Identification Number:
DI 22510 TN 19
Intended Audience:See Transmittal Sheet
Originating Office:ORDP ODP
Title:Development of Consultative Examinations (CE)
Type:POMS Transmittals
Program:All Programs
Link To Reference:
 
DELAYED IMPLEMENTATION TRANSMITTAL (DIT)
DIT's ARE FOR FUTURE IMPLEMENTATION AND DISPLAYED
FOR INFORMATIONAL AND TRAINING PURPOSES ONLY

PROGRAM OPERATIONS MANUAL SYSTEM
Part DI – Disability Insurance
Chapter 225 – Case Development Procedures
Subchapter 10 – Development of Consultative Examinations (CE)
Transmittal No. 19, 09/24/2019

Audience

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

Originating Component

ODP

Effective Date

11/04/2019

Background

We are updating our POMS to provide guidance about how to notice and confirm a scheduled consultative examination (CE) appointment. This update is the result of a workgroup convened for improving these procedures and reflects comments and suggestions to address specific issues surrounding CE notice and confirmation procedures. The updated procedures emphasize the importance of making a reasonable effort to confirm CE attendance.

Summary of Changes

DI 22510.016 Consultative Examination (CE) Appointment Special Scheduling Procedures

We updated instructions regarding who should receive a CE appointment notice, how to make a reasonable effort to confirm the CE appointment, and special handling cases.

We relocated information about special handling to DI 23007.001.

We relocated information about involving a third-party contact to DI 23007.015.

We clarified when an adjudicator may discontinue attempts to get a claimant to attend a CE appointment and how to proceed with development and determinations for such cases.

We addressed alternative and special CE scheduling procedures.

We changed the definition of alternative CE scheduling from 10 days or less from the CE appointment notice to 14 days or less.

We standardized the time required for the claimant to return our call to 10 calendar days from the date of the message if the adjudicator must leave a message when making a reasonable effort to confirm CE attendance via telephone.

DI 22510.017 Consultative Examination (CE) Appointment Notice

We simplified the instructions for notifying the CE source of scheduled appointments and emphasized the importance of sending collateral information with the request for the CE.

DI 22510.019 Consultative Examination (CE) Appointment Notice Follow up and Reminder

We simplified the instructions for notifying the CE source of scheduled appointments and emphasized the importance of sending collateral information with the request for the CE.

Conversion Table
Old POMS ReferenceNew POMS Reference
DI 22510.019DI 22510.016

DI 22510.016 Consultative Examination (CE) Appointment Special Scheduling Procedures

CITATIONS:

20 CFR 404.1516 through 404.1519t , and 416.916 through 416.919t

The CE appointment special scheduling procedures apply only for the situations described in this section. They apply at the initial and reconsideration level of review. Follow the special scheduling procedures in addition to the general CE procedures. When a special scheduling procedure conflicts with the general CE procedures, you should follow the special scheduling procedure.

See also:

  • DI 22510.017 Consultative Examination (CE) Appointment Notice

  • DI 22510.019 Consultative Examination (CE) Appointment Notice Follow up and Reminder

  • DI 23007.010 Failure to Attend a Consultative Examination (CE) Appointment

  • NL 00705.745 Model Consultative Examination (CE) Appointment Notice and forms

A. CE appointment scheduling in special handling situations

For additional information on cases that require special handling, see DI 23007.001A.

1. In any special handling situation:

  • Carefully consider any request for accommodation. Document your actions in response to any request for accommodation on an SSA-5002, the claims communication section of eCAT, or the DDS worksheet.

  • Attempt to involve a designated third-party contact, whenever appropriate. For information on involving a designated third-party contact with a CE appointment, see DI 22510.016B in this section.

2. If the claimant needs language assistance:

  • Provide an interpreter free of charge. Do not require a claimant who needs language assistance to provide his or her own interpreter.

  • Follow the guidelines regarding interpreters for claimants with LEP in DI 23040.001.

3. If the claimant is homeless:

  • Attempt to involve the third party immediately. Do not wait until a homeless claimant fails to attend a CE appointment to involve the third party.

  • Schedule the CE appointment as quickly as possible.

  • Assist in making travel arrangements according to State agency guidelines, even if only a short distance is involved (e.g., provide a printed map, verbal directions, taxi voucher, or a subway token).

4. If the claim involves mental impairment:

  • Consider involving a third party when arranging a CE appointment.

