Effective Dates: 3/28/2024 - Present

Identification Number:
DI 22510 TN 40
Intended Audience:See Transmittal Sheet
Originating Office:ORDP ODP
Title:Development of Consultative Examinations (CE)
Type:POMS Full 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. 40, 03/28/2024

Audience

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

Originating Component

ODP

Effective Date

Upon Receipt

Background

During the COVID-19 national public health emergency (PHE), the agency expanded the use of video technology to include conducting telehealth consultative examinations (THCE) at a claimant’s home or other locations. In addition, the THCE Policy Workgroup, led by the Office of Disability Policy (ODP), recommended that the agency expand its use of video technology to include certain speech and language consultative examinations (CE). In December 2021, ODP published EM-21073 for this purpose. In April 2023, ODP published EM-23027 to allow DDS to continue scheduling THCEs after the end of the PHE. The changes summarized below incorporate the emergency instructions into the POMS, and EM-23027 will be archived upon publication of the POMS.

Summary of Changes

DI 22510.013 Telehealth Consultative Examination (THCE) - General

This new POMS section defines a THCE, provides general requirements for scheduling THCEs, and specifies privacy and information security requirements for CE providers

DI 22510.014 Telehealth Consultative Examination (THCE) Agreement and Notice

This new POMS section outlines requirements for obtaining a claimant’s agreement to participate in a THCE, notice requirements, and a requirement that CE reports indicate whether the examination was conducted via telehealth.

DI 22510.013 Telehealth Consultative Examination (THCE) - General

A. Definition of a telehealth consultative examination (THCE)

A THCE is a consultative examination (CE) that:

  • •

    Uses audio and video technology to allow remote interaction between a CE source and a claimant or beneficiary,

  • •

    Requires the claimant or beneficiary to participate using a personal device at their home or other private location, and

  • •

    Requires the claimant or beneficiary to participate using a platform selected by the CE source.

For information on:

B. General THCE guidelines

Disability Determination Services (DDS) may schedule a THCE only if all the following requirements are met:

  • •

    The type of THCE is permitted (see DI 22510.013C in this section),

  • •

    The claimant (parent of a minor child or legal guardian) agrees to participate in a THCE (see DI 22510.014C),

  • •

    The claimant meets all the requirements in DI 22510.013D in this section, and

  • •

    The CE source meets the privacy and information security requirements in DI 22510.013E.1 in this section.

C. Types of THCEs permitted

DDS may schedule the following types of THCEs for claimants aged 5 and older:

  1. 1. 

    Psychiatric CEs

  2. 2. 

    Psychological CEs without standardized testing

  3. 3. 

    Speech and language CEs

    • •

      When scheduling a speech and language THCE for a child whose primary language is Spanish, DDS must require the CE source to use standardized tests published in Spanish.

    • •

      When scheduling a speech and language THCE for claimants whose primary language is not English, DDS must choose a CE source who is fluent in the claimant’s primary language.

    • •

      DDS must not use interpreters for speech and language THCEs.

D. Claimant requirements

1. Determining when a THCE is appropriate

Before offering a claimant the opportunity to participate in a THCE, DDS must consider whether a THCE is appropriate. DDS should review the available evidence, supplemented by any interactions with the claimant, to identify any significant limitations in the claimant's ability to:

  • •

    Hear others in face-to-face conversations (including with the use of a hearing aid(s)),

  • •

    Follow simple instructions, and

  • •

    Concentrate.

If the claimant has or alleges significant limitation in any of these capacities, DDS will schedule an in-person CE. DDS may ask for medical or psychological consultant, or medical advisor, advice to help decide whether a THCE is appropriate for the claimant.

2. Technology and environment for THCEs

The claimant must:

  • •

    Participate from a private, quiet environment conducive to the examination,

  • •

    Have a reliable internet connection, and

  • •

    Use a device with a camera and microphone (audio and video are required), such as a smartphone, tablet, laptop, or desktop computer.

IMPORTANT: For speech and language THCEs, the claimant cannot use a smartphone because the screen is too small for standardized testing. Instead, the claimant must use a tablet with a diagonal screen display of at least 9.7 inches, a laptop, or a desktop computer.

If the claimant cannot meet all the above requirements, DDS will schedule an in-person CE.

NOTE: The CE source must confirm that the internet connection allows both the CE source and claimant to adequately see, hear, and participate in the THCE. In addition, the CE source must also ask the claimant to confirm participation from a private location. If these conditions are not met, the CE source will terminate the THCE, and DDS will schedule an in-person CE.

