Effective Dates: 7/29/2026 - Present

Identification Number:
DI 24501 TN 33
Intended Audience:
Originating Office:LP DP
Title:General - Medical Evaluation
Type:POMS Full 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. 33, 02/25/2025

Originating Component

DP

Effective Date

Upon Receipt

Background

Disability Policy is revising this POMS section for consistency with processes for completing the SSA-416 and MA-416 in the Disability Case Processing System (DCPS). In addition, we are updating guidance for consistency with a new POMS section for adjudicating cases at the reconsideration level.

Summary of Changes

DI 24501.006 SSA-416-UF Medical Evaluation

We updated this POMS section to:

  • •

    Update the instructions for completing the SSA-416 and MA-416 in DCPS;

  • •

    Remove references to eCAT or legacy systems;

  • •

    Update terminology and policy references in the tables;

  • •

    Remove instructions for using the SSA-416 to adopt initial level medical assessment(s), for consistency with new POMS section;

  • •

    Combine instructions for using the SSA-416 to document no medically determinable impairment and insufficient evidence;

  • •

    Remove descriptions for the evaluation period and cross-referenced POMS instead; and

  • •

    Clarify when the box for completing the medical portion of the disability claim is and is not checked.

DI 24501.006 SSA-416 Medical Evaluation

A. When to use the SSA-416 (Medical Evaluation) and MA-416 (Medical Advisor Evaluation)

1. Medical consultant (MC) and psychological consultant (PC) medical evaluation

The MC/PC uses the SSA-416 (Medical Evaluation) to document medical evaluation of any of the following medical findings for adult claims and some child claims*:

Medical Findings:

For Additional Policy Information, see:

Evidence does not establish (or is insufficient to establish) a severe physical medically determinable impairment (MDI), or a combination of physical MDIs, that is severe and meets the duration requirement
  • •

    DI 24505.001 Individual Must Have a Medically Determinable Severe Impairment

  • •

    DI 24505.005 Evaluation of Medical Impairments that are Not Severe

  • •

    DI 25205.005 Evidence of a Medically Determinable Impairment

  • •

    DI 25220.005 Determining If a Child Has a Severe Impairment(s)

  • •

    DI 25505.030 Evaluation of the Duration Requirement for Disability

Impairment meets or medically equals a physical listing
  • •

    DI 24508.005 Impairment Meets a Listing

  • •

    DI 24508.010 Impairment or Combination of Impairments Equaling a Listing - Medical Equivalence

  • •

    DI 25220.010 Meets or Medical Equals

Continuing disability review (CDR) medical evaluation
  • •

    DI 28005.030 Step-by-Step Discussion of the Title XVI Child Continuing Disability Review (CDR) Sequential Evaluation Process

  • •

    DI 28010.015 Comparison of Symptoms, Signs, and Laboratory Findings When Evaluating Medical Improvement (MI)

  • •

    DI 28010.050 Adjudicator and Medical or Psychological Consultant (MC/PC) Roles in Considering Medical Improvement (MI)

*NOTE: Title XVI Childhood Disability (DC) claims do not require the use of an SSA-416 or MA-416, but these forms may be used for scenarios that do not require a domain evaluation (see DI 25230.001).

2. Using the MA-416 for a Medical Advisor’s (MA) analysis

The MA will use the MA-416 for electronic and paper claims in the Disability Case Processing System (DCPS) to enter his or her full medical analysis in the “Evaluations and Assessments” section on the “Impairment Severity/Sign” page in DCPS.

For more information on:

B. Who signs the SSA-416 and MA-416

The signer may be an:

  • •

    MC,

  • •

    PC, or

  • •

    MA (MA-416 only available in DCPS).

For a detailed explanation of MC, PC, and MA roles, see DI 24501.001.

C. How to complete the SSA-416 and MA-416

The MC/PC completes the SSA-416 and the MA completes the MA-416 for electronic and paper claims in DCPS. When processing electronic and paper claims, access the SSA-416 and MA-416 in the “Evaluation and Assessments” section on the “Impairment Severity/Sign” page in DCPS. For more information about medical evaluations in electronic cases, see DI 81020.110.

NOTE: The disability examiner (DE) may assist in completing the SSA-416 and MA-416, but only the MC, PC, or MA may sign the form. The DE cannot edit a medical assessment that the MC, PC, or MA has signed. For more information on editing a signed medical assessment, see DI 81020.110B.2.

The following chart provides instructions on how to complete the SSA-416 and MA-416:

Form Section

Action

1. Evaluation Period

Select the evaluation period covered in the medical evaluation from the dropdown list:

  • •

    Current evaluation

  • •

    Date last insured (DLI)

  • •

    12 months after onset

  • •

    Other period(s)

For more information about medical evaluation, see DI 24501.002.

2. Subject

Identify which type of medical finding you are documenting (e.g., meets or medically equals listing). There may be more than one subject for each SSA-416 and MA-416.

3. Evaluation

Document the medical evaluation in this section. As appropriate, address the following:

4. MC/PC Statement and Signature (SSA-416 only)
  • •

    Check the box labeled “These findings complete the medical portion of the disability determination” when the evaluation is complete.

  • •

    Do not check the box when the medical evaluation is preliminary, partial, or advisory.

  • •

    Click the “Sign and Save 416 Evaluation” button. This will populate the signer's medical specialty code per DI 24501.004, as well as the date signed.

5. MA Signature (MA-416 only)

Click the “Sign and Save MA-416 Evaluation” button. This will populate the signer's medical specialty code per DI 24501.004, as well as the date signed.

IMPORTANT: For more information on completing the SSA-416 and MA-416 in DCPS, see the most recent DCPS Claims Analysis Functionality Guide.


DI 24501 TN 33 - General - Medical Evaluation - 7/29/2026