Identification Number:
DI 22505 TN 31
Intended Audience:See Transmittal Sheet
Originating Office:ORDP ODP
Title:Development of Medical Evidence of Record (MER)
Type:POMS Transmittals
Program:All Programs
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM
Part DI – Disability Insurance
Chapter 225 – Case Development Procedures
Subchapter 05 – Development of Medical Evidence of Record (MER)
Transmittal No. 31, 04/01/2021

Audience

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

Originating Component

ODP

Effective Date

04/02/2021

Background

QAT, no IRD or AC signoff required.

Summary of Changes

DI 22505.012 Development Issue - No Evidence Furnished from an Acceptable Medical Source

Section B.2. We updated the listing numbers regarding amputations and obvious impairment.

DI 22505.030 Obtaining Medical Evidence by Telephone

Included in error.

DI 22505.035 Follow-up on Requests for Medical Evidence of Record (MER)

Included in error.

DI 22505.012 Development Issue - No Evidence Furnished from an Acceptable Medical Source

A. Policy - claimant protection

1. Safeguard against denial

To safeguard against the denial of claims solely because we are unable to obtain evidence and/or the claimant is unable to furnish evidence of disability from an acceptable medical source (see DI 22505.003A.) due to circumstances beyond the claimant's control, consider other methods of obtaining the necessary medical evidence.

2. Claimant unable to furnish evidence of disability

Obtain a consultative examination (CE) when clinical details are needed to establish:

  1. a. 

    The existence of a medically determinable impairment, and

  2. b. 

    The claimant's functional limitations and remaining abilities.

3. Mental impairments

  1. a. 

    The policy stated above also addresses cases involving mental impairments, including those for which there is no medical source.

  2. b. 

    When obtaining a CE, give the CE provider background information, including:

    • complete longitudinal functional information from the claimant, and, if necessary, other nonmedical sources (per DI 22511.011); and

    • other background information (e.g., field office (FO) observations) when available.

  3. c. 

    Develop evidence of functional limitations in accordance with DI 22511.007.

B. Policy - obvious impairments

1. Clinical details unnecessary

Normally, medical reports will be obtained from medical sources. There will be rare instances when

  • The claimant has an obvious impairment (see DI 22505.012B.2.b.); and

  • Has been unable to obtain a medical report even with assistance of the FO and disability determination services (DDS); and

  • No purpose would be served by purchasing an examination from a medical source solely to certify the existence of such an obvious impairment.

2. Obvious impairments

A determination of disability may be made without evidence from a medical source only when the FO or DDS has:

  1. a. 

    Seen the claimant; and

  2. b. 

    Described the existence of amputations of extremities identified in Listing 1.20A. or 101.20A., or total blindness due to the loss of both eyes.

DI 22505.030 Obtaining Medical Evidence by Telephone

CITATIONS:

20 CFR 404.1520b and 416.920b

A. When to request evidence by telephone from a medical source

You may use the telephone to expedite development of medical evidence to:

  • Obtain evidence quickly for an expedited processing claim (e.g., a claimant alleges end-stage renal disease and you need documentation on form CMS-2728 (ESRD Medical Evidence Report Medicare Entitlement and/or Patient Registration).

  • Verify a diagnosis on a medical report (e.g., a treatment note states claimant has small cell carcinoma but you need to clarify a non-definitive pathology report).

  • Resolve an inconsistency or discrepancy in a medical report.

  • Clarify what is hand-written in a medical report.

  • Initiate medical or psychological consultant (MC/PC) contact with a medical source.

B. Procedure for requesting medical evidence by telephone and fax

These procedures apply to medical evidence that you request by telephone initially, and any medical evidence that supplements medical evidence that you received initially over the telephone or in writing. For instructions on developing supplemental evidence see DI 22505.008.

1. Telephone contact with a medical source’s support staff to obtain MER

In most cases, you do not need to speak directly to the medical source for evidence. An office secretary, office manager, receptionist, hospital medical records technician, or other person who has access to the claimant’s medical records may be able to provide the needed information. Call the source’s office and:

  1. a. 

    Explain the need for the requested medical evidence.

  2. b. 

    Determine whether the office can receive and send faxes.

    1. 1. 

