Effective Dates: 6/26/2025 - Present

Identification Number:
DI 22505 TN 49
Intended Audience:
Originating Office:ORDP ODP
Title:Development of Medical Evidence of Record (MER)
Type:POMS Full 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. 49, 06/26/2025

Originating Component

ODP

Effective Date

Upon Receipt

Background

The Office of Disability Policy (ODP) is clarifying that the Disability Determination Services (DDS) develops a complete medical history beginning with the potential onset date (POD) for consistency with SSR 18-1p, to prevent insufficient development, and to avoid duplicate development with automated functions like Medical Evidence Gathering and Analysis through Health Information Technology (MEGAHIT). In addition, ODP clarified that the DDS is not required to routinely request evidence from consistently uncooperative sources and documentation requirements in Disability Case Process System (DCPS).

Summary of Changes

DI 22505.001 Medical and Nonmedical Evidence

We updated this section to:

  • •

    Replace AOD with POD in Subsection A.3,

  • •

    Clarify that responsibilities for developing evidence apply at the initial and reconsideration levels and add a cross-reference to the policy for CDR development in Subsection B.2,, and

  • •

    Make other non-substantive changes to improve usability.

DI 22505.006 Requesting Evidence - General

We updated this section to:

  • •

    Add sources that are consistently uncooperative to the list of situations that do not require routine requests in Subsection A.3,

  • •

    Remove references to eCAT and update instructions for case documentation using DCPS in Subsection A.3,

  • •

    Replace AOD with POD in Subsection C.1.a,

  • •

    Remove references to legacy systems in Subsection C.1.b and C.2, and

  • •

    Make other non-substantive changes to improve usability.

DI 22505.007 Developing Evidence from Medical Sources

We updated this section to:

  • •

    Remove "summary" from case development worksheet for consistency with DCPS in Subsection C, and

  • •

    Make other non-substantive changes to improve usability.

DI 22505.001 Medical and Nonmedical Evidence

CITATIONS:

Social Security Act - Sections 216(i), 223(d), 1614(e), and 1633(b).
Regulations - 20 CFR Sections 404.1502, 404.1512 through 404.1519h and 416.902, 416.912 through 416.919h.

A. Definitions for medical and nonmedical evidence

1. Evidence

Evidence is anything the claimant or anyone else submits to us or that we obtain that relates to his or her claim for benefits.

For what we do not consider evidence, see DI 24503.001B.

For categories of evidence, see DI 24503.005.

2. Every reasonable effort

Every reasonable effort means that we will:

  • •

    Make an initial request for medical records from the claimant’s own medical sources and entities that maintain a medical source’s evidence. For Title XVI child cases, this includes evidence from the child’s school and teachers.

  • •

    Make one follow-up request any time between 10 and 20 calendar days after the initial request if we do not receive the evidence.

  • •

    Allow a minimum of 10 calendar days from the date of follow-up request for the medical source or entity to reply.

Allow more time for a particular source when experience with that source indicates a longer period is advisable. For follow ups on requests for medical evidence, see DI 22505.035B.

For developing evidence on functioning in Title XVI child cases, see DI 25205.010.

3. Complete medical history

Before we make a determination that a claimant is not disabled, we will make every reasonable effort to develop the claimant’s complete medical history. Complete medical history means the records of the claimant’s medical sources covering at least the 12 months prior to whichever date is earliest:

  • •

    The month of filing.

  • •

    The protective filing date (PFD).

  • •

    The date last insured (DLI) (disability insurance benefits case).

  • •

    The prescribed period (PP) ending date (disabled widow(er) benefits case).

  • •

    The attainment of age 22 (childhood disability benefits case).

If the claimant alleges that his or her disability began less than 12 months before the month of filing, PFD, DLI, end of the PP, or attainment of age 22, we will develop a complete medical history beginning with the potential onset date, unless there is reason to believe that the disability began earlier.

For information on when to develop outside the 12-month period, see DI 22505.006A.2.

4. Medical source

A medical source is an individual who is:

  • •

    Licensed as a healthcare worker by a State and working within the scope of practice permitted under State or Federal law, or

  • •

    Certified by a State as a speech-language pathologist or a school psychologist and acting within the scope of practice permitted under State or Federal law.

IMPORTANT: The term medical source includes both acceptable medical sources and medical sources who are not acceptable medical sources. For information on who is an acceptable medical source, see DI 22505.003A.

5. Nonmedical source

A nonmedical source is any source of evidence who is not a medical source. This includes, but is not limited to, the claimant, educational personnel, public and private social welfare agency personnel, family members, caregivers, friends, neighbors, and clergy.

6. Entity

An entity refers to an organization that maintains a medical source's records. Generally, entity means the medical clinic, medical facility, or hospital where a medical source evaluated, examined, or treated the claimant.

