If the DDS receives a claim with a health information technology (HIT) flag:
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View the “HIT Analysis Alert” message, when present (for more information regarding
viewing messages, see Certified Electronic Folder (CEF) Messages DI 81020.090C);
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Review the SSA-3367 (Disability Report – Field Office), SSA-3368 (Disability Report
– Adult), or SSA-3820 (Disability Report – Child), and any medical evidence submitted
by the applicant; and
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Review the health IT documents: HIT MER located in the back yellow section of the
EF and other health IT documents, such as HIT Request, HIT No Request, HIT Response,
HIT Extract, and HIT SSA-827 Issue located in the blue section of the EF.
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HIT MER is presented in a HIT Standard Document. HIT Standard Documents include narrative
reports for the following:
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Audiometry/Audiology Reports
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Electrocardiographs, Electrocardiograms (ECG)
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Stress Testing (exercise, pharma)
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Electroencephalograms (EEG)
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Electromyography (EMG)/Nerve Conduction Studies
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Mental Status Evaluations
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Neuropsychological Testing
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Computed Tomography (CT) Reports
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Magnetic Resonance Imaging (MRI) Reports
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Positron Emission Tomography (PET) Reports
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Diffusing Capacity for Carbon Monoxide (DLCO) Studies
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Pulmonary Function Tests (PFT)
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Bone Marrow Biopsy/Aspiration
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Ultrasound (excluding Dopplers)
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Admission Summaries/History and Physicals
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Emergency Room (ER) Notes
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Consults (Inpatient and/or Outpatient)
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Mental/Behavioral Health Notes
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Physical /Occupational Therapy Notes
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Antineoplastic Therapy Notes
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Blood Transfusion Records
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HIT Standard Documents exclude graphical evidence or images for the following:
The health IT documents appear on the DDS case processing worksheet the same as any
medical evidence received.
NOTE: Health IT actions are annotated as “HIT” in the EF instead of health
IT.
If, after reviewing the file, the medical evidence is not sufficient for a fully favorable
determination:
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1.
Continue normal case development;
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2.
Send medical records requests to all appropriate sources reported by the applicant
and use health IT documents to target development, if appropriate.
If a HIT Response document is in the EF, determine if a traditional medical records
request to the health IT participating source(s) is appropriate. For more information
on when a traditional request is needed, see DI 22505.006C.1.c.
If the HIT MER does not cover the relevant time period alleged by the claimant or
if it provides clues that additional medical records be available (e.g., in paper
form or in another system), determine if a call to the health IT participating source(s)
or to the claimant is necessary to ensure that the alleged period of treatment is
addressed.
If there is Health Information Technology (HIT) medical evidence in the yellow folder,
prior to utilizing traditional means to request follow-up medical evidence, utilize
electronic means for following up for medical records, such as a HIT User Trigger.
Also, use Electronic Records Express (ERE), if available.
Initiate a traditional medical records request to the health IT participating source(s),
as needed.
Follow current procedures to obtain a consultative exam (CE), as needed (see Consultative
Examinations (CE) – DI 81020.070). Attach HIT MER as background evidence, if appropriate.