence or action that requires the claimant’s cooperation. For example, you do not need to follow up with the claimant on work history or activities of daily living forms that he or she has not yet submitted. You still must, however, ensure that you make every reasonable effort to develop a complete medical history without the claimant’s cooperation in accordance with DI 22505.001A.2. Once you have made this reasonable effort, make a determination using the sequential evaluation process based on the evidence in the file, see DI 23007.015.

G. Regulation basis code

Use the “Insufficient Evidence Furnished” regulation basis code in accordance with DI 26510.045. Do not use a failure or refusal to attend a CE regulation basis code.

For instructions on the personalized disability explanation, see DI 26530.020D.1.

REMEMBER: Even if the claimant does not attend (i.e., refuses or misses) a CE appointment, you must still make a determination using the sequential evaluation process based on the evidence in file, see DI 23007.015.

DI 22510.017 Notifying Consultative Examination (CE) Source of Scheduled Appointment

CITATIONS:

20 CFR 404.1516 through 404.1519t , and 416.916 through 416.919t

A. Notifying the CE source of the appointment in writing

Notify the CE source of the appointment in writing and include the following:

  1. 1. 

    Date and time of the CE appointment,

  2. 2. 

    Required type of CE, required tests, and specific issues for the CE source to address,

  3. 3. 

    Authorizing documents (e.g., an authorization for diagnostic studies or claim for payment),

  4. 4. 

    Form(s) to complete, such as a request for the CE medical opinion of what the claimant can still do despite his or her impairment(s),

  5. 5. 

    A duplicate, fax, or other agency-approved electronic transmission of an originally signed and dated SSA Authorization To Disclose Information To The Social Security Administration unless the source prefers to use its own authorization forms, see DI 11005.055, and

  6. 6. 

    Background information on the claimant as described in DI 22510.017B in this section.

For a rescheduled CE appointment, notify the CE source of the change and include the information listed above in 22510.017A.

B. Providing collateral evidence to the CE source

The quality of the collateral evidence sent to the CE source is more important than the quantity of information. Send the CE source longitudinal information relevant to the reason for the examination requested. Longitudinal evidence is particularly critical for cases involving mental impairments. In some cases, requests for lab work, x-rays, and other diagnostic studies without an examination may not require background information. However, send the background information to the CE source when it provides context to a particular diagnostic study, such as the claimant’s most recent cardiac consultation when ordering a treadmill exercise test.

Examples of information you might consider sending a CE source include relevant medical evidence including any medical opinion(s) or forms completed by the claimant or others, such as the SSA-3373 Function Report - Adult.

NOTE: Comply with State law governing the release of information. Do not offer any opinion, implied or stated, about the severity of the claimant’s impairment(s), or make any statement or comment that would be prejudicial to the claimant.

C. Reference

DI 11005.055 Completing Form SSA-827 Authorization to Disclose Information to the Social Security Administration (SSA)

DI 22510.019 Consultative Examination (CE) Appointment Notice Follow up and Reminder

CITATIONS:

20 CFR 404.1512 through 404.1519t , and 416.912 through 416.919t

NOTE: These procedures are not required for CE appointments scheduled 10 days or less before the date of the appointment, see DI 22510.016C2.

A. CE appointment communication procedures

For who to contact when the claimant does not requires special handling, see DI 23007.005A.

For who to contact when the claimant requires special handling, see DI 23007.005B.

For how to make a reasonable effort to identify and involve a third party, see DI 23007.010.

B. Claimant confirms the CE appointment

When the claimant confirms he or she will attend the CE appointment scheduled for a specific location, date, and time:

  • Document the CE appointment confirmation on an SSA-5002 Report of Contact , the claims communication section in eCAT, or DDS worksheet, and

  • Make any required CE appointment reminder per DI 22510.019D in this section.

NOTE: When the claimant confirms the CE appointment in writing, add the confirmation to the file. There is no need to document elsewhere.

C. Claimant states he or she will not attend the CE appointment

When the claimant tells you that he or she will not attend the CE appointment, consider whether he or she has a good reason. For examples of good reasons, see DI 23007.001B.

When the claimant requires special handling, you must make a reasonable effort to identify and involve a third party prior to discontinuing efforts to secure evidence that requires claimant cooperation.

For instructions on making a reasonable effort to identify and involve a third party, see DI 23007.010 . When the Field Office (FO) documented that the claimant refused to identify a third party contact, do not attempt to identify a third party, see DI 23007.001C.

D. Claimant does not respond to CE appointment notice

When the claimant does not confirm the CE appointment within 10 days from the date of the CE notice, you must follow up to determine whether the claimant will attend the CE appointment.

1. Special handling required

When the claimant requires special handling:

  • Make a reasonable effort to identify and involve a third party to assist the claimant. For additional information on special handling, see DI 23007.001A.

