SSA - POMS: DI 11010.545 - Payment for Medical Evidence of Record (MER)

A. Background

In title II disability cases, the DDS will pay a reasonable fee, in accordance with its established payment rates, for MER requested by us (e.g., SSA or the DDS) from a non-Federal source if a fee is charged. The DDS will not pay for the examinations or tests upon which the MER is based. The DDS also has the authority to pay for unsolicited MER when, in its judgment, the evidence is needed to adjudicate a claim.

In DDS jurisdiction claims involving special medical evidence arrangement situations, where the FO asks a claimant to take a request for a medical report directly to a non-Federal source, tell the claimant to inform the source that we will pay a reasonable fee for the existing record if a fee is charged. Where medical evidence is developed with a non-Federal special arrangement source, inform the source that SSA will pay a reasonable fee for the medical evidence of record when a fee is charged. Tell the source that if a fee is charged, he or she should submit an invoice that shows the claimant's name and SSN with the medical report. If you receive the evidence and/or invoice, forward both the evidence and invoice to the DDS for disposition.

B. Procedure - payment for foreign medical evidence of record

When appropriate, tell disabled claimants living in Canada, Mexico, and other foreign countries, and foreign medical sources from whom reports are requested, that SSA will pay a reasonable fee for medical reports obtained from a source other than the United States Government for Title II disability claims if a fee is charged. Usually, OCO/OIO or the Department of State Foreign Service Post will request the medical reports through the claimant. The border district offices, however, may also request medical reports for disabled claimants residing in Canada or Mexico.

NOTE: If DDS requests medical evidence from a foreign source for a claimant residing in the U.S., the DDS will be responsible for paying the source.

C. Procedure – payment for medical evidence of record requested by the FO — special situations

Usually, the DDS has the principal role in requesting medical evidence of record. The FO becomes involved in the process when it is necessary to obtain medical evidence through the claimant or from a special arrangement source. The FO also has the responsibility for obtaining medical evidence upon request in certain non-State claim situations. For example, disability claims with RR involvement, Medicare claims based on ESRD in which a decision of title II disability before age 22 is required to establish parental dependency for ESRD Medicare insured status, and in foreign claims where the border FOs are frequently asked to obtain medical evidence for claimants living in Canada or Mexico.

Where the FO obtains medical evidence from a special arrangement source in a State case, the evidence and the invoice for payment are both sent to the appropriate DDS for action. The DDS has knowledge that the medical evidence requested has been received and is able to justify payment. In each of the above non-State situations, the FO associates the evidence with the claims folder and sends the claim to the designated component for development. The invoice, however, is sent to the Division of Finance for payment. Since the Division of Finance does not receive either the case folder or the medical evidence, it is necessary to provide adequate documentation that will justify payment. The following instructions provide the documentation required for each invoice to permit the Division of Finance to make payment.

D. Procedure - payment procedures

1. Requesting MER in Non-State Claims

Advise the medical source that if a fee is charged for the cost of preparing the medical report, SSA will pay a reasonable fee in accordance with established payment rates. Tell the source to submit an invoice with the medical report and to enter the claimant's name and SSN on the invoice. If an invoice is not submitted with the report, assume that no fee is charged for preparing the report. If a medical source sends an invoice for payment at a later date, consult the systems records for identifying information and forward the invoice to the Division of Administrative Payment Services (DAPS). (See DI 11010.545D.4. for the complete address.)

NOTE: When requesting MER from a medical source, follow the DDS practices of the State in which you are located. Ascertain the reasonable amount that SSA is authorized to pay from the DDS current fee scale. Border FOs requesting MER from Canadian and Mexican sources will also use the fee schedule appropriate for the State in which the border FO is located.

Where a medical source is located across State lines, the FO should contact the DDS in the State in which the source is located for fee schedule amounts.

If a charge from a medical source exceeds the amount designated in the DDS fee schedule, include a brief note to the Division of Finance with the invoice indicating the reasonable amount SSA is authorized to pay.

2. Documentation

The Division of Finance will pay any properly authorized and certified invoice for medical evidence requested by any SSA or other government employee with procurement authority. Three conditions must be met to support each payment; i.e., regulations stipulate that each request for payment must include an authorizing document, an invoice, and a receiving report. An authorizing document and receiving report must accompany each invoice when submitted to the Division of Finance for payment.

a. Authorization

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An authorizing document is evidence of the delegated authority to procure goods or services. The letter requesting medical evidence from the source (physician, hospital, etc.) may serve as the authorizing document. The request to the medical source must be signed by an individual with procurement authority, such as the FO manager.
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Send an authorizing document with the voucher or the invoice. Keep a copy of the letter to attach to the voucher/invoice.
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Send the letters requesting medical records under the signature of the FO manager.
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Guide language for an authorizing document is provided in this section. See DI 11010.545D.2.c.

b. Voucher/Invoice

At the very minimum each invoice must show:

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The complete name and mailing address of the medical source (or claimant if he/she has paid the medical source and is requesting reimbursement) to which the payment should be sent;
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The name and SSN of the claimant, or claimants, as appropriate;
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The amount of the charge; and
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The employer identification number (EIN) of the medical source if an incorporated organization, or the payee Social Security number (SSN) for an unincorporated medical source. The Office of Finance needs this information to prepare reports to the Internal Revenue Service.

c. Certification Statement

Every SSA or other government employee who receives medical evidence of record (MER), must place the following statement on the invoice:

"I certify that this medical evidence was received by me."