B. Overview of evidence responsibilities

1. Claimant responsibilities

Generally, the claimant has to prove to us that he or she is blind or disabled. This duty is ongoing and applies at each level of the administrative review process. The claimant must tell us about or submit all evidence known to him or her that relates to whether or not the claimant is blind or disabled.

2. Disability Determination Services (DDS) responsibilities

Before we make a determination that the claimant is not disabled, we will:

  • •

    Make every reasonable effort to develop the claimant’s complete medical history, see DI 22505.001A.2, in this section,

  • •

    Contact the claimant's medical sources and entities that maintain the claimant's medical records when developing the complete medical history, see DI 22505.001A.3, in this section,

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    Review all available prior paper and electronic folders,

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    Copy, scan or fax the relevant evidence from the prior folder(s) into the current folder, and

  • •

    Consider all relevant evidence about the claim, including relevant evidence from prior folders, when making a determination.

For determining the need for a prior paper folder, see DI 20505.010.

For the definition of relevant evidence, see DI 24501.016B.2.

For developing vocational evidence, see DI 22515.001.

For more information on case development responsibilities, see DI 22501.002.

NOTE: The responsibilities for developing evidence apply at the initial and reconsideration levels of adjudication. For more information on developing medical evidence in continuing disability review cases, see DI 28030.020. Be alert to situations where the claimant may need assistance with case development.

DI 22505.006 Requesting Evidence - General

A. Policy requirements for development

1. Evidence from all sources

The Disability Determination Services (DDS) develops medical evidence, including diagnostic tests, from all sources the claimant identifies, or we discover during development who have treated or evaluated the claimant for any alleged, documented, or discovered impairment(s) during the applicable 12-month period. For the definition of complete medical history and the 12-month period, see DI 22505.001A.3.

2. Developing medical evidence outside of the 12-month period

Generally, the DDS develops medical evidence to cover the period required for medical evaluation. For more information on medical evaluation requirements, see DI 24501.002B.

When developing medical evidence outside of the 12-month period, the DDS must use judgment and carefully consider the case factors of a particular case, such as:

3. When not to make routine requests

Generally, the DDS does not make routine requests for medical evidence in the following situations:

  • •

    The medical source is deceased or retired. However, a medical source may transfer his or her records to a successor upon retirement. When we determine a medical source has transferred records or records remain at the entity that maintains a medical source's records, request the records from the successor or entity that maintains such records.

  • •

    The source is consistently uncooperative (i.e., the source will not submit information on any claimant).

  • •

    The evidence is clearly unrelated to the impairment(s), such as routine dental care.

NOTE: If not requesting evidence from a medical source for any reason, the DDS must document the name of the source and reason for not requesting the evidence on a Case Note in the Disability Case Processing System (DCPS) and “write to” the case development worksheet or on an SSA-5002 (Report of Contact).

B. Procedure for development

1. Before requesting evidence

DDS must do the following before requesting evidence:

  • •

    Review the current folder to determine the specific development needed,

  • •

    Consider development already undertaken in the current folder and all available prior paper and electronic folders to avoid duplicate development,

  • •

    Copy any relevant evidence from the prior folder(s) to the current folder, and

  • •

    Determine whether additional development is needed.

For the definition of relevant evidence, see DI 24501.016B.2.

For more information on reviewing and copying relevant evidence from a prior folder(s), see DI 20505.010.

For instructions on copying documents from a prior electronic folder(s), see DI 81005.052.

2. Initial requests for evidence

The DDS requests the evidence from medical sources needed to evaluate the claim. When more than one development action is required, perform the actions concurrently. For example, request evidence from all medical sources at the same time.

Consider methods to expedite development, such as:

  • •

    Electronic evidence requests, such as Electronic Records Express (ERE) and Health Information Technology (HIT).

  • •

    Telephone.

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    Fax.

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    Claimant participation.

NOTE: If requesting the claimant’s assistance to obtain the evidence, provide the claimant with a medical evidence request, a signed SSA-827, and a pre-addressed return envelope.

For information on developing evidence from foreign medical sources for non-citizens, see DI 23515.005.

For information on developing evidence from foreign medical sources for US citizens, see DI 43510.005 and GN 00301.190.

3. Requests for prior paper folders

The DDS must request a prior paper folder(s) in accordance with DI 20505.010C.2.

For information on requesting a prior paper folder(s), see DI 20505.015.

C. Types of requests

1. HIT

Medical Evidence Gathering and Analysis Through Health Information Technology (MEGAHIT) creates and sends an automated request to HIT partners when the field office (FO) transfers an electronic case to the DDS. The DDS may also create and send a user-triggered request to HIT partners after case transfer, if needed. For more information on HIT, see DI 81020.020E. For more information on HIT partners, see SSA Health IT Partner Information.

a. Period covered by automated HIT request

For initial-level cases, the automated request covers the period from:

  • •

    12 months prior to the potential onset date (POD) to the date of the request for a Title II or a concurrent Title II and Title XVI case, or

  • •

    12 months prior to the protective filing date to the date of the request for a Title XVI only case.

