Identification Number:
DI 22505 TN 33
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. 33, 09/02/2021

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

Upon Receipt

Background

The Office of Disability Policy (ODP) is revising this POMS section to provide information about different types of requests, including requesting evidence through Health Information Technology (HIT). We are reorganizing the content and clarifying when to develop evidence outside of the 12-month period. We are also adding instructions to review all available prior folders and copy the relevant evidence from the prior folder to the current folder.

Summary of Changes

DI 22505.006 Requesting Evidence - General

We are adding:

  • A list of factors to consider when developing outside of the 12 -month period with cross-references to the applicable policy.

  • Instructions to copy relevant evidence from a prior folder(s) to the current folder and when to request a prior paper folder(s). We also added cross-reference to the definition of "relevant evidence."

  • Information to distinguish between traditional and HIT requests.

  • Instructions on when to request graphical evidence not available through the HIT standard document.

We are clarifying that:

  • When we consider development already undertaken, it includes evidence from prior folders.

  • We must request evidence through HIT for HIT partners except when the evidence needed is not available through HIT.

We are providing information about the period covered by automated HIT requests and when to create a user-triggered HIT request.

Conversion Table
Old POMS ReferenceNew POMS Reference
DI 22505.006DI 22505.006

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 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 the case development worksheet, Electronic Claims Analysis Tool, Disability Case Processing System (DCPS), or 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,

  • 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 instructions on copying documents from a prior electronic folder, 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.

  • Fax.

  • 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 20505.010.

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 alleged onset date (AOD) 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 the legacy system, 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.

  • 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 issue.

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

  • 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 for 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.

  • Policy requires graphical evidence (for example, images or tracings) for abnormal testing.

  • 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.

  • 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 the legacy system or 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 for HIT partners, see DI 22505.006C.1.c. in this section.


DI 22505 TN 33 - Development of Medical Evidence of Record (MER) - 9/02/2021