      If the source can receive and send faxes:

      • Fax the medical source the request for medical evidence, the invoice, and an SSA-827 (Authorization to Disclose Information to the Social Security Administration (SSA)), if he or she has not already received one.

      • Ask the medical source to fax the requested evidence back to the certified electronic folder (CEF), using the fax number for your region by placing the bar-coded cover sheet on top of the first page of the document to ensure accurate placement in the case file. For information on faxing documents into the CEF see DI 81010.090C.

        NOTE: It is not necessary for the source to fax the SSA-827.

    2. 2. 

      If the source cannot receive and send faxes, you may request and receive evidence by U.S. mail or other delivery services.

2. Telephone contact with a medical source

IMPORTANT: You are not required to send an SSA-795 to the source for signature if the supplemental contact produced no new evidence, or simply confirmed evidence already received. However, you must still document the supplemental contact.

If you need to speak directly with a medical source in order to complete a medical assessment, telephone contact is appropriate. If the medical source provides new and material evidence:

  1. a. 

    Explain to the source that you will:

    • document the information provided on form SSA-795 (Statement of Claimant or Other Person) for his or her review; and

    • send it for his or her review, date, and signature.

  2. b. 

    Document the information the medical source provides on form SSA-795.

  3. c. 

    Request the medical source sign and return the completed form to document the file.

  4. d. 

    Determine whether the office can receive and send faxes.

    1. 1. 

      If the office can receive and send faxes:

      • Fax the medical source the SSA-795, and an SSA-827, if he or she has not already received one.

      • Ask the medical source to fax the requested evidence back to the certified electronic folder (CEF), using the fax number for your region by placing the bar-coded cover sheet on top of the first page of the document to ensure accurate placement in the case file. For information on faxing documents into the CEF see DI 81010.090C. It is not necessary for the source to fax the SSA-827.

        EXCEPTION: For Electronic Disability Collect System (EDCS) exclusions ask the source to fax you the evidence directly.

    2. 2. 

      If the office cannot send and receive faxes, you may request and receive evidence by U.S. mail or other delivery services.

REMEMBER: Document all development actions using the electronic claims analysis tool (eCAT). For electronic processing exclusions, document development in the case summary.

C. Completing the SSA-795

Discuss and record the relevant information on the SSA-795. To view this form, go to SSA-795.

EXCEPTION: The SSA-795 will be available to all Disability Determination Services (DDSs) upon rollout of the Disability Case Processing System (DCPS). DDS legacy systems may not have the capacity to generate an SSA-795. If your legacy system cannot generate the SSA-795, use the appropriate locally available format.  Include all of the information detailed in this section.

1. Identification

In the applicable blocks on the top of the SSA-795 enter all the following:

  • The claimant’s name and social security number.

  • The complete name of the person making the statement (i.e. the person to whom you are speaking) and their relationship to the claimant (e.g., Jane Jones, Dr. Smith’s office manager). Indicate the person’s medical credentials, if any.

2. Body of evidence

The statement content begins after the established lead-in language, “Understanding that this statement is for the use of the Social Security Administration, I hereby certify that -.”

In the body of the SSA-795, document the evidentiary information provided. Use the person’s own words to the extent possible.

3. Administrative note

Explain who documented the telephone conversation and when.

Example of an administrative note: “This statement was initially provided to John Doe, State DDS by telephone on 01/21/2015.”

D. Documenting determinations using SSA-795 evidence

Document all SSA-795 issues on the electronic claims analysis tool disability determination explanation (eCAT DDE).

1. SSA-795 required prior to adjudication

If you don’t have other acceptable medical evidence that addresses the issue(s), you must wait for a signed telephone report (SSA-795) to document a:

  • partially favorable allowance, or

  • denial.

For example, the medical evidence establishes that the claimant received hemodialysis while hospitalized subsequent to a traffic accident. There is no evidence regarding the necessity for chronic hemodialysis. To satisfy the requirements in Listing 6.03, you contact the source to confirm chronic kidney disease (CKD), current dialysis, and that dialysis will be ongoing. However, the source indicates that the claimant suffered acute kidney failure that resolved prior to discharge. Assessment of the claimant’s impairment(s) directs a durational denial. You must wait for the signed SSA-795 to document the issue of kidney failure.