3. Proper identification for THCEs

If the claimant is an adult or a child with a valid, unexpired government-issued photo identification (ID) (e.g., United States (U.S.) State-issued driver’s license, U.S. State-issued ID card, U.S. passport, U.S. military ID, or U.S. tribal ID), the claimant must show their ID over the video connection as evidence of identity. If the claimant is an adult who does not have the required ID, DDS will schedule an in-person CE.

If the claimant is a child without a government-issued photo ID:

  • •

    The claimant must show, over the video connection, an original ID document as evidence of age and identity, such as a government-issued non-photo ID (e.g., birth certificate) or a nongovernment-issued photo ID (e.g., student ID), or

  • •

    The CE source must include a physical description of the claimant in the CE report unless the CE source is the claimant's own medical source and has a treating relationship with the claimant.

IMPORTANT: DDS must confirm that an adult claimant has current and valid, unexpired government-issued photo ID before scheduling a THCE.

NOTE: The CE source must verify the claimant's identity and document verification in the CE report (see DI 22510.015A.3 and DI 22510.035A). If the CE source is unable to verify the identity of the claimant, the CE source will terminate the THCE, and DDS will schedule an in-person CE.

E. CE source requirements

1. Privacy and information security

Only qualified CE sources who are “covered entities” under the Health Insurance Portability and Accountability Act (HIPAA) as defined in 45 CFR 160.103, and follow HIPAA rules and requirements, may conduct THCEs. HIPAA and associated HIPAA Rules sufficiently protect participant privacy and agency interests. The CE source is responsible for ensuring compliance with HIPAA’s requirements relating to telehealth platform or applications.

For more information on selecting a qualified CE source, see DI 22510.010.

2. Licensure

Generally, a CE source may only conduct CEs across State borders if they are licensed in multiple states or hold a license that permits them to do so. Many State licensing laws and regulations disallow healthcare providers to practice across state borders without appropriate licensing in other state(s). However, some States permit healthcare providers to practice across State borders during exigent circumstances, such as National or State emergencies, to meet healthcare needs. Confirm state licensing requirements before scheduling a THCE with a CE source who is located in a different State than the claimant.

F. DDS processing of assistance requests (AR) for THCEs

DDS will process ARs submitted by Office of Hearing Operations (OHO) (or other adjudicating components) for THCEs that meet all the following requirements:

  • •

    The type of THCE is permitted (see DI 22510.013C in this section), and

  • •

    The requesting office has contacted the claimant (parent of a minor child or legal guardian) and has obtained agreement to participate in a THCE (see DI 22510.014C), and

  • •

    The requesting office has documented the claimant’s (parent of minor a child or legal guardian) agreement in the folder (see DI 22510.014C).

NOTE: If the AR does not meet these requirements, DDS may reject the AR. For more information on ARs for CEs, see DI 29501.010 and DI 29505.001. For OHO procedures for obtaining and documenting agreement to participate in a THCE, see HALLEX I-2-5-20.

DI 22510.014 Telehealth Consultative Examination (THCE) Agreement and Notice

A. Agreement requirement to participate in a THCE

The claimant (parent of a minor child or legal guardian) must agree in advance to the claimant’s participation in a THCE. Disability Determinations Services (DDS) will not schedule the THCE unless:

  • •

    The appropriate individual(s) per DI 22510.014B in this section agree to participate, and

  • •

    The agreement is documented per DI 22510.014C in this section.

DDS will schedule an in-person consultative examination (CE) in the absence of such agreement.

B. Who must agree to participate in a THCE

IMPORTANT: An appointed representative (AR) may not agree to the claimant's participation on the claimant's behalf.

1. Adult claims

For adults, the claimant (or, if applicable, legal guardian) must agree to the claimant's participation.

2. Child claims

IMPORTANT: The parent or legal guardian of a minor child must agree to be present at the THCE.

a. Children under age 12

For children aged 5 until attainment of age 12, the parent (or, if applicable, legal guardian) must agree to the child's participation.

b. Children over age 12

For children aged 12 until attainment of age 18, both the claimant and parent (or, if applicable, legal guardian) must agree to the child's participation.

C. Obtaining agreement to participate in a THCE

DDS must contact the claimant (parent of a minor child or legal guardian) by telephone or by letter to:

  • •

    Explain the need for a CE,

  • •

    Explain the option to attend a THCE,

  • •

    Explain the claimant requirements for a THCE in DI 22510.013D,

  • •

    If applicable, explain the need for an email address to participate in a THCE, and

  • •

    Ask whether the claimant (parent of a minor child or legal guardian) understands and agrees to participate in a THCE.

IMPORTANT: DDS should not contact the claimant (parent of a minor child or legal guardian) about a THCE until the DDS has made every reasonable effort to obtain evidence from the claimant's medical source(s) and has determined that a CE is needed. For more information on when to purchase a CE, see DI 22510.005.