For Title II and Title XVI reconsideration-level cases, the automated request covers the period from the date of the last HIT request at the initial level of review to the date of the new request. If there is not a prior HIT request, HIT will not create and send an automated request. The DDS must create a user-triggered HIT request per DI 22505.006C.1.b., in this section.

For all continuing disability review cases, the automated request covers the period from 12 months prior to the date of the request.

b. When to create a user-triggered HIT request

The DDS creates and sends a user-triggered request to HIT partners using DCPS, or the MEGAHIT website for the period requested.

Create a user-triggered request in the following situations:

  • •

    There is no response to the automated HIT request five hours after submission.

  • •

    There is a retrieval/conversion error.

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    The automated response is not sufficient (for example, the period of adjudication is not covered or the list of documents is blank).

  • •

    The automated request does not occur in a reconsideration-level case.

  • •

    We have resolved a prior SSA-827 (Authorization to Disclose Information to the Social Security Administration (SSA)) issue.

  • •

    We identify a HIT partner as a medical source after the FO transfers the case to the DDS.

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    We need additional records after receipt of the automated response.

NOTE: A wet-signed SSA-827 is valid for HIT partners for nine months from the date of the signature. In addition, some HIT partners only accept an e827.

IMPORTANT: HIT allows up to ten user-triggered requests to all HIT partners at each level of adjudication.

c. When to create a traditional request to HIT partners

HIT is the preferred type of request because it promotes expedited and efficient case processing. The DDS must review the evidence received in the automated HIT response before requesting evidence from HIT partners through a traditional request.

Make a traditional request for records only when the evidence needed is not available through HIT, such as:

  • •

    The HIT response indicates a claimant or beneficiary cannot be found.

  • •

    The HIT partner does not share sensitive records.

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    Policy requires graphical evidence (e.g., images or tracings) for abnormal testing.

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    A medical consultant (MC) indicates that the DDS needs graphical evidence for testing.

NOTE: Most HIT partners share sensitive records, which makes a traditional request for sensitive records a rare occurrence. For the list of HIT partners that do not share sensitive records, refer to local DDS procedures.

d. When to request graphical evidence for abnormal testing

Certain types of tests provide graphical evidence (for example, images or tracings) that are not included in the HIT standard document. For information on the HIT standard document, see DI 81020.020E.

Create and send a traditional request to HIT partners for graphical evidence when the testing is abnormal for:

  • •

    Visual field tests.

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    Audiograms.

  • •

    Pulmonary function tests (PFT).

  • •

    Cardiac stress tests.

A traditional request to HIT partners may also be needed for graphical evidence when the testing is abnormal for:

  • •

    Electrocardiograms (ECG) when required to meet or medically equal a cardiovascular listing.

  • •

    Other tests with graphical evidence (for example, Doppler studies or Holter monitors) when requested by the MC.

NOTE: A traditional request for other testing with graphical evidence should be rare and depends on individual case facts.

2. Traditional requests

The DDS creates a traditional request using DCPS and sends the request to the medical source by mail, fax, or the request function of ERE. Make requests clear and concise to elicit the types of evidence needed to support the claim.

For when to send a traditional request to HIT partners, see DI 22505.006C.1.c., in this section.

DI 22505.007 Developing Evidence from Medical Sources

A. Request medical evidence

We request medical evidence from each medical source that the claimant identifies as having evaluated, examined, or treated him or her. For the definition of medical source, see DI 22505.001A.4.

For general instructions on requesting medical evidence, see DI 22505.006.

For a suggested model letter to use when requesting medical evidence of record in adult claims, see NL 00705.770.

B. Content of medical evidence

Generally, medical evidence should include:

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    Medical history

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    Objective medical evidence (medical signs, laboratory findings, or both)

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    Prescribed treatment and claimant’s response to the treatment

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    Diagnosis and prognosis

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    Medical opinion

NOTE: You are not required to follow up with a medical source solely to obtain a medical opinion. For more information about follow up requests for medical evidence, see DI 22505.035.

C. When to request a medical opinion

Generally, we request a medical opinion, along with medical evidence, through a request for medical evidence. Request a medical opinion from all of the claimant’s medical sources with the exception of the following situations or sources:

  • •

    In statutory blindness cases.

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    From a laboratory.

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    From a medical source who previously refused to provide medical opinions for all of his or her patients.

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    From a Department of Veterans Affairs (VA) facility. (As a matter of policy, the VA does not permit its physicians and psychologists to provide this type of opinion.) For additional information, see DI 22505.022.

  • •

    From the National Personnel Records Center. For additional information, see DI 22505.024.

Document all disability development undertaken on the case development worksheet in the Disability Case Processing System. For details, see DI 20503.001E.


DI 22505 TN 49 - Development of Medical Evidence of Record (MER) - 6/26/2025