Effective Dates: 12/30/2024 - Present

Identification Number:
DI 22510 TN 51
Intended Audience:See Transmittal Sheet
Originating Office:ORDP ODP
Title:Development of Consultative Examinations (CE)
Type:POMS Full Transmittals
Program:All Programs
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM

Part DI – Disability Insurance

Chapter 225 – Case Development Procedures

Subchapter 10 – Development of Consultative Examinations (CE)

Transmittal No. 51, 12/30/2024

Audience

PSC: DE, DEC;
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

The Office of Disability Policy updated this section to be consistent with DI 26535.042, a new section that provides definitions of individuals and entities with whom we correspond and send notices and outlines who must receive correspondence when multiple parties authorized to act on behalf of a claimant or are designated to assist a claimant.

Summary of Changes

DI 22510.016 Claimant Consultative Examination (CE) Notice and Confirmation Procedures

We updated this section as follows:

  • •

    Removed references to the applicant;

  • •

    Simplified instructions for who we will contact by referencing DI 23007.005;

  • •

    Clarified that DDS must make a reasonable effort to involve a third party prior to discontinuing attempts to develop evidence that requires a claimant's cooperation;

  • •

    Added a reference to DI 26535.042, Recipients of Correspondence and Notices – Initial Claims, for whom to send the written notice of CE,

  • •

    Clarified who may confirm a CE;

  • •

    Clarified the time we allow to confirm a scheduled CE as 10 calendar days from the date of the initial written notice before making a reasonable effort to confirm the CE;

  • •

    Clarified where to document a conversation in DCPS;

  • •

    Streamlined and clarified what the DDS may say when contacting the claimant or one of their contacts by telephone, and when leaving a voicemail message;

  • •

    Added instructions to verity the claimant's or their contact's identity during telephone contact;

  • •

    Added instructions to also send a letter when the DDS leaves a voicemail message for the claimant or one of their contacts;

  • •

    Changed alternatively scheduled CE to short notice CE and explained what they are; and

  • •

    Clarified procedures for scheduling certain unusual types of CEs.

 

DI 22510.016 Claimant Consultative Examination (CE) Notice and Confirmation Procedures

CITATIONS:

20 CFR 404.1516 through 404.1519t and 416.916 through 416.919t

A. When to schedule a CE appointment

When a CE is needed and the claimant has cooperated with other requests for evidence or action (e.g., forms completion, etc.), schedule the CE. The Disability Determination Services (DDS) is not required to obtain the claimant's agreement before scheduling an in-person CE.

When the claimant did not cooperate with the initial request or the follow up request for evidence or action, do not schedule the CE. However, for cases requiring special handing, when a CE is needed and the claimant has not cooperated with the follow up request for evidence or action, the DDS must make a reasonable effort to involve a third party prior to discontinuing attempts to develop evidence (including a CE) that requires the claimant's cooperation.

For more information on:

B. Written notice of CE appointment to the claimant

Send the written notice of the CE appointment to the applicable individuals in accordance with DI 26535.042C. For the CE appointment notice, see NL 00705.745.

The CE appointment notice to the claimant must include the following:

  • •

    Why the CE (and additional tests, if applicable) is needed,

  • •

    An explanation that the Social Security Administration will pay for the CE and may also reimburse some travel expenses if the claimant qualifies,

  • •

    An explanation on payment of travel expenses, if applicable (see DI 39525.005),

  • •

    The name, address, and telephone number of the CE provider,

  • •

    The date, time, and type of CE appointment,

  • •

    A reminder to bring a current, valid government-issued identification (ID), preferably a photo ID,

  • •

    A reminder to bring all medications in their original containers and any other medical aids (e.g., hearing aids, eyeglasses, contact lenses, assistive device, etc.),

  • •

    The requirement to confirm CE attendance and to respond immediately if the claimant cannot attend the CE appointment for any reason,

  • •

    A request to notify DDS when an interpreter is needed (see DI 23040.001),

  • •

    An explanation that DDS will send a copy of the CE report to the claimant's medical source when the claimant provides written authorization,

  • •

    The following due process language, "If you fail to keep an appointment without notifying us, we may make a decision based on the evidence we already have in file. We may find that you are not eligible, or no longer eligible, for disability benefits,"

  • •

    The DDS contact information for questions, appointment confirmation and rescheduling, and feedback after the appointment, and

  • •

    SSA Publication No. 05-10087 A Special Examination Is Needed for Your Disability Claim.

NOTE: DDS may exclude the CE provider telephone number if the CE provider refuses to share their telephone number with the claimant.

C. Who may confirm a CE appointment

The claimant (or their legal guardian), the appointed representative (AR), or a third party (for claims requiring special handling, as defined in DI 23007.001C) may confirm or refuse the CE appointment, or request to reschedule the CE if a good reason exists.

For more information on:

  • •

    The applicable individual(s) to contact to confirm a CE, see DI 23007.005.

  • •

    Examples of a good reason for non-cooperation, see DI 23007.001B.

D. Confirming the CE appointment

How DDS confirms the CE appointment depends on whether the CE appointment is more than 10 days or less than 10 days from the date of the written notice.

