Effective Dates: 10/08/2021 - Present Previous | Next

TN 12 (10-21)

DI 20503.001 Documenting the Disability Folder – Disability Determination Services (DDS)

A. Policy on material in disability folders

All disability folders (e.g., electronic, modular, and two-part brown) must contain material that documents the development steps and is:

  • •

    Essential to the disability determination; and

  • •

    Required for continuing disability reviews (CDRs).

NOTE: The claimant’s file is a legal document and must reflect an objective assessment. Avoid subjective comments that may be interpreted as bias.

B. What is essential material and relevant evidence

1. Definition of essential material

Essential material is necessary to make the disability determination and applies to certified electronic folders (CEFs), modular disability folders (MDFs), and brown, non-MDF folders used prior to the inception of the MDF.

Essential material includes, but not limited to:

  • •

    The case development summary worksheet (see DI 20503.001E in this section) or any other documentation describing the development steps completed;

  • •

    All unproductive requests (discard consultative examination (CE) notices to the medical source, regardless of whether the claimant kept the appointment).

Also, see:

  • •

    DI 81020.065 Electronic Case Documentation

  • •

    DI 81020.230 Documenting and Copying Comparison Point Decision (CPD) Relevant Evidence and Preparing the Electronic Continuing Disability Review (eCDR) Rationale

2. Definition of relevant evidence

Relevant evidence is a type of essential material that is relevant to the issues in the case, including, but not limited to:

  • •

    Establishing a medically determinable impairment (see DI 24501.020);

  • •

    Assessing severity (see DI 24505.001);

  • •

    Determining duration (see DI 25505.000);

  • •

    Establishing the onset date of disability (see DI 25505.000);

  • •

    Documenting fraud or similar fault (see DI 23025.000).

NOTE: A prior folder(s) may include evidence that is relevant to a new claim (e.g., IQ tests, x-rays, pathology findings, cardiac tests, operative reports, etc.). The disability examiner (DE) must review all available prior folders, determine which evidence is relevant, and include the relevant evidence in the new claim (see DI 20505.010). For more information on determining which evidence is relevant or irrelevant, see DI 20503.001D.4. in this section.

C. Procedures for handling essential material

Disability examiners (DEs) must adhere to the following guidelines for handling essential material in CEFs and MDFs, including prior folder evidence (see DI 81020.030):

  • •

    Organize material in chronological order by date received at each level of the process, unless otherwise noted. For information on procedures for filing in MDFs, see DI 70005.005. For information on copying documents from prior folders in CEFs, see DI 81005.052C;

  • •

    Include the SSA-887 (Summary of Evidence) or an equivalent form based on your local business process for pre-hearing (PH) level or disability hearing unit (DHU) claims;

  • •

    Retain the SSA-448 (Request for Medical Advice), the SSA-416 (Medical Evaluation), or local equivalent form(s) in the folder. These forms document communication between the DE, medical consultant, psychological consultant, and medical advisor, and they are essential to making the disability determination.

Also, see:

  • •

    DI 81020.035 Document Management Architecture (DMA) Barcodes and Document Indexing

  • •

    DI 81020.130 Electronic Case Closure

D. What is nonessential material and irrelevant evidence

1. Definition of nonessential material

Nonessential material does not serve to document the disability determination, is of no value for future reviews, and should be discarded. This definition applies to material in:

  • •

    CEFs;

  • •

    MDF; and

  • •

    Brown non-MDF folders (used prior to the inception of the MDF).

NOTE: If in doubt as to whether evidence is essential or nonessential, the disability adjudicator must keep the evidence in file.

2. What includes nonessential material

Nonessential material includes, but not limited to:

  • •

    Duplicate medical evidence (see DI 20503.003);

  • •

    Internal DDS routing and case management slips;

  • •

    Blank form(s) included with letters to claimants, medical sources, third parties, etc. if identified in the list of notice enclosures (e.g., “Enclosure: SSA-3369-BK (Work History Report), SSA-3380-BK (Function Report Adult Third Party),” etc.); and

  • •

    Irrelevant evidence (see DI 20503.001D.3. in this section)

Also, see:

DI 70005.005 General Overview of the Paper Modular Disability Folder (MDF)

3. Definition of irrelevant evidence

Irrelevant evidence is material that does not meet the definition of relevant evidence as described in DI 20503.001B.2. in this section.