  • Always attempt to involve a third party as directed by CE appointment notice follow-up procedures in DI 22510.019D.

5. If the claimant is unable to travel due to a health reason or risk:

The claimant may report or the evidence may suggest that the claimant is unable to travel due to a health reason or health risk. If so:

  1. a. 

    Confer with the claimant’s medical source MS, if possible, about the need for the CE appointment. Determine whether the MS agrees it is reasonable for the claimant to travel to the CE appointment.

  2. b. 

    If the claimant will not travel or the MS advises against travel to a CE appointment due to a health reason or health risk:

    • Schedule the CE appointment at the claimant’s residence, if appropriate. Consider the need for, and availability of, special equipment or facilities.

    • Do not schedule a CE at the claimant’s residence if the claimant does not want the CE held at his or her residence, or if we cannot obtain the needed CE evidence in the residential setting. Make a reasonable effort to obtain necessary evidence from the claimant’s sources. Then make a determination based on the evidence in the file, see DI 23007.015.

B. Guidelines for involving a designated third-party contact with a CE appointment

The claimant usually provides the name of someone we can contact to help him or her with the claim. We refer to this person as the designated third-party contact or third party. The designated third party is not the claimant’s doctor, but knows about the claimant’s medical conditions.

The claimant may designate a third-party contact verbally or in writing (e.g., on the SSA-3368-BK , Disability Report - Adult, Section 2, or SSA-3441-BK , Disability Report - Appeal, Section 1.D, or the SSA-454-BK Continuing Disability Review Report, Section 2). The FO may provide additional third party information in Section 11 Remarks on forms SSA-3368-BK, SSA-3441-BK or SSA-454-BK.

For a definition of a third party, see DI 23007.001B.

For information on making a reasonable effort to identify and involve a third party, see DI 23007.010.

C. Guidelines for involving an appointed representative with a CE appointment

Any claimant may appoint a representative to act on his or her behalf in the matter of a disability claim. Identify represented claimant cases by the completed Form SSA-1696 (Appointment of Representative), or equivalent writing, in file. If the claimant appoints a representative, we flag the file “representative involved.”

  1. 1. 

    The appointed representative may confirm or refuse the CE appointment for the claimant.

  2. 2. 

    When contacting the appointed representative about the CE:

    • Send all written correspondence to the appointed representative and to the claimant.

    • Direct all telephone contact to the appointed representative unless asked to communicate directly with the claimant.

      NOTE: You may speak with an unappointed assistant, instead of the appointed representative, if the representative delegated responsibility for handling the CE scheduling matter to the assistant, see GN 03910.025.3.

    • Advise an appointed representative who asks to accompany the claimant to the CE appointment to make the request directly to the CE source. Also, advise the representative that the CE source’s decision is controlling. If the appointed representative objects to the CE source, see DI 22510.010E.

See also:

  • GN 03910.040 Appointment and Revocation of Appointment of Representative

  • GN 03910.050 Contacting a Represented Claimant

  • DI 31001.010 Disability Determination Services (DDS) Responsibilities When an Appointed Representative is Involved

D. Involving an applicant, other than the claimant, with the CE appointment

If an applicant filed for the claimant, send all written correspondence to the applicant and to the claimant. Direct all telephone contact to the applicant who has filed for the claimant unless asked to communicate directly with the claimant.

E. Scheduling an appointment if a CE source is not available in the claimant’s immediate area

If a CE source is not available in the claimant’s immediate area:

  • Schedule the CE appointment at the most convenient location to the claimant (e.g., consult a map or contact the claimant).

  • For guidelines on purchasing a CE in a neighboring State, see DI 39545.225.

  • For guidelines on travel reimbursement, see DI 39525.005.

F. Scheduling a CE appointment for an incarcerated claimant

REMINDERS: If the correctional facility has relevant medical records, you must make every reasonable effort to obtain them, see DI 22505.001A.2. For guidelines on pre-release case processing, see DI 23530.001.

  1. 1. 

    If you need to schedule a CE appointment for an incarcerated claimant, determine if the following options are available:

    • The staff medical source at the facility has permission to do the CE at the facility;

    • The facility may permit an outside CE source selected by the adjudicator to do the CE at the facility, or

    • The facility may permit the claimant to attend a CE at an outside facility selected by the adjudicator.

  2. 2. 

    If the claimant can attend the CE under any of the options in this section, make necessary arrangements for the appointment.

