TN 3 (02-01)

DI 22505.040 Payment for Medical Evidence of Record (MER)

A. Policy — Disability Determination Services (DDS) Responsibilities

The DDS is responsible for:

  • Advising medical sources that payment may be made in accordance with required specified fee schedules;

  • Informing the source of the detailed kind of evidence needed for adjudication;

  • Developing techniques for obtaining the needed evidence as economically as possible;

  • Authorizing payment in accordance with the DDS fee schedule and for MER it requests in its own behalf or for any SSA component (see DI 11010.545D. for field office payment procedures in non-State claims); and

  • Monitoring its claim development experience and adjusting payment procedures as necessary.

B. Policy — Payment

1. MER

We will pay physicians not employed by the Federal government and other non-Federal providers of medical services, including chiropractors and school systems for school psychologists, if there is a charge, for the reasonable cost of preparing, reproducing, or abstracting existing medical evidence that we require and request.

NOTE: If school records include evidence from a school psychologist, then the evidence may be paid for as MER. If the school records do not include evidence from a school psychologist, then the evidence may be paid for as an “other” cost (DI 39548.001).

2. Prior Tests And Examinations

Payment will not be made for the cost of the actual examination(s) or test(s) upon which MER is based.

3. Unsolicited MER

Payment may be made for unsolicited MER submitted by claimants, their representatives, or medical sources, but only if the evidence is:

  • Useful in adjudication; or

  • Duplicative, but the claimant, the claimant's representative, or medical source submitted it in good faith.

EXAMPLE: Payment may be made if a duplicative report is received from a physician even though similar information has been previously submitted by a hospital. Assume the physician was unaware that the report was a duplicate unless there is evidence indicating otherwise.

4. Federal Sources

Payment for MER from Federal sources will not be offered or made.

5. State Or Municipal Sources

Payment may be made for charges for MER from State or municipal sources such as hospitals, institutions, or clinics as with any other types of medical sources.

6. Claimant Liability

  1. a. 

    The claimant should not be asked to meet any part of the cost of the purchase of MER from non-Federal sources.

  2. b. 

    In the rare case in which the source charges the claimant an additional fee beyond what the DDS can pay, this is between the source and the claimant; the DDS is not involved.

7. Payment Appeal

  1. a. 

    There is no formal appeal process for review of denied requests for payment or reimbursement.

  2. b. 

    However, the DDS is responsible for reviewing cases in which the claimant, the claimant's representative, or source expresses dissatisfaction with its initial payment or reimbursement decision.

  3. c. 

    Any requests for review received by SSA components involving a DDS payment decision will be forwarded to the DDS for appropriate action.

C. Procedure

1. Payment

Pay for evidence per DI 22505.040B. For detailed guidance on DDS payment for MER, see DI 39545.000 Purchased Medical Services.

2. Payment Appeal

  1. a. 

    Review the facts and either confirm or revise the initial payment decision.

  2. b. 

    Maintain a record of sources whose payment requests have been denied.

  3. c. 

    Bring problems that cannot be resolved at the DDS to the attention of the Assistant Regional Commissioner, Management and Operations Support.

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DI 22505.040 - Payment for Medical Evidence of Record (MER) - 02/28/2001
Batch run: 06/30/2014