Effective Dates: 06/28/2022 - Present Previous | Next

Last Update: 6/28/2022 (Transmittal I-3-187)

HA 01320.036 Excluded Medical Sources of Evidence

Renumbered from HALLEX section I-3-2-36

A. General Policy

Generally, the Social Security Administration (SSA) considers all submitted evidence when determining whether a claimant is blind or disabled under the Social Security Act (Act). However, under 20 CFR 404.1503b and 416.903b, SSA will not consider evidence from an excluded medical source of evidence (excluded medical source) under sections 223(d)(5)(C) and 1614(a)(3)(H)(i) of the Act unless:

  • •

    A good cause exception applies (see Hearing Appeals and Litigation Law (HALLEX) Manual HA 01320.036D.1.); or

  • •

    The evidence was previously considered in a prior administrative level or continuing disability review (CDR) and other conditions are present as described in HALLEX HA 01320.036D.2.

NOTE: 

An adjudicator must disregard evidence when there is reason to believe that fraud or similar fault (FSF) was involved in the providing of the evidence even if a good cause exception exists (see HALLEX HA 01395.000).

B. Identifying Excluded Medical Sources

Excluded medical sources are medical sources that have been:

  • •

    Convicted of a felony under section 208 or section 1632 of the Act;

  • •

    Excluded from participating in any Federal health care program under section 1128 of the Act; or

  • •

    Imposed with a civil monetary penalty (CMP), assessment, or both, for submitting false evidence under section 1129 of the Act.

Under 20 CFR 404.1503b and 416.903b, excluded medical sources must provide a written statement of exclusion each time they furnish evidence related to a claim for initial or continuing benefits under titles II or XVI of the Act.

NOTE 1: 

Evidence furnished by excluded medical sources includes evidence they have generated, created, or otherwise have within their possession.

NOTE 2: 

Excluded medical sources furnish evidence to SSA directly or indirectly through a claimant, representative, or other individual or entity.

NOTE 3: 

If an excluded medical source furnishes evidence to SSA without including a written statement of exclusion, Appeals Council (AC) staff will follow instructions found in HALLEX HA 01320.036F in addition to all other applicable subsections within HALLEX HA 01320.036.

1. Written Statement of Exclusion Requirement

All written statements of exclusion must include the following:

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    The heading, WRITTEN STATEMENT REGARDING SECTION 223(d)(5)(C) OF THE SOCIAL SECURITY ACT – DO NOT REMOVE;

  • •

    The name and title of the excluded medical source; and

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    The basis for the exclusion.

As applicable, written statements of exclusion must also include:

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    The date of the felony conviction under section 208 or section 1632 of the Act;

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    The reason, effective date, and expected length of exclusion under section 1128 of the Act and whether the exclusion was waived by the Office of Inspector General of the Department of Health and Human Services (HHS OIG); and

  • •

    The date of the final decision imposing the CMP, assessment, or both, for submitting false evidence under section 1129 of the Act.

2. Finding the Written Statement of Exclusion

The written statement of exclusion should be located before the first page (but after any barcode page) of any evidence furnished by an excluded medical source directly or indirectly through a claimant, representative, or other individual or entity related to a claim for initial or continuing benefits under titles II or XVI of the Act.

NOTE 1: 

AC staff will not move a written statement of exclusion that is not placed before the first page (but after any barcode page) of the evidence. Evidence from an excluded source should not be re-organized into multiple exhibits under HALLEX HA 01210.015.

NOTE 2: 

If an excluded medical source provides an unclear or incomplete written statement of exclusion, AC staff may contact the medical source for clarification or additional information. If the medical source cannot be reached after one attempt, the AC may exclude the medical source's evidence unless there is information available to apply a good cause exception(s). AC staff must record the details of any contact on a form SSA-5002, Report of Contact, and scan or place it in section E of the claim(s) file.

C. Annotating the Claim(s) File

When a claim(s) file contains evidence from an excluded medical source, AC staff must annotate the file as follows:

  • •

    In cases with an electronic claim(s) file, AC staff will annotate the document in eView, adding a note to the specific excluded evidence that reads Excluded Medical Source. If only a portion of the document is from an excluded medical source, specify the page(s) within the document from the excluded medical source. AC staff will also change the document type to Excluded Medical Source.