1. The CE appointment is more than 10 days from the written notice

When the CE is not confirmed within 10 calendar days from the date of the initial written notice, make a reasonable effort to confirm that the claimant will attend the CE appointment. When DDS does not make a reasonable effort to confirm, and the claimant fails to attend the CE appointment, DDS must make a reasonable effort to find out why the claimant missed it. When the applicable individual(s) as discussed in DI 22510.016C in this section provides a good reason for missing the CE appointment, reschedule the CE.

a. Attendance is confirmed

When the CE is confirmed within 10 calendar days from the date of the initial written notice, document the confirmation on an SSA-5002 (Report of Contact) or on a Case Note in the Disability Case Processing System (DCPS), and "write to" the case development worksheet (CDW). For details on how to document when a claimant confirms a CE, see DI 22510.019B.

NOTE: When the claimant confirms the CE appointment in writing, add the confirmation to the folder. There is no need to document elsewhere.

b. Attendance is not confirmed

When the CE is not confirmed within 10 calendar days from the date of the initial written notice, DDS must make one attempt to confirm by telephone contact to ask for confirmation. For claims requiring special handling, you must also attempt one telephone contact to identify and involve a third party. When you are unable to speak to the applicable individual(s) as discussed in DI 22510.016C in this section, and you cannot leave a message, send a call in letter.

For additional details on what to do when the required contact does not confirm a CE, see DI 22510.019D.

NOTE: When the claimant or AR does not respond to your telephone contact or call-in letter to confirm attendance, cancel the CE appointment unless the claim requires special handling. When the claim requires special handling, cancel the CE appointment only when the claimant and third party (when you are able to identify and involve a third party) does not respond to your telephone contact or call-in letter to confirm attendance.

IMPORTANT: If someone other than the claimant or one of the required contacts answers the phone, or if you leave a voicemail message, leave only enough information so they know to return the call. Do not disclose any unnecessary personal information about the claimant or their disability claim.

1. You speak to one of the required contacts

When you speak to one of the required contacts (see DI 23007.005), do the following:

  • •

    Verify the claimant or third party's identity prior to discussing any details of the case (see DI 39567.210 and GN 00203.020),

  • •

    Confirm the claimant will attend the CE, or reschedule the CE when there is a request to do so and a good reason is provided, and

  • •

    Provide a reminder that failure to attend the CE appointment may result in you making a determination based on the evidence in file, which means that you may find the claimant not disabled.

Document the date, content of your conversation, and with whom you spoke, on an SSA-5002 or in a Case Note in DCPS, and "write to" the CDW.

2. You leave a message

You may leave a message on the voicemail recording system of a telephone number in the claim file that is attributable to the contact. You must also send the contact a call-in letter following the instructions in DI 22510.016D.1.b.3. in this section

Include only the following information:

  • •

    Your name, title, telephone number and date that you called,

  • •

    A request that the contact return the call within 10 calendar days from the date of the message.

Document the date, content of your message, and with whom you left it, on an SSA-5002 or in a Case Note in DCPS, and "write to" the CDW.

3. You send a call-in letter

Include the following information:

  • •

    Your name, title, telephone number and date of the letter,

  • •

    The date, time, and location of the CE appointment,

  • •

    A request that the contact call you to confirm the CE appointment within 10 calendar days from the date of the letter, and

  • •

    A reminder that failure to confirm the CE appointment will cause you to cancel it and may result in you making a determination based on the evidence in file, which means that you may find the claimant not disabled.

For the Claimant CE Confirmation Call In Letter, see NL 00705.747.

For the Third Party CE Confirmation Call In Letter, see NL 00705.748.

2. The CE appointment is 10 days or less of the written notice (i.e., short notice CE)

By short notice CE, we mean the CE appointment is scheduled 10 days or less from date of the written notice. Short notice CE scheduling is recommended only when you have difficulty locating the claimant after the passage of time (e.g., a homeless claimant). Do not reschedule the CE using a short notice appointment unless the claimant or one of their contacts requests it. 

a. The claim does not require special handling

Take the following actions:

  • •

    Contact the claimant by telephone to notify them of the short notice CE and to confirm their attendance. Follow the procedures in DI 22510.016D.1.b.1. in this section for confirming the CE appointment.

  • •

    Reschedule a short notice CE if the claimant:

    • –

      Asks prior to the scheduled appointment, or

    • –

      Provides a good reason to have missed the CE.

Document the date, the content of your conversation(s), and with whom you spoke, on an SSA-5002 or in a Case Note in DCPS, and "write to" the CDW.

b. The claim requires special handling

Take the following actions:

  • •

    Contact the claimant by telephone to notify and confirm the CE appointment, following the procedures in DI 22510.016D.1.b.1. in this section;

  • •

    Reschedule the CE if the claimant asks prior to the scheduled appointment.

If the claimant misses a short notice CE appointment.

  • •

    Call or send a letter to the claimant and third party asking them to call you within 10 calendar days;

  • •

    Reschedule the CE if the claimant or third party calls and provides a good reason for failing to attend the CE. Discuss how to ensure the claimant will attend the rescheduled CE;

  • •

    If the claimant or third party fails to call you within 10 calendar days from the date of the letter, stop attempts to get the claimant to attend a CE.