4. Who determines what evidence is irrelevant

Only the DE making the determination on a case may decide which evidence is relevant or irrelevant. The DE cannot delegate this decision to anyone who is not making a determination on the case. Once the DE decides what evidence is irrelevant, any staff may carry out the handling and retention procedures.

NOTE: When the hearing office initiates an assistance request to the DDS, the DDS DE does not determine the relevancy of the evidence.

5. What to do when an electronic document contains both relevant and irrelevant evidence

When an electronic document contains both relevant and irrelevant evidence, adjudicators must:

  • •

    Create a new document for the relevant evidence by following the instructions in DI 81020.065E.3.; and

  • •

    Annotate on the case development summary worksheet the new document containing only relevant evidence; annotate the original document from which the relevant evidence was extracted and briefly describe the materials not retained in the folder, including the type of material and the reason for discarding it.

  • •

    Move the original document containing both relevant and irrelevant evidence into the green section (Current Development/Temporary) of the CEF. All material in the green section of the CEF will automatically be discarded after all quality reviews applicable to the current level of adjudication are completed.

NOTE: Page-level manipulation is dependent on the DDS’s jurisdictional control of the document.

6. What to do with nonessential material

After all quality reviews related to the current level of adjudication are complete, DE’s must:

  • •

    Discard nonessential material in a manner that prevents unauthorized disclosure according to the instructions in DI 81020.055. For information on disposal of paper records in MDFs, see DI 39567.220B;

  • •

    Include a brief description of material not retained in file, including the type of material and the reason for discarding (e.g., duplicate medical evidence received from the same source);

  • •

    Retain any irrelevant evidence received as part of an informal remand unless a wholly favorable determination is effectuated.

7. Discarding nonessential material from the CEF

Move the material to the green (Current Development/Temporary) section of the CEF. All material in the green section of the folder is automatically discarded after all quality reviews are complete.

NOTE: Do not delete nonessential material from a CEF (e.g. using the computer’s delete button) at any time.

8. Discarding nonessential material from the paper MDF

When discarding nonessential material from the MDF:

  • •

    Label material “Nonessential Material - Destroy After All Reviews Have Been Completed” (see exhibit of sample Nonessential Material flag in DI 20503.010); and

  • •

    Place in the green section (Current Development/Temporary) of the MDF; or

  • •

    Attach to the file if there is not enough room in the green section.

When all actions at the current level of adjudication are complete, including the component review, the office taking the last action will discard the material marked with the Nonessential Material flag.

E. What is the case development summary worksheet

1. Definition of the case development summary worksheet

The case development summary is a worksheet the DE prepares to:

  • •

    Document all disability development undertaken;

  • •

    Record the receipt or non-receipt of requested evidence;

  • •

    Describe any material not kept.

2. Procedure for handling the worksheet

Permanently retain the worksheet as the top document in the Medical Records (Yellow/Back) section of the MDF or the CEF. Fully document all development pertaining to the current determination on the worksheet if development requests are not in file.

Also, see:

DI 20503.005 Exhibit - Model Case Development Summary.

3. How to prepare a worksheet

When preparing the case development summary worksheet ensure that:

  • •

    All entries are precise and easily understood by subsequent reviewers and adjudicators, including quality reviewers, administrative law judges and the Federal courts.

  • •

    The entries stand alone and do not require a coding key or interpretive guide to decipher (i.e., no encrypted entries).

  • •

    DE’s complete a new worksheet at each level of adjudication through the disability hearing officer level.

  • •

    Locally created DDS development worksheets must contain the required claimant and development information described in DI 20503.001E.3. through DI 20503.001E.6. in this section.