For Office of Hearing Operations (OHO) procedures for obtaining and documenting agreement to participate in a THCE, see HALLEX I-2-5-20.

1. Contact by telephone

  1. a. 

    When contacting the claimant (parent of a minor child or legal guardian) by telephone, DDS will:

    • •

      Confirm the individual is in a private location in which no one can overhear the conversation,

    • •

      Verify the individual's identity consistent with existing policy for disclosure and identity (DI 39567.210 and GN 00203.020),

    • •

      Advise the individual that personal information will be collected during this telephone call, and

    • •

      Respond to questions, if applicable.

  2. b. 

    After verifying the individual's identity, DDS will read aloud the call script, which provides required information for the claimant (parent of a minor child or legal guardian) to determine their willingness and ability to participate in a THCE and solicits their agreement to proceed with scheduling a THCE. For Children aged 12 until attainment of age 18, read the call script aloud to both the parent or legal guardian and the claimant.

    The call script for adults is here -

    View In PDF

    The call script for adults with a legal guardian is here -

    View In PDF

    The call script for children is here -

    View In PDF

  3. c. 

    DDS will document the telephone conversation (i.e., agreement or lack of agreement to participate in the THCE), along with a copy of the script, in a Case Note in the Disability Case Processing System (DCPS) and "write to" the Case Development Worksheet (CDW).

IMPORTANT: If the claimant (parent of a minor child or legal guardian) does not have internet access or requests a copy of the Privacy Act statement for their records, send the full Privacy Act statement by letter.

REMINDER: If the claimant has an AR, the DDS must obtain the AR’s consent to contact the claimant before making direct contact with the claimant (parent of a minor child or legal guardian) by telephone, unless the AR has already given permission to contact the claimant directly. For more information on contacting a represented claimant by telephone, see DI 31001.010B. If the AR refuses to permit direct contact with the claimant by telephone, DDS will send a letter to the claimant with a copy to the AR. Document the telephone conversation with the AR (i.e., consent or lack of consent to contact the claimant) in a Case Note in DCPS and "write to" the CDW.

2. Contact by letter

When contacting the claimant (parent of a minor child or legal guardian) by letter, DDS will send the THCE Agreement Form below.

The THCE Agreement Form for adults is here -

View In PDF

The THCE Agreement Form adults with legal guardians is here -

View In PDF

The THCE Agreement Form for children is here -

View In PDF

If the claimant (parent of a minor child or legal guardian) does not respond to the letter, DDS will schedule an in-person CE.

If the claimant (parent of a minor child or legal guardian) returns the completed THCE Agreement Form, DDS will ensure the form is included in the certified electronic folder (CEF).

NOTE: If the claimant (parent of a minor child or legal guardian) contacts DDS by telephone after receiving the letter, answer questions, if applicable, and document the conversation per DI 22510.014C in this section. If DDS obtains all the required information by telephone, there is no need to return the form.

D. THCE appointment notice from DDS by letter

Follow existing policy for:

  • •

    CE appointment notice and confirmation procedures in DI 22510.016.

  • •

    CE appointment notice follow up and reminder in DI 22510.019.

In addition, the written CE appointment notice must include the following:

1. Technology Information

The written CE appointment notice must include the name of the specific video technology to be used, and:

  • •

    The instructions for how to use the chosen technology and the web address for the appointment, or

  • •

    A statement that the CE source or DDS will send the instructions for how to use the chosen technology and the hyperlink for the appointment.

2. Option to attend a CE in person

The THCE appointment notice must include the statement, “If you decide that you want to attend/you want [name of claimant] to attend an in-person examination instead of a telehealth examination, please call us before the examination so that we can reschedule.”

3. SSA Publication No. 64-126

To help claimants prepare for a THCE, include SSA Publication No. 64-126 Tip Sheet: Preparing for a Telehealth Consultative Examination with the CE appointment notice as an enclosure or include a statement about where to find the publication online at https://www.ssa.gov/pubs.

E. THCE information from DDS or CE source by email

The email for the THCE may include:

  • •

    The name of the claimant (parent of a minor child or legal guardian),

  • •

    The appointment date and time,

  • •

    The hyperlink to the appointment, and

  • •

    The instructions for using the video technology.

IMPORTANT: The email cannot mention the appointment is for a disability claim, the type of appointment, or any personally identifiable information (PII) (e.g., SSN or date of birth) about the claimant other than the information authorized in the bullets above. For more information on using email to send PII, see AIMS GAM 15.04.07.

F. CE report content for THCEs

Follow existing policy for:

In addition, the CE report must include:

  • •

    A statement that the CE was conducted using video technology, and

  • •

    The name of the video application used.

 

DI 22510 TN 40 - Development of Consultative Examinations (CE) - 3/28/2024