  3. 3. 

    If the claimant cannot attend a required CE because none of the options in this section are available:

    • Document the details of the development undertaken on an SSA-5002, the claims communication section of eCAT or the DDS worksheet with the details of the development undertaken; and

    • Process the failure to cooperate determination under DI 23007.015.

      EXCEPTION: If the case is a Title II continuing disability review, see DI 28065.030.

G. Scheduling an expedited CE appointment for a date 10 days or less in the future

  1. 1. 

    As early as possible:

    • Contact the claimant by telephone to determine whether he or she agrees to attend the CE appointment; and

    • Send the CE appointment notice to the claimant.

  2. 2. 

    If you reach the claimant, and the claimant agrees to attend the CE appointment:

    • Explain the necessary details of the appointment, including location, date, and time.

    • Explain that if the claimant does not attend the CE appointment, we may make a determination based on the evidence in file. Explain that this means we may find that he or she is not disabled.

  3. 3. 

    If you do not confirm that the claimant will attend the appointment before the date of the appointment, reschedule the appointment. NOTE: Short notice is a good reason to decline the appointment. If the claimant does not agree to attend a short-notice appointment and asks for a later appointment, reschedule. You cannot establish failure to cooperate if the claimant asks for more notice for a CE appointment.

  4. 4. 

    Document the details of the development undertaken on an SSA-5002, the claim communication section of eCAT, or the DDS worksheet.

  5. 5. 

    If the claimant does not require special handling and agrees to attend the CE appointment, but does not attend, follow the instruction in DI 23007.010.

  6. 6. 

    Prior to discontinuing efforts to secure evidence that requires claimant cooperation for a claimant that requires special handling, you must make a reasonable effort to identify and involve a third party. For instructions on making a reasonable effort to identify and involve a third party, see POMS DI 23007.010

DI 22510.017 Consultative Examination (CE) Appointment Notice

CITATIONS:

20 CFR 404.1516 through 404.1519t , and 416.916 through 416.919t

A. Notifying the CE source of the appointment in writing

Notify the CE source of the appointment in writing and include the following:

  1. 1. 

    Date and time of the CE appointment;

  2. 2. 

    Required type of CE, required tests, and specific issues for the CE source to address;

  3. 3. 

    Authorizing documents (e.g., an authorization for diagnostic services or claim for payment);

  4. 4. 

    Form(s) to complete, such as a request for the CE source’s statement of what the claimant can still do despite his or her impairment(s);

  5. 5. 

    A duplicate, fax, or other agency-approved electronic transmission of an originally signed and dated SSA-827 (Authorization to Release Information to the Social Security Administration), unless the source prefers to use its own authorization forms, see DI 11005.055; and

  6. 6. 

    Background information on the claimant as described in this section.

B. Providing background information to the CE source

The quality of the background information sent to the CE source affects the quality of the CE report more than the quantity of the information. Provide any longitudinal information necessary to ensure a quality CE report, especially in cases involving mental impairments. Provide background information to the CE source based on the specific case facts, rather than on a minimum or maximum number of pages.

Provide duplicates or summaries of relevant evidence such as:

  • Medical evidence of record including any medical opinion(s);

  • The most recently completed disability report form in file (i.e., SSA-3368 (Disability Report-Adult), SSA-3820 (Disability Report-Child), SSA-3441 (Disability Report-Appeal), or SSA-454 (Continuing Disability Review Report);

  • Forms completed by the claimant or others, such as the SSA-3373-BK (Function Report-Adult); and

  • Information extracted from documents used in communications, such as from a Disability Determination Services (DDS) medical or psychological consultant, if the information will be helpful to the CE source.

NOTE: Comply with State law governing the release of information. Do not offer any opinion, implied or stated, about the severity of the claimant’s impairment(s), or make any statement or comment that would be prejudicial to the claimant.

C. Notifying the claimant of the CE appointment in writing

Send a CE appointment notice to the claimant.

  • If the claimant has an appointed representative also send written notice to the appointed representative, see DI 22510.016C.

  • If the applicant is someone other than the claimant also send written notice to the applicant, see DI 22510.016D.

Options for notifying the claimant in writing of the CE appointment:

1. Using the CE appointment notice model letters

See model CE appointment notice and forms:

  • NL 00705.745A Model 1 CE appointment notice.

