PROGRAM OPERATIONS MANUAL SYSTEMPart DI – Disability InsuranceChapter 225 – Case Development ProceduresSubchapter 10 – Development of Consultative Examinations (CE)Transmittal No. 46, 10/11/2024
Audience
Originating Component
ODP
Effective Date
Upon Receipt
Background
The Office of Disability Policy is updating these POMS sections to provide updated guidance about processing cases with improperly signed consultative examination (CE) reports. In addition, we are providing updated guidance about releasing CE reports with the claimant's consent as well as making updates for consistency with the Disability Case Processing System (DCPS).
Summary of Changes
DI 22510.020 Guidelines for Reviewing and Obtaining Corrected Consultative Examination (CE) Reports
We updated this POMS section to:
Remove the acronym "CE" from the section title;
Delete subsection A and make subsection B the new subsection A and subsection C the new subsection B;
Rename subsections A and A.2;
Update the cross-reference in subsection A.2.a to DI 22510.015B.1;
Add cross-references to subsection A.2.b.3;
Clarify a potential life-threatening situation in subsection A.4;
Relocate the model language from subsection A.4 to new POMS section NL 00705.753 and DI 22510.070;
Add cross-references to DI 22510.065 and new POMS section DI 22510.070 in subsection A.4;
Rename subsections B, B.1, and B.2;
Update the instructions in subsections B.1 and B.2;
Update documentation requirements throughout for consistency with case processing in DCPS; and
Delete subsection D "References".
DI 22510.065 Sending the CE Report to the Claimant's Medical Source
Rename the section;
Rename subsections A and B;
Add cross-references in subsection A to DI 81001.030B2, GN 03340.035D, and GN 03305.005C4;
Provide new instructions in subsection B clarifying when an Authorization to Release CE Report Form is considered complete;
Add new subsection C;
Update instructions about releasing CE reports and relocated from subsection B to new subsection C; and
Update documentation requirements throughout for consistency with case processing in DCPS.
The Disability Determination Services (DDS) may receive CE reports through Electronic Records Express (ERE), by mail, or by facsimile (fax). If there is any question about whether the CE source transmitted a faxed CE report:
Contact the CE source to verify that they sent the CE report via fax; and
Document the contact in a Case Note in the Disability Case Processing System (DCPS) and "write to" the case development worksheet (CDW).
Review each CE report, including revised or corrected reports, for completeness and the following required information:
Does the document properly identify the claimant as required by DI 22510.015B.1?
Is the CE report complete?
Were all the pages of the CE report received?
Does it contain the information requested?
Does it document evidence reviewed during the course of the appointment? See DI 22510.035B.1 and DI 22510.100B.1.
Is it internally consistent?
Are all the disorders, diseases, impairments, and complaints described in the history adequately assessed and reported in the clinical findings?
Do the conclusions correlate with the findings from the medical history, the clinical examination, and the laboratory tests, and explain all abnormalities?
Does the report address important or relevant complaints (within the scope of the requested exam) noted in other evidence in the file (e.g., blindness in one eye, amputations)?
Did the CE source properly sign the CE report? For signature requirements, see DI 22510.015C.
Did the CE source submit a copy of any records provided to them directly from the claimant at the examination (see DI 39542.240)?
If any of the required information in DI 22510.020B.2. in this section is missing or incomplete, contact the CE source to:
Explain what is inadequate about the report; and
Request the missing information or a revised and corrected report; and
Document the contact in a Case Note in DCPS and "write to" the CDW.
The DDS may release a copy of the CE report to the claimant's medical source if the claimant provides written consent. Follow procedures in DI 22510.065. For cover letter model language, see NL 00705.753.
The DDS may release a copy of the CE report to the claimant's medical source without the claimant's consent if the CE report discloses new diagnostic information or test results that reveal a potentially life-threatening situation (i.e., an emergency, life or death situation where harm is believed to be imminent). In this situation, consent is not required. Follow procedures in DI 22510.070. For cover letter model language, see NL 00705.753.