    NOTE: 

    If the evidence was exhibited at the hearing level, AC staff will not be able to annotate the file with the flag or note as explained here. In this situation, AC staff will only annotate the case processing system as explained below.

  • •

    In cases with a paper claim(s) file, AC staff will print out the following flag, fill in the requested information, and attach it to the front of the paper file. AC staff will also identify in the Remarks section of the flag the document (and if not the entire document, the pages within that document) that contains evidence from an excluded medical source.

Flag for Paper Claim(s) Files

In all cases, AC staff must document that the file contains evidence from an excluded medical source in the case processing system by creating an annotation that reads “Excluded Medical Source.”

D. Evaluating Evidence from Excluded Medical Sources

The AC must exclude evidence from an excluded medical source that is furnished directly or indirectly through a claimant, representative, or other individual or entity related to a claim for initial or continuing benefits under titles II or XVI of the Act, unless a good cause exception applies.

The exclusion will also depend on when the evidence was furnished and whether it was considered at a prior administrative level.

1. Evidence Falls within a Good Cause Exception

When a good cause exception applies, the AC may consider the qualifying evidence from the excluded medical source when issuing an action.

NOTE 1: 

There may be instances where some, but not all, of the evidence from an excluded medical source meets the criteria of a good cause exception. In those instances, the AC may consider the evidence that meets the good cause exception criteria and exclude the evidence that does not.

NOTE 2: 

Even if a good cause exception applies, the AC must always disregard evidence when there is reason to believe that FSF was involved in the providing of the evidence (see HALLEX HA 01395.000).

The good cause exceptions are:

  • •

    The evidence covers treatment that occurred before the date of the source's felony conviction under section 208 or 1632 of the Act;

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    The evidence covers treatment that occurred when the source was not excluded from participating in any Federal health care program under section 1128 of the Act (i.e., before the source was excluded from participating in any Federal health care program under section 1128 of the Act, or after the source was reinstated by HHS OIG and allowed to resume participation in any Federal health care program);

  • •

    The evidence covers treatment that occurred before the date the source received a final decision imposing a CMP, assessment, or both, for submitting false evidence under section 1129 of the Act;

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    The source is excluded solely because the source cannot participate in any Federal health care program under section 1128 of the Act, but HHS OIG has waived that section 1128 exclusion; and

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    The evidence is a laboratory finding(s) about a physical impairment(s), and there is no indication that the finding is unreliable (see 20 CFR 404.1502(c) and 416.902(g) for guidance on what constitutes a laboratory finding).

2. Evidence Considered at a Prior Administrative Level or CDR

a. Evidence Considered Prior to November 2, 2016

If evidence from an excluded medical source was considered in a determination, decision, or CDR before November 2, 2016, the evidence must continue to be considered at each subsequent step of the administrative review process and in any subsequent CDR, unless there is reason to believe that FSF was involved in the providing of the evidence. This requirement applies regardless of whether the excluded medical source resubmits the same evidence on or after November 2, 2016.

EXAMPLE: 

An administrative law judge (ALJ) issues a hearing decision on November 1, 2016, denying a claim for title II benefits. In issuing that decision, the ALJ considered a September 24, 2016 opinion from Dr. Smith. The claimant files a request for review on November 25, 2016. That same day, Dr. Smith submits additional evidence and includes a written statement of exclusion, reporting a felony conviction under section 208 of the Act on January 1, 2013. The AC must consider Dr. Smith's September 24, 2016 opinion unless there is reason to believe that FSF was involved in the providing of the evidence. The AC must exclude the additional evidence Dr. Smith submitted the same day as the claimant's November 25, 2016 request for review unless a good cause exception applies and there is no reason to believe that FSF was involved in the providing of the evidence.

b. Evidence Considered on or After November 2, 2016

If evidence from an excluded medical source was considered in a determination, decision, or CDR on or after November 2, 2016, the evidence must continue to be considered at each subsequent step of the administrative review process and in any subsequent CDR unless there is reason to believe that FSF was involved in the providing of the evidence, or it was incorrectly considered by a previous adjudicator.

