Effective Dates: 10/24/2023 - Present

Identification Number:
DI 23060 TN 7
Intended Audience:See Transmittal Sheet
Originating Office:ORDP ODP
Title:Evidence from Excluded Medical Sources of Evidence
Type:POMS Full Transmittals
Program:All Programs
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM

Part DI – Disability Insurance

Chapter 230 – Special Issues

Subchapter 60 – Evidence from Excluded Medical Sources of Evidence

Transmittal No. 7, 10/24/2023

Audience

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

Originating Component

ODP

Effective Date

Upon Receipt

Background

We revised our POMS for identifying excluded medical sources of evidence. This transmittal includes additional information and instructions regarding initial notification of excluded status for medical sources, follow-up notification of excluded status for medical sources, and eView and DCPS processing instructions for excluded medical sources.

Summary of Changes

DI 23060.020 Identifying Excluded Medical Sources of Evidence

Subsection A: New , we added Initial notification of excluded status for medical sources) that gives instructions and discusses the notification we provide when a medical source of evidence is initially excluded and placed on the Department of Health and Human Services' (HHS) Office of Inspector General’s (OIG) List of Excluded Individuals and Entities (LEIE).

We relocated the initial notification (also known as a fact sheet) we send to the excluded providers to the beginning of the section because it relates to the new subsection A.

We reorganized the instructions for the follow-up notification we give providers who do not self-identify as excluded medical sources of evidence after being initially notified by us of their excluded status, and have embedded a follow-up notice to be sent to these providers.

We added eView and DCPS processing instructions for excluded medical sources, including information discussing the Excluded Source badge, flag, and document type. We made these changes to be responsive to feedback we received.

We updated relevant citations, links, and webpages to reflect accurate information and references.

DI 23060.020 Identifying Excluded Medical Sources of Evidence

CITATIONS:

42 U.S.C. 423(d)(5)(C), 1382c(a)(3)(H)(i); 20 CFR 404.1503b and 416.903b

A. Initial notification of excluded status for medical sources

When a medical source of evidence is initially excluded and placed on the Department of Health and Human Services' (HHS) Office of Inspector General’s (OIG) List of Excluded Individuals and Entities (LEIE), the Social Security Administration's (SSA) Office of Disability Policy (ODP) sends an initial notice (also known as a fact sheet) by mail to inform the medical source that they are now an excluded medical source of evidence. The notice informs the medical source of their excluded status and explains the procedures they must follow to self-identify as an excluded medical source of information. See the link to the notice here.

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B. Excluded medical sources of evidence must provide a written statement of exclusion

Excluded medical sources of evidence must provide a written statement of exclusion each time they furnish medical evidence to us directly or indirectly through an appointed representative, claimant, or other individual or entity.

Adjudicators have no duty to proactively research and identify whether a source of medical evidence is an excluded medical source of evidence on their own. However, if an excluded source has not provided a written statement of exclusion, and an adjudicator receives clear documentation that a source is an excluded medical source of evidence, the adjudicator:

  • •

    must exclude the source’s evidence (unless there is sufficient information to apply a good cause exception(s) based on DI 23060.030B); and

  • •

    must refer the source to SSA’s OIG. See how to refer an excluded medical source of evidence to SSA’s OIG, in DI 23060.040.

An example of clear documentation is an email from an administrator or professional relations officer to staff stating that John Doe, M.D. is an excluded medical source of evidence because John was convicted of a felony under section 208 of the Social Security Act (Act) on November 2, 2016.

Another example of clear documentation that a source is an excluded medical source of evidence is the existence of a badge for the medical source in the Disability Case Processing System (DCPS) vendor repository (DVR). DCPS includes the "Excluded Source" badge for the excluded medical source after the source's status is verified.

C. Contents and placement of the written statement of exclusion

1. Contents of the written statement of exclusion

All written statements of exclusion must include the following:

  1. a. 

    The heading, “WRITTEN STATEMENT REGARDING SECTION 223(d)(5)(C) OF THE SOCIAL SECURITY ACT – DO NOT REMOVE;”

  2. b. 

    The name and title of the excluded medical source of evidence; and

  3. c. 

    The reason we cannot consider the evidence furnished by the excluded medical source of evidence – i.e., that the medical source was:

    • •

      Convicted of a felony under section 208 or 1632 of the Act;

    • •

      Excluded from participating in any Federal health care program under section 1128 of the Act; or

    • •

      Imposed with a civil monetary penalty (CMP), assessment, or both, for submitting false evidence under section 1129 of the Act.