  • NL 00705.745B Model 2 CE appointment confirmation form.

  • NL 00705.745C Model 3 Authorization form for release of a copy of the CE report to the claimant’s doctor.

2. Using the free-form CE appointment notice

If you do not use the model CE appointment notice NL 00705.745A, send a free-form CE appointment notice. Include the following:

  1. a. 

    Why we need the CE and why we may need additional tests;

  2. b. 

    Who the notice is from;

  3. c. 

    A statement that the Social Security Administration will pay for the appointment;

  4. d. 

    The date, time, type of the CE appointment, and the name, address, and telephone number of the CE source (or your telephone number, if the CE source does not want his or her telephone number shared with the claimant);

  5. e. 

    The requirement to confirm the appointment within 10 days of the receipt of the letter and

    instructions for responding to the notice, including a request that the claimant respond immediately if he or she cannot attend the CE appointment or if the claimant’s medical source (MS) tells him or her not to attend the CE appointment;

  6. f. 

    A reminder the claimant must bring all medications in their original containers or a print out of his or her current medications from the pharmacy, along with any other medical aids (e.g., hearing aid(s) or eyeglasses) to the CE appointment;

  7. g. 

    Closeout language stating:

    1. 1. 

      If you do not confirm your appointment, we may cancel the appointment.

    2. 2. 

      If you do not attend your appointment, we may make a decision based on the evidence we already have in your file.

    3. 3. 

      If we have to cancel, or you miss your appointment, we may find that you are not eligible or no longer eligible for disability benefits.

  8. h. 

    Information about payment for claimant for travel expenses per DI 39525.005;

  9. i. 

    An explanation that we will send a copy of the CE report to the claimant’s MS if we receive the claimant’s written authorization;

  10. j. 

    A request for the claimant to notify us if he or she needs an interpreter, see DI 23040.001; and

  11. k. 

    The CE leaflet (SSA Publication No. 05-10087, A Special Examination Is Needed for Your Disability Claim).

REMINDER: If the CE source is not the claimant’s MS, you should also ask the claimant to bring government issued photo identification to the CE appointment. This will allow the CE provider to positively identify the claimant; see DI 22510.015A.

NOTE: If a scheduled CE appointment is no longer required, inform the claimant and the CE source immediately.

DI 22510.019 Consultative Examination (CE) Appointment Notice Follow up and Reminder

CITATIONS:

20 CFR 404.1512 through 404.1519t , and 416.912 through 416.919t

NOTE: These procedures are not required for CE appointments scheduled 10 days or less before the date of the appointment, see DI 22510.016G.

A. Special CE appointment communication procedures

B. Claimant confirms the CE appointment

If the claimant confirms he or she will attend the CE appointment scheduled for a specific location, date, and time:

  • Document the CE appointment confirmation on an SSA-5002, the eCAT claim communication section, and

  • Make any required CE appointment reminder per DI 22510.019E in this section.

C. Claimant states he or she will not attend the CE appointment

If the claimant tells you that he or she will not attend the CE appointment, consider whether he or she has a good reason. For examples of good reasons, see DI 23007.001.

  • If the claimant provides a good reason why he or she cannot attend the CE appointment, reschedule it.

  • If the claimant does not provide a good reason and does not require special handling, adjudicate the claim under insufficient evidence procedures in DI 23007.015.

  • Prior to discontinuing efforts to secure evidence that requires claimant cooperation for a claimant that requires special handling, you must make a reasonable effort to identify and involve a third party. For instructions on making a reasonable effort to identify and involve a third party, see POMS DI 23007.010. If there is FO documentation in file that the claimant refused to identify a third party contact, stop attempting to identify a third party, see DI 23007.001C.

D. Claimant does not respond to CE appointment notice

If the claimant does not confirm the CE appointment, you must follow up to determine whether the claimant will attend the CE appointment.

1. Special handling required

If the claimant requires special handling:

  • Make a reasonable effort to identify and involve a third party to assist the claimant. For additional information on special handling, see DI 23007.001A.

  • Attempt to reach a designated third-party contact at the same time you follow up with the claimant.

  • Make a phone call attempt to the third party. If the phone call is successful or you can leave a message explain the reason for your call.

  • Send a call-in letter to the third party if you do not reach him or her by phone or leave a message, or you prefer to contact the third party by letter.

REMINDER If the telephone is not is not in service, you cannot speak to the claimant, or cannot leave a message, send a call in letter per DI 22510.019D.3.