Document the date, content of your conversation(s), and with whom you spoke, on an SSA-5002 or in a Case Note in DCPS, and "write to"  the CDW.

E. The claimant fails to attend the CE appointment

Document the missed CE or the reason the claimant will not attend the CE on an SSA-5002 or on a Case Note in DCPS, and "write to" the CDW. When the DDS has a missed CE notice, include a copy of that notice in the folder.

1. The claim does not require special handling

When DDS confirms or attempted to confirm the CE in accordance with DI 22510.016D in this section, and the claimant fails to attend the CE, do not reschedule the CE unless:

  • •

    The claimant (or their legal guardian) or AR calls prior to case finalization, and

  • •

    Provides a good reason.

When the above does not occur, do not reschedule the CE and stop attempts to get the claimant to attend the CE.

When you did not attempt to confirm the claimant attendance at the CE appointment in accordance with DI 22510.016D in this section:

  • •

    Contact the claimant (or their legal guardian) or AR by telephone to ask why the claimant failed to attend the CE appointment (see DI 23007.005).

  • •

    Reschedule the CE when the claimant has a good reason for failing to attend the CE. Otherwise, do not reschedule the CE and stop attempts to get the claimant to attend the CE.

2. The claim requires special handling

When the claim requires special handling, make a reasonable effort to identify and involve a third party. After you have done so, only reschedule the CE when the claimant or third party calls you prior to case finalization and provides a good reason for the claimant missing or refusing to attend the CE. If this does not occur, do not reschedule the CE and stop attempts to get the claimant to attend the CE.

For more information on:

  • •

    Claims that require special handling, see DI 23007.001A.

  • •

    How to make a reasonable effort to identify and involve a third party, see DI 23007.010.

Document the date, content of the conversation, and with whom you spoke, on an SSA-5002 or on a Case Note in DCPS, and "write to" the CDW.

F. Unusual CE appointment scheduling procedures

These procedures apply to situations when it is difficult to schedule a CE due to unusual circumstances.

When using these procedures, document attempts to schedule a CE appointment on an SSA-5002 or on a Case Note in DCPS, and "write to" the CDW.

1. The claimant is incarcerated

Determine if one of the following scheduling options are available:

  • •

    The facility's staff medical source (or an outside CE source selected by DDS) can perform the CE at the facility, or

  • •

    The facility will permit the claimant to attend the CE at an outside facility selected by DDS.

Try to accommodate the facility’s preferred date, time, and conditions. When DDS cannot schedule a CE using these procedures, stop attempts to get the claimant to attend a CE.

2. There is no CE in the claimant's immediate area

Schedule the CE appointment at the most convenient location for the claimant.

For information on:

3. The claimant alleges an inability to travel due to health risk

When possible, contact the claimant’s medical source by telephone to determine whether the claimant can travel to a CE. When the medical source advises against it, or the claimant will not agree to attend the CE due to the alleged health risk, when possible:

  • •

    Schedule an in-person CE at the claimant’s residence, or

  • •

    Schedule a THCE if permitted.

However, if the claimant does not have a medical source, the medical source opines that the CE presents no health risk, or the medical source does not respond, and the claimant will not agree to attend an in-person or a THCE (or the type of CE needed is not permitted via telehealth), do the following:

  • •

    Explain that failure to attend the CE might result in a finding of not disabled, and

  • •

    Stop your attempts to get the claimant to attend a CE (see DI 22510.016G in this section).

Document your efforts on an SSA-5002 or on a Case Note in DCPS, and "write to" the CDW.

4. The claimant or AR requests the AR to attend the CE

When the claimant or AR requests that the AR accompany the claimant to the CE, advise the AR to make the request directly to the CE source. Also, advise the AR that the CE source’s decision is controlling.

5. The claimant requests an accommodation(s)

For information on accommodation requests, see GN 00211.001.

G. The effect of stopping attempts to get a claimant to attend the CE

When DDS makes all efforts to notify the required contacts and confirm the CE in accordance with DI 22510.016A through DI 22510.016E in this section, but the claimant fails to attend the CE, DDS may stop attempts to get the claimant to cooperate. DDS is not required to pursue additional evidence that requires the claimant’s cooperation.

EXCEPTION: This does not apply to claimants who are in situations described in DI 22510.016F in this section. In those instances, you must still pursue all other evidence that requires the claimant’s cooperation.

However, DDS still must ensure that every reasonable effort is made to develop a complete medical history without the claimant’s cooperation in accordance with DI 22505.001A.2 before making a determination based on the evidence in file using the sequential evaluation process.

For more information on:

  • •

    Actions to take before making a determination based on the evidence in the file, see DI 23007.015B.

  • •

    Using the sequential evaluation process to make a determination based on evidence in file, see DI 23007.015C.

  • •

    The appropriate regulation basis code and personalized disability explanation, see DI 23007.015D.


DI 22510 TN 51 - Development of Consultative Examinations (CE) - 12/30/2024