PROGRAM OPERATIONS MANUAL SYSTEMPart DI – Disability InsuranceChapter 710 – Processing Disability Claims Filed in the United States by Canadian and Mexican ResidentsSubchapter 01 – Processing Title II Disability Claims Filed in the United States by Canadian ResidentsTransmittal No. 2, 08/03/2021
This is a Quick Transmittal. These revisions do not change or introduce new policy or procedure.
Request from Operations to provide additional clarification about payments for medical services above the fee schedule. No change to the current instructions.
Summary of Changes
DI 71001.050 Disability Determination Services (DDS) Procedures for Payment of Medical Services above the Fee Schedule
We moved the DDS reminder to maintain written approval from the regional office to the first paragraph. We added clarification for the DDS when completing an exception request. We added a note about completing the form.
The Disability Determination Services (DDS) must obtain regional office (RO) approval before agreeing to pay any charges that exceed the consultative examinations (CE) or the medical evidence of record (MER) fee schedule, or both. If it is necessary to pay a charge that exceeds the DDS fee schedule for MER or a CE, the DDS must submit a written request to the regional office requesting a fee schedule exception. The DDS must maintain the RO's written response for audit purposes. The exception request must:
Explain why it is necessary to pay a fee above the schedule;
Outline any difficulties in obtaining the medical evidence, necessary test(s) or negotiating a fee; and
Explain how the proposed fee was determined.
States must follow state guidance (including State Agency Fee Schedule) when approving expenses for charges that exceed the fee schedule. This includes costs for travel (airfare, car, etc) per diem for food and lodging.
DDS reports costs in the Medical Costs of Consultative Examinations section of the eMOR and Form SSA-4513 - State Agency Report of Obligations for SSA Disability Programs.
Do not record costs for medical services above the fee schedule in the Other or Applicant Travel section of the eMOR under any circumstance.
20 CFR 404.1626
20 CFR 416.1026 Fiscal
DI 39506.001A DDS Financial Management
DI 39545.600D Fee Schedules—Negotiated Rates.