2. Telephone follow up to confirm the claimant will attend the CE appointment

  1. a. 

    If the claimant provided a telephone number, attempt to reach the claimant by telephone.

  2. b. 

    If you reach the claimant:

    1. 1. 

      Ask the claimant if he or she will attend the CE appointment.

    2. 2. 

      Remind the claimant that if he or she does not attend the CE appointment, we may make a determination based on the evidence in file.

    3. 3. 

      Explain that this means we may find that he or she is not disabled.

    4. 4. 

      If the claimant tells you he or she will not attend the CE appointment, consider whether he or she has a good reason. For examples of good reasons, see DI 23007.001B.

      • If the claimant provides a good reason why he or she cannot attend the CE appointment, reschedule it.

      • If the claimant does not provide a good reason and the claimant doesn't require special handling, adjudicate the claim under refusal to attend a CE procedure in DI 23007.015.

  3. c. 

    If the telephone number is not in service or if you do not reach the claimant on the second attempt, send a call-in letter per DI 22510.019D.3. in this section.

  4. d. 

    Document the development on an SSA-5002, in the claim communication section of eCAT, or DDS worksheet.

3. Contact by phone not possible

  1. a. 

    If the claimant does not have a telephone or you did not reach the claimant by telephone, send a call-in letter. Indicate in the letter that if the claimant does not respond within 10 calendar days of the letter, we may make a determination based on the evidence in file. Explain that this means we may find that he or she is not disabled.

  2. b. 

    Allow 10 days from the date of the call-in letter for the claimant to respond.

  3. c. 

    If the claimant calls before the CE appointment, ask if he or she will attend. Remind the claimant that if he or she does not attend the CE appointment, we may make a determination based on the evidence in file. Explain that this means we may find that he or she is not disabled.

  4. d. 

    If the claimant tells you he or she will not attend the CE appointment, consider whether he or she has a good reason. For examples of good reasons, see DI 23007.001B.

    • If the claimant provides a good reason why he or she cannot attend the CE appointment, reschedule it.

    • If the claimant does not provide a good reason, adjudicate the claim using the instructions in DI 23007.015.

  5. e. 

    If the claimant does not respond within the time allowed, you may cancel the CE appointment and process the determination per DI 23007.015.

4. If you did not send the call-in letter more than 10 days before the CE appointment

  1. a. 

    Do not cancel the CE appointment.

  2. b. 

    If the claimant does not attend the CE appointment and does not respond before expiration of the call-in letter, and the claimant does not require special handling, process the determination using the instructions in DI 23007.015. You are not required to do additional follow up under DI 23007.010.

  3. c. 

    If the claimant does not attend the CE, but responds before expiration of the call-in letter, consider whether he or she has a good reason for missing the appointment. For examples of good reasons, see DI 23007.001B.

    1. 1. 

      If the claimant provides a good reason why he or she did not attend the CE appointment, reschedule it.

    2. 2. 

      If the claimant does not provide a good reason, and does not require special handling, adjudicate the claim using the instructions in DI 23007.015. NOTE: If the claimant requires special handling, see DI 25510.019D of this section.

    3. 3. 

      Document your development on an SSA-5002, the claims communication section of eCAT, or the DDS worksheet.

5. The claimant confirms the appointment

  1. a. 

    If a claimant confirms that he or she will attend a scheduled CE appointment, you must attempt to remind the claimant of the appointment, unless:

    • You reached the claimant during a follow up to the CE appointment notice performed within 10 calendar days of the CE appointment, or

    • The scheduled CE appointment was for a date 10 days or less in the future, see DI 22510.016G.

  2. b. 

    Make the CE appointment reminder 10 calendar days prior to the date of the CE appointment. If the reminder date falls on a non-business day, make the reminder on the next business day.

  3. c. 

    You may make the CE appointment reminder by telephone or by mail.

  4. d. 

    If you reach the claimant by telephone or choose to send the CE appointment reminder by mail, provide:

    • The CE appointment information,

    • A reminder that if he or she does not attend the CE appointment we may make a determination based on the evidence already in file, and

    • An explanation that this means we may find that he or she is not disabled.

  5. e. 

    Document your development on an SSA-5002, the claim communication section of eCAT, or the DDS worksheet.



DI 22510 TN 19 - Development of Consultative Examinations (CE) - 11/04/2019