  • Attempt to reach a third party at the same time you follow up with the claimant.

  • Make a phone call attempt to the third party. When the phone call is successful or you can leave a message, explain the reason for your call.

  • Send a call in letter to the third party when you do not reach him or her by telephone or leave a message.

For details on what to include in your conversation, message, or letter to the third party, see DI 23007.010C.

REMINDER When the telephone is not in service, you cannot speak to the claimant, or cannot leave a message, send a call in letter per DI 22510.019D.3.

2. Telephone follow up to confirm the claimant will attend the CE appointment

  1. a. 

    When the claimant provided a telephone number, attempt to reach the claimant by telephone.

  2. b. 

    When you reach the claimant:

    1. 1. 

      Ask the claimant if he or she will attend the CE appointment.

    2. 2. 

      Remind the claimant that if he or she does not attend the CE appointment, we may make a decision based on the evidence in file.

    3. 3. 

      Explain that this means we may find that he or she is not disabled.

    4. 4. 

      When the claimant tells you he or she will not attend the CE appointment, consider whether he or she has a good reason. For examples of good reasons, see DI 23007.001B.

      • When the claimant provides a good reason why he or she cannot attend the CE appointment, reschedule the CE.

      • When the claimant does not provide a good reason and the claimant does not require special handling, adjudicate the claim using the procedures in DI 23007.015.

  3. c. 

    When the telephone number is not in service or you do not reach the claimant, send a call in letter per DI 22510.019D.3. in this section.

  4. d. 

    Document the date and content of your conversation on an SSA-5002 Report of Contact , the claims communication section in eCAT, or DDS worksheet.

3. Contact by telephone not possible

When the claimant does not have a telephone or you did not reach the claimant by telephone, send a call in letter.

  1. a. 

    Indicate in the letter that if the claimant does not respond within 10 calendar days from the date of the letter, we may make a decision based on the evidence in file. Explain that this means we may find that he or she is not disabled.

  2. b. 

    Allow 10 days from the date of the call in letter for the claimant to respond.

  3. c. 

    When the claimant calls before the CE appointment, ask if he or she will attend. Remind the claimant that if he or she does not attend the CE appointment, we may make a decision based on the evidence in file. Explain that this means we may find that he or she is not disabled.

  4. d. 

    When the claimant tells you he or she will not attend the CE appointment, consider whether he or she has a good reason. For examples of good reasons, see DI 23007.001B.

    • When the claimant provides a good reason why he or she cannot attend the CE appointment, reschedule the CE.

    • When the claimant does not provide a good reason, adjudicate the claim using the instructions in DI 23007.015.

  5. e. 

    When the claimant does not respond within 10 calendar days from the date of the letter, you may cancel the CE appointment and process the determination per DI 23007.015.

4. If you did not send the call in letter more than 10 days before the CE appointment

  1. a. 

    Do not cancel the CE appointment.

  2. b. 

    When the claimant does not attend the CE appointment and does not respond within 10 calendar days from the letter, and the claimant does not require special handling, process the determination using the instructions in DI 23007.015. You are not required to do additional follow ups under DI 23007.010.

  3. c. 

    When the claimant does not attend the CE, but responds within 10 calendar days from the call in letter, consider whether he or she has a good reason for missing the appointment. For examples of good reasons, see DI 23007.001B.

    1. 1. 

      When the claimant provides a good reason why he or she did not attend the CE appointment, reschedule it.

    2. 2. 

      When the claimant does not provide a good reason, and does not require special handling, adjudicate the claim using the instructions in DI 23007.015. NOTE: If the claimant requires special handling, see DI 25510.019D of this section.

    3. 3. 

      Document your development on an SSA-5002 Report of Contact , the claims communication section of eCAT, or the DDS worksheet.

5. The claimant confirms the appointment

  1. a. 

    When a claimant confirms that he or she will attend a scheduled CE appointment, you must attempt to remind the claimant of the appointment, unless:

    • You reached the claimant during a follow up to the CE appointment notice performed within 10 calendar days of the CE appointment, or

    • The scheduled CE appointment is for a date 10 days or less in the future, see DI 22510.016C2.

  2. b. 

    Make the CE appointment reminder 10 calendar days prior to the date of the CE appointment. When the reminder date falls on a non-business day, make the reminder on the next business day.

  3. c. 

    You may make the CE appointment reminder by telephone or by letter.

  4. d. 

    When you reach the claimant by telephone or choose to send the CE appointment reminder by letter, provide:

    • The CE appointment information,

    • A reminder that if he or she does not attend the CE appointment we may make a decision based on the evidence already in file, and

    • An explanation that this means we may find that he or she is not disabled.

  5. e. 

    Document your development on an SSA-5002 Report of Contact , the claim communication section of eCAT, or the DDS worksheet.


DI 22510 TN 19 - Development of Consultative Examinations (CE) - 1/06/2020