4. Required claimant information on the worksheet

The following claimant information is required and must be entered on the case development summary worksheet:

  • •

    Name and Social Security Number (SSN);

  • •

    Date of birth (DOB);

  • •

    Appointed representative (AR) information;

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    Level of claim (e.g., initial, reconsideration, CDR, etc.);

  • •

    Type of claim (e.g., Disability Insurance Benefits (DIB), Childhood Disability Benefits (CDB), Disabled Window(er) Benefits (DWB), Disabled Individual (DI), Medicare for Qualified Government Employment (MQGE)).

NOTE: For DWB and CDB claims also enter the wage earner’s name and SSN.

5. Required development information on the worksheet

Document on the case development summary worksheet initial and follow-up requests for medical and nonmedical evidence made by:

  • •

    Mail;

  • •

    Telephone;

  • •

    Fax;

  • •

    Electronic Records Express (ERE); or

  • •

    Other means.

For information on whether to retain or discard requests and notices, see DI 20503.001F in this section.

Also, see:

  • •

    DI 22505.006 Requesting Evidence – General

  • •

    DI 22505.035 Follow-up on Requests for Medical Evidence of Record (MER)

6. How to document development steps on the worksheet

Enter the following information to document the development steps.

a. Brief explanation of development

Provide a brief explanation of development, such as:

  • •

    Reason(s) the individual’s own medical source(s) was not used to perform a CE;

  • •

    Reason(s) requested development was curtailed (e.g., sufficient but not all evidence obtained to support a determination as to disability). This is not necessary for fully favorable determinations.

b. Required entries for successful requests

The following entries for successful requests, if not retained in file, are required on the worksheet to document development. These instructions apply to both initial and follow-up requests:

  • •

    Date of the request;

  • •

    Request method (i.e., telephone, mail, fax, ERE, etc.);

  • •

    Names of all sources contacted;

  • •

    Identification of adjudicator (e.g., DE, DHO, etc.); and

  • •

    Scheduled consultative examinations or tests requested and subsequently not required.

NOTE: In these instances, promptly notify the CE source that the examination or test is not required. In addition, promptly notify the claimant and the claimant’s AR, if applicable, that the examination or test has been cancelled. Annotate the worksheet accordingly, indicating the method of notification (e.g., telephone, mail, etc.).

F. Guidelines for retaining or discarding MER requests, CE notices, claimant requests, or third party requests

1. Productive and unproductive requests for MER

a. Unproductive requests

For unproductive requests (i.e., no responses), or incomplete responses (i.e., lacking a relevant part), retain the MER request letter.

b. Productive requests

For productive requests:

  • •

    Discard the MER request letter;

  • •

    Annotate the case development summary worksheet with “MO requested” if a medical opinion (MO) was not received A report is not considered incomplete if a medical opinion was requested but not received (see DI 22505.007B);

  • •

    Annotate the worksheet with “CE interest requested” if the MER request to a medical source asked if the source is interested in performing a CE.

NOTE: The remarks “MO requested” and “CE interest requested” are not required on the worksheet until the DDS implements the necessary software to post these remarks automatically.

2. CE notices

a. To the claimant

  • •

    Discard the CE notice to the claimant if the appointment was kept;

  • •

    Retain the CE notice to the claimant if the appointment was missed.

b. To the medical source

  • •

    Discard the CE notice to the medical source regardless of whether the appointment was kept. The CE notice to the medical source can be discarded because the corresponding CE notice to the claimant is retained if the appointment was not kept.

  • •

    Annotate the worksheet as to why the individual’s own medical source(s) was not used for a CE.

3. Claimant requests

  • •

    For unproductive requests, retain the request letter.

  • •

    For productive requests, discard the request letter (e.g., requests for completion of an SSA-3373-BK (Function Report - Adult) or SSA-3369-BK (Work History Report), call-in letters, etc.)

4. Third party requests

  • •

    For unproductive requests, retain the request letter.

  • •

    For productive requests, discard the request letter (e.g., requests for completion of an SSA-3380-BK (Function Report-Adult-Third Party), call-in letters, etc.)

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0420503001
DI 20503.001 - Documenting the Disability Folder – Disability Determination Services (DDS) - 10/08/2021
Batch run: 10/01/2024
Rev:10/08/2021