Instances in which evidence from an excluded medical source may have been incorrectly considered in an adjudication include:

  • •

    The excluded medical source did not provide a written statement of exclusion, but should have done so;

  • •

    A previous adjudicator did not identify the written statement of exclusion provided by the excluded medical source; or

  • •

    A previous adjudicator incorrectly applied a good cause exception.

c. Evidence Excluded on or After November 2, 2016

If evidence from an excluded medical source was first excluded in a determination, decision, or CDR on or after November 2, 2016, the evidence must continue to be excluded at each subsequent step of the administrative review process and in any subsequent CDR unless it was incorrectly excluded by a previous adjudicator (i.e., evidence from a source that the adjudicator misidentified as an excluded medical source or failed to apply an applicable good cause exception).

If the evidence was incorrectly excluded by a previous adjudicator, the evidence must be considered in the current claim(s).

E. Addressing Evidence from Excluded Medical Sources in AC Action

When issuing an action, the AC must state whether the evidence from an excluded medical source was included or excluded and provide reason(s) for the inclusion or exclusion. The statement will be made if the evidence was submitted at the AC level or if it was incorrectly considered by a previous adjudicator.

NOTE: 

When evaluating an appeal of a dismissal or decision, the AC will consider a claimant or appointed representative's allegation that evidence was incorrectly included or excluded under 20 CFR 404.1503b and 416.903b.

1. When All Evidence Has Been Excluded

If the AC excludes all of the evidence from an excluded medical source, the action document must include the language provided below depending on the type of action document.

a. Denial Notice or Interim Notice:

Include the following language under “What We Considered”:

Unless there is good cause, the law prevents the Social Security Administration from considering evidence furnished by medical sources who have been convicted of a felony under section 208 or 1632 of the Social Security Act (Act); excluded from participating in any Federal health care program under section 1128 of the Act; or imposed with a civil monetary penalty, assessment, or both, under section 1129 of the Act, for submitting false evidence.

We were not able to consider certain evidence in your case because it was furnished by a medical source(s) who falls within one of these categories.

Immediately following this language, the AC will also include the following information:

  • •

    The name(s) of the excluded medical source(s); and

  • •

    A brief description of the evidence from the excluded medical source(s) that is being excluded.

b. Remand Order, Dismissal Order, or Decision Order

Include the following language in the text of the order:

Unless there is good cause, the law prevents the Social Security Administration from considering evidence furnished by medical sources who have been convicted of a felony under section 208 or 1632 of the Social Security Act (Act); excluded from participating in any Federal health care program under section 1128 of the Act; or imposed with a civil monetary penalty, assessment, or both, under section 1129 of the Act, for submitting false evidence.

The Appeals Council was not able to consider certain evidence in this case because it was furnished by a medical source(s) who falls within one of these categories.

Immediately following this language, the AC will also include the following information:

  • •

    The name(s) of the excluded medical source(s); and

  • •

    A brief description of the evidence from the excluded medical source(s) that is being excluded.

2. When All Evidence Has Been Considered

If the AC considers all of the evidence from an excluded medical source because a good cause exception applies, the action document must include the language provided below depending on the type of action document.

a. Denial Notice or Interim Notice

Include the following language under “What We Considered”:

Unless there is good cause, the law prevents the Social Security Administration from considering evidence furnished by medical sources who have been convicted of a felony under section 208 or 1632 of the Social Security Act (Act); excluded from participating in any Federal health care program under section 1128 of the Act; or imposed with a civil monetary penalty, assessment, or both, under section 1129 of the Act, for submitting false evidence.

Although certain evidence in your case was furnished by a medical source(s) who falls within one of these categories, we were able to consider it because we found that a good cause exception(s) applies.