If the claimant does not have a medical source and the CE report indicates an emergency, life or death situation where harm is believed to be imminent, advise the claimant in a letter to see a health care provider for evaluation or treatment. If the claimant is unable to pay for such services, inform the claimant of any local agency or medical facility where they can obtain the medical services at limited or no cost. In addition to sending a letter to the claimant, the DDS should also attempt to contact the claimant by telephone to provide this information. For cover letter model language, see DI 22510.070. The DDS should refer to the language in DI 22510.070 when contacting the claimant by telephone.
IMPORTANT: Include a copy of the letter in Section E (Disability Related Development (Blue)) of the disability folder.
There may be situations when the DDS receives a CE report that is unsigned or improperly signed by the CE source but the content of the CE report, along with the other evidence in file, is sufficient for a determination. Follow the procedures below to process these types of cases. These procedures apply to both written and electronic signatures. For more information on signature requirements for CE reports see DI 22510.015C.
If the CE report is unsigned or improperly signed and the determination is not fully favorable:
Do not adjudicate or close the case. The DDS must wait until they receive a properly signed CE report.
Document the attempts to obtain a properly signed report in a Case Note in DCPS and "write to" the CDW.
If a properly signed report cannot be obtained from the CE source who originally performed the CE for any reason, the DDS must reschedule the CE with another qualified CE source (see DI 22510.010).
The DDS includes the unsigned or improperly signed CE report in the disability folder (see DI 81020.070C).
If the CE report is unsigned or improperly signed and the determination is fully favorable:
Document the attempts to obtain a properly signed CE report in a Case Note in DCPS and "write to" the CDW.
Adjudicate and close the case.
The DDS includes the properly signed CE report, obtained post adjudication, in Section F (Medical Records (Yellow Back)) of the disability folder.
If the DDS does not obtain a properly signed CE report after the case has been adjudicated, contact the Regional Office for instructions.
When the claimant has given consent, send a copy of the CE report to the claimant's medical source.
Also, see:
DI 81001.030B.2 for information on when a claimant or representative requests a copy of the CE report.
GN 03340.035D for information on when a parent or legal guardian requests a copy of the CE report for a minor child.
GN 03305.005C4 for restrictions on parental disclosure of a minor child's CE report.
The DDS provides written notice of a CE appointment which includes an explanation that the DDS will send a copy of the CE report to the claimant's medical source when the claimant provides written authorization (see DI 22510.016B). Generally, the DDS includes the Authorization to Release CE Report Form (see NL 00705.745) with the CE Appointment Notice.
The returned Authorization to Release CE Report Form is considered completed when:
It is signed, dated, and received within 90 days of the signature date,
It includes the first and last name of the person or entity to whom the CE report should be released, and
It includes the address of the person or entity to whom the CE report should be released.
IMPORTANT: This form is only used to release a CE report to a claimant's medical source (or entity (i.e., organization) that maintains the medical source's records). If the person or entity listed on the authorization form is a nonmedical source (e.g., third party or educational source), handle as a claimant disclosure in accordance with GN 03305.001.
Follow the steps below when releasing the CE report, with a cover letter, to the claimant's medical source. For cover letter model language, see NL 00705.753.
Release the CE report to the claimant's medical source.
Explain in a cover letter that the report is being sent at the request of the claimant.
Include a copy of the cover letter to the medical source in Section E (Disability Related Development (Blue)) of the disability folder and document the Case Development Worksheet (CDW) in the Disability Case Processing System (DCPS) that a copy of the CE report was sent to the claimant's medical source.
NOTE: Do not delay adjudication when development is required per DI 22510.065C.1 in this section. If the case is ready for adjudication, close it and release the CE report after the authorization is received.
Request a new, fully completed and signed authorization form from the claimant prior to releasing the CE report.
If the claimant returns a fully completed and signed authorization form, include it in Section E (Disability Related Development (Blue)) of the disability folder. Follow the instructions in DI 22510.065C.1 in this section.
NOTE: Do not delay adjudication when development is required per DI 22510.065C.2 in this section. If the case is ready for adjudication, close it and release the CE report after the authorization is received.
Take no further action. However, if the CE report discloses new information that reveals a potentially life-threatening situation, follow the instructions in DI 22510.020A.4, DI 22510.070 and GN 03316.135.