2. SSA-795 not required prior to adjudication

You do not need to wait for the signed SSA-795 if the claim is a fully favorable allowance. Document the case file with the issue(s) that the signed SSA-795 resolves. Place the signed SSA-795 in the file post-adjudicatively.

For example, the medical evidence establishes that the claimant received hemodialysis while hospitalized subsequent to a traffic accident. There is no evidence regarding the necessity for chronic hemodialysis. To satisfy the requirements in Listing 6.03, you contact the source to confirm chronic kidney disease (CKD), current dialysis, and that dialysis will be ongoing. The source indicates that the claimant’s traumatic kidney failure did not resolve. The claimant is currently receiving dialysis, and the source opines the need for chronic hemodialysis or transplant. If the established onset date (EOD) is fully favorable, you do not need to wait for the signed SSA-795 that documents the issue of CKD and chronic hemodialysis.

E. References

  • DI 22505.008 Developing Supplemental Evidence

  • DI 22505.035 Follow-up on Requests for Medical Evidence of Record (MER)

  • DI 81020.020 Electronic Case Development

  • DI 81020.035 Document Management Architecture (DMA) Barcodes and Document Indexing

  • DI 81020.060 Receiving Evidence in Disability Determination Services (DDS)

  • OS 15010.425 SSA-795, Statement of Claimant or Other Person

DI 22505.035 Follow-up on Requests for Medical Evidence of Record (MER)

A. Policy for following-up on MER requests

1. Every reasonable effort required for MER

We must make every reasonable effort to help claimants obtain medical evidence from all of their medical sources. See DI 22505.001A.2.

NOTE: In child claims under Title XVI, we also must make every reasonable effort to obtain evidence from all relevant non-medical sources. See DI 25205.001.

2. When follow-up may not be required for MER

You are not required to follow-up with a medical source solely to obtain a medical opinion. However, you should recontact a medical source for specific information about a claimant's functional abilities and limitations if necessary to adjudicate a claim. See DI 22505.008C.

B. Procedure for following-up on MER requests

1. How to follow-up

Follow-up with the source by:

  • mailing a letter to the source,

  • faxing a letter to the source,

  • calling and speaking to the source by telephone, or

  • calling the source by telephone and leaving a clear and detailed message on the source's voicemail.

Any of these contacts constitute a successful follow-up attempt with the source. For more instructions on how to request and document receipt of evidence by telephone or fax, see DI 22505.030.

2. When to follow-up

a. Regular claims

  1. 1. 

    Initiate one follow-up request for each medical source that has not provided requested MER at any time between 10 and 20 calendar days after the initial request.

  2. 2. 

    Allow at least 10 calendar days from the date of the follow-up request for the source to reply. Allow more time for a particular source to reply when experience with that source indicates a longer period is advisable.

b. Compassionate Allowances (CAL) and Quick Disability Determinations (QDD)

For procedures about when to follow-up in CAL and QDD claims, see DI 23022.040D.

3. When to stop follow-up activities

a. Sufficient evidence for an allowance

If the case contains sufficient evidence to make a fully favorable determination, do not await receipt of or follow-up on outstanding MER requested from other medical sources. See DI 24515.020.

b. Source clearly will not provide evidence

Discontinue follow-up activities when circumstances of contact with a medical source clearly indicate that the medical source cannot or will not at any time provide the requested MER.

4. Documentation requirements

In all cases, document the details of all follow-up activities on the electronic claims analysis tool disability determination explanation (eCAT DDE) or on the Case Disability Summary Worksheet. See DI 20503.001E.

C. References

  • DI 20503.001 Documenting the Disability Folder - Disability Determination Services (DDS)

  • DI 22505.003 Medical and Other Evidence of an Individual’s Impairment(s)

  • DI 22505.007 Developing Initial Evidence from Medical Sources

  • DI 22505.008 Developing Supplemental Evidence

  • DI 22505.030 Obtaining Medical Evidence by Telephone

  • DI 23022.040 Compassionate Allowances and Quick Disability Determinations Fast-Track Case Development


DI 22505 TN 31 - Development of Medical Evidence of Record (MER) - 4/02/2021