As applicable, all written statements of exclusion must also include:

  • •

    The date of the felony conviction under section 208 or 1632 of the Act;

  • •

    The reason, effective date, and expected length of exclusion under section 1128 of the Act, and whether HHS’ OIG waived the exclusion; and

  • •

    The date of the CMP, assessment, or both, for submitting false evidence under section 1129 of the Act.

2. Placement of the written statement of exclusion

Excluded medical sources of evidence should place the written statement of exclusion after the barcode page, but before the first page of evidence.

If a written statement of exclusion is placed somewhere else in the evidence, adjudicators will not move it. Evidence from an excluded source should not be reorganized into multiple documents as explained in DI 70005.005 and DI 81001.005.

D. Unclear or incomplete written statements of exclusion

If a written statement of exclusion does not include information that allows an adjudicator to determine whether a good cause exception(s) may apply, the adjudicator should contact the excluded medical source of evidence for clarification or additional information.

For a list of the five good cause exceptions, see DI 23060.030B and

for instructions on developing supplemental evidence, see DI 22505.008.

E. Annotating case folders at the initial and reconsideration level of adjudication

1. Certified electronic folders

Adjudicators need to perform the following actions in eView:

  • •

    Add the "Excluded Medical Source of Evidence" flag through eView. See how to add a flag in DI 81020.085B; and

  • •

    Change the document type of the affected evidence to document type number 0028 "Excluded Medical Source of Evidence." For more information on document types, see DI 81020.040.

Adjudicators do not need to add an annotation in DCPS because DCPS indicates when there is evidence from an excluded medical source in a claim in two ways:

  • •

    DCPS adds the "Excluded Source" badge.

  • •

    DCPS adds the "Excluded Source" case flag.

2. Paper case folders

For paper cases:

  • •

    Print out the “Excluded Medical Source of Evidence” flag ;

  • •

    Fill in the requested information;

  • •

    Identify the evidence furnished by the excluded medical source of evidence and explain the evaluation of it in the Remarks section; and

  • •

    Attach the completed flag to the front of the paper case folder.

NOTE: When an excluded medical source of evidence does not provide the required written statement of exclusion, the Office of Hearing Operations (OHO) staff should follow the instructions in Hearings, Appeals, and Litigation Law (HALLEX) manual I-2-5-15 F, and Office of Appellate Operations (OAO) staff should follow the instructions in HALLEX I-3-2-36 F

F. Refer questions about excluded medical sources of evidence to SSA’s public website or national 800 number network

SSA cannot answer questions about why, how, or when a medical source was:

  • •

    Convicted of a felony under section 208 or 1632 of the Act;

  • •

    Excluded by HHS’ OIG from participating in any Federal health care program under section 1128 of the Act; or

  • •

    Imposed with a CMP, assessment, or both, for submitting false evidence under section 1129 of the Act.

For additional information, refer to our public webpage at https://www.ssa.gov/applyfordisability/ and click on the link: Information on Excluding Certain Medical Sources' Evidence . You may also call us at 1-800-772-1213 (TTY 1-800-325-0778).

G. Follow-up notice if an excluded medical source does not provide required written statement of exclusion

When an SSA excluded medical source of evidence furnishes evidence to us but does not provide the required written statement of exclusion, the following components will mail a follow-up notice to the medical source. Depending on the adjudicative level of the claim, staff at ODD, OHO, or OAO is responsible for mailing this notice. The component responsible for mailing the notice must:

  • •

    Retain a copy of the follow-up notice and a record indicating the date of any violation (any evidence dated after the date of exclusion listed in the LEIE) of 20 CFR 404.1503b(c) and 416.903b(c); and

  • •

    Email a copy of the notice to ^ODP BBA 812.

See the link to the follow-up notice here.

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If a medical provider identified as an excluded source of medical evidence continues to submit evidence without self-identifying, refer the excluded provider to SSA's OIG for investigation and possible penalty by completing a referral through the Allegation Referral Intake System (ARIS). For instructions on referring non-compliant excluded medical sources of evidence to SSA’s OIG, see DI 23060.040.

 

DI 23060 TN 7 - Evidence from Excluded Medical Sources of Evidence - 10/24/2023