The SSA or other government employee must sign and date the invoice below the statement. The FO or other SSA employee should also place the common accounting number (CAN) and subobject class code (SOC) of the component requesting the MER on the invoice sent to the Office of Finance, DCFAM. (See Common Accounting Numbers (CAN) and Object Classification Codes Handbook.) If the component requesting the MER is:

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The Office of International Operations, (foreign claims), enter -- CAN 4005113-SOC 2533
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The Great Lakes Program Service Center, (railroad claims), enter -- CAN 4005518-SOC 2528
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The Office of Disability Operations, (end-stage renal disease claims), no CAN or SOC is necessary. Invoices for these claims will be sent directly to the Division of Accounting of the Health Care Financing Administration. (See DI 11010.545D.4.)

If you cannot send the original invoice to the Office of Finance for payment, include the following additional signed statements on either a photocopy of the invoice or on any copy except the original: "This invoice is being certified in lieu of the original copy. No other invoice will be submitted."

3. Letter to Medical Source to Obtain MER

When requesting MER from a medical source, the FO may use the guide language in the model letter. The letter provides the essential information that we should furnish when requesting a medical source to send us its records. The language may be adapted to fit the situation and direct the source to provide the specific information we need.

Social Security Adminisrtration

(Field Office Address)

Refer to:

Phone:

Date

(Name and address of medical source)

Dear ____________:

Re: (Enter claimant's name, SSN and address)

We are writing to obtain medical evidence on behalf of _____________ who has applied for benefits based on disability/blindness under the Social Security Act. The claimant has asked us to request the evidence because we are responsible for determining whether the claimant is disabled or blind.

To make such a determination, we need medical evidence that will enable us to make an independent determination as to the nature, severity, and duration of the claimant's impairment(s). Thus, we are seeking evidence of sufficient detail that will include medical history, clinical and laboratory findings, clinical course, therapy and response to treatment, diagnosis, and prognosis. We request that you furnish us either a report of such evidence, or if such evidence is unavailable, a statement to that effect. The original authorization signed by the claimant is enclosed. We are also enclosing a report form for your convenience, although a narrative report on your stationery or copies of your records are perfectly acceptable. If available, please also include copies or summaries of pertinent hospital or consultative reports.¹

[1] [FOR ADULTS] We would also like to have a statement, based on your medical findings, expressing your opinion about the claimant's ability, despite the functional limitations imposed by the impairment(s), to do work-related (insert A, B, or both, as appropriate). ²

(2) [FOR CHILDREN] We would also like to have a statement, based on your medical findings, expressing your opinion about the child's functional limitations in learning, motor functioning, performing self-care activities, communicating, socializing, and completing tasks (and, if the child is a newborn or young infant from birth to age 1, responsiveness to stimuli)².

We are authorized to pay up to _________ for a report of the evidence requested and you may include an invoice with the report.³ If you are requesting payment for the evidence, the invoice must include the following information:

a.

The claimant's name and Social Security number;
b.

Your employer identification number if you are incorporated; or
c.

Your Social Security Number if you are unincorporated.

Payment cannot be made without this information. A preaddressed, stamped envelope is enclosed for your reply. If you have any questions, please call this office.

Your prompt response will help ensure a speedy decision on this claim. Thank you for your cooperation.

Sincerely,

Field Office Manager

Enclosures

Insert A - physical activities such as sitting, standing, walking, lifting, carrying, handling objects, hearing, speaking, and traveling.

Insert B - mental activities such as understanding and memory; sustained concentration and persistence; social interaction; and adaptation.

____________________________

¹Omit this sentence if the request is to a hospital.

²Omit this sentence in statutory blindness claims.

³Omit this sentence if the request is to a Federal source.

4. Routing MER Invoices

Field offices should send all invoices received for MER in non-State railroad and foreign claims to the address below:

SSA
DAPS Attn: Tony Dolgoff
P.O. Box 47
Baltimore, MD 21235

Send all invoices received for MER in non-State ESRD cases to:

Health Care Financing Administration
Division of Accounting
P.O. Box 7520
Baltimore, MD 21207-0520

SSA offices are requested to call the Division of Finance on DAPS Inquiries Line (410) 965–0607 for instructions in any situation in railroad and foreign claims cases not covered by these payment procedures.

Social Security

Program Operations Manual System (POMS)

DI 11010.545 Payment for Medical Evidence of Record (MER)