CE appointments must allow sufficient time for the CE source to take a case history, when appropriate, and to perform the requested type of examination. For specific scheduling intervals, see DI 39545.250A.

For detailed CE report requirements, see DI 22510.015B in this section.

The CE report should include::

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  documentation that the claimant provided proof of identity by showing a valid and current government photo identification (ID) (e.g., United States (U.S.) State-issued driver’s license, U.S. State-issued non-driver identity card, U.S. passport, U.S. military ID, student or school ID, etc.),
  
  OR

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  a physical description of the claimant, to help ensure that CE source examines the claimant, unless the CE source is the claimant’s treating source.

For detailed signature requirements, see DI 22510.015C in this section.

Explain when and how the source should submit the CE report.

Advise the CE source of the established rates of payment (fee schedules) and customary procedures for fee authorization.

See details:

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  DI 39545.600 Fee Schedules

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  DI 39545.625 Developing Fee Schedules

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  DI 39545.650 Using the Medicare Fee Schedule and Current Procedural Terminology (CPT) Codes

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  DI 39545.675 Exhibit 3 – DDS Guide to Establishing a Fee Schedule

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  DI 39545.700 Maintaining and Monitoring Fee Schedules

Explain that the Privacy Act:

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  prohibits use of the examination report prepared for us (including background material furnished to the source);

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  strictly prohibits unauthorized disclosure of claimant information and subjects unauthorized disclosure to legal penalties;

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  gives the claimant access rights to records we maintain about him or her. Therefore, we cannot guarantee the CE source confidentiality.

Explain that the CE source must contact the Disability Determination Services (DDS) immediately when:

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  anyone, including the claimant, requests a copy of the CE report or associated records; see GN 03300.000.

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  the CE source is subject to a court order concerning the source’s CE records or related testimony. Instruct the CE source that he or she should provide the DDS with a copy of the court order, either by fax or by email. Explain to the CE source that he or she must wait for instruction from the DDS before releasing records or disclosing information in response to a request or court order.

NOTE: If the CE source notifies the DDS of a court order, contact the Associate Regional Commissioner for Management and Operations Support for case-specific instructions. See details in GN 03330.010.

A complete CE involves all the elements of a standard examination in the applicable medical specialty. The report should be complete enough to show the nature, severity, and duration of the impairment and the claimant’s ability to function.

The medical report should include the following elements:

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  The claimant’s major or chief complaint(s) and any other abnormalities, or lack thereof, reported or found during examination or laboratory testing. (The report should reflect the claimant’s own statement of symptoms, not simply the CE source’s statements or conclusions.)

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  A detailed description, within the area of specialty of the examination, of the history of the major complaint(s).

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  A detailed description and disposition of pertinent “positive” and “negative” objective findings based on the history, examination, and laboratory tests related to the major complaint(s) and any other abnormalities, or lack thereof, reported or found during examination or laboratory testing.

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  The results of laboratory and other tests (e.g., x-rays) performed in accordance with the requirements stated in the Listing of Impairments.

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  Diagnosis and prognosis.

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  A medical opinion (MO) from the CE source expressing an opinion about what the claimant can still do despite his or her impairment(s).

An MO is a medical opinion about the adult claimant’s ability to do work-related activities or, in child claims, the child’s ability to function. While we ordinarily request an MO as part of the CE process, the absence of an MO does not make a CE report incomplete. However, the report must be complete enough to enable an independent reviewer to determine the nature, severity and duration of the impairment(s) and, in adult claims, the claimant’s ability to perform basic work-related functions. See DI 22510.020B.3. for information regarding clarification of inadequate CE reports.

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  original written signatures, signed in ink, also known as “wet” signatures, on the original paper copy of the CE report;

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  facsimiles, photocopies, or scanned images of written (“wet”) signatures;

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  electronic signature attestations submitted through the Electronic Records Express (ERE) attestation process.

IMPORTANT: ERE is the only electronic signature technology approved by the agency for obtaining policy-compliant CE report signatures.

For an explanation of how to adjudicate a claim with an unsigned or improperly signed CE report in file, see DI 22510.020C.

Registered CE sources submit electronically signed copies of CE reports using the ERE “click and sign” feature. This produces an attestation that is electronically linked to, and included with, the CE report in the certified electronic folder (CEF). The ERE attestation reads:

“I am certifying, under penalty of perjury, that I have been authorized or contracted by the Disability Determination Services to examine the claimant named in the attached, and produced a consultative examination report for that claimant. The report is accurate. By checking the “I have read and agreed with the above” checkbox below, I am certifying that I personally conducted, or personally participated in conducting, the consultative examination and have electronically signed the report contained within.”

NOTE: For paper folders, the CE report must contain a printout of the ERE attestation along with the ERE signature. The ERE signature shows the printed name of the signer or the signer’s personal identification number (PIN)/user name; and the month, day, and year of the signature.

IMPORTANT: An electronic “signature” produced by a CE source’s own electronic recordkeeping system does not meet our requirements for an acceptable CE report signature.

The CE source signature, or an acceptable copy of the signature, must appear on the copy of the CE report in the disability folder.

Consider a CE report unsigned or improperly signed if it contains:

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  an annotation of “not proofed” or “dictated but not read”;

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  a rubber stamped signature of a medical source; or

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  the CE source's signature entered by any other person.