Immediately following this language, the AC will also include the following information:

  • •

    The name(s) of the excluded medical source(s);

  • •

    A brief description of the evidence being considered as follows:

    • •

      If the AC is issuing a denial notice, the exhibit number(s) and page number(s) of evidence from the excluded medical source(s) that is being considered; or

    • •

      If the AC is issuing an interim notice, a brief description of the evidence from the excluded medical source(s) that is being considered; and

  • •

    Which good cause exception(s) applies.

b. Remand Order, Dismissal Order, or Decision Order

Include the following language in the text of the order:

Unless there is good cause, the law prevents the Social Security Administration from considering evidence furnished by medical sources who have been convicted of a felony under section 208 or 1632 of the Social Security Act (Act); excluded from participating in any Federal health care program under section 1128 of the Act; or imposed with a civil monetary penalty, assessment, or both, under section 1129 of the Act, for submitting false evidence.

The Appeals Council was able to consider certain evidence in this case because, although it was furnished by a medical source(s) who falls within one of these categories, the Appeals Council found that a good cause exception(s) applies.

Immediately following this language, the AC will also include the following information:

  • •

    The name(s) of the excluded medical source(s);

  • •

    A brief description of the evidence being considered as follows:

    • •

      If the AC is issuing a decision, the exhibit number(s) and page number(s) of evidence from the excluded medical source(s) that is being considered; or

    • •

      If the AC is issuing a remand order or dismissal order, a brief description of evidence from the excluded medical source(s) that is being considered; and

  • •

    Which good cause exception(s) applies.

3. When Some Evidence Has Been Excluded and Some Evidence Has Been Considered

If the AC considers some evidence but also excludes some evidence from an excluded medical source, the action document must include the language provided below depending on the type of action document.

a. Denial Notice or Interim Notice:

Include the following language under “What We Considered”:

Unless there is good cause, the law prevents the Social Security Administration from considering evidence furnished by medical sources who have been convicted of a felony under section 208 or 1632 of the Social Security Act (Act); excluded from participating in any Federal health care program under section 1128 of the Act; or imposed with a civil monetary penalty, assessment, or both, under section 1129 of the Act, for submitting false evidence.

We were able to consider certain evidence but also excluded certain evidence in your case because, although it was furnished by a medical source(s) who falls within one of these categories, we found that a good cause exception(s) applies only to some of that evidence.

Immediately following this language, the AC will also include the following information:

  • •

    The name(s) of the excluded medical source(s);

  • •

    A brief description of the evidence as follows:

    • •

      If the AC is issuing a denial notice, the exhibit number(s) and page number(s) of evidence from the excluded medical source(s) that is being considered and a brief description of the evidence that is being excluded; or

    • •

      If the AC is issuing an interim notice, a brief description of the evidence from the excluded medical source(s) that is being considered and excluded;

  • •

    For the evidence being considered, which good cause exception(s) applies; and

  • •

    For the evidence being excluded, a statement that no good cause exception(s) applies.

b. Remand Order, Dismissal Order, or Decision Order

Include the following language in the text of the order:

Unless there is good cause, the law prevents the Social Security Administration from considering evidence furnished by medical sources who have been convicted of a felony under section 208 or 1632 of the Social Security Act (Act); excluded from participating in any Federal health care program under section 1128 of the Act; or imposed with a civil monetary penalty, assessment, or both, under section 1129 of the Act, for submitting false evidence.

The Appeals Council was able to consider certain evidence but also excluded certain evidence in this case because, although it was furnished by a medical source(s) who falls within one of these categories, the Appeals Council found that a good cause exception(s) applies only to some of that evidence.

Immediately following this language, the AC will also include the following information:

  • •

    The name(s) of the excluded medical source(s);

  • •

    A brief description of the evidence as follows:

    • •

      If the AC is issuing a decision, the exhibit number(s) and page number(s) of evidence from the excluded medical source(s) that is being considered and a brief description of the evidence that is being excluded; or

    • •

      If the AC is issuing a remand order or dismissal order, a brief description of the evidence from the excluded medical source(s) that is being considered and excluded;

  • •

    For the evidence being considered, which good cause exception(s) applies; and

  • •

    For the evidence being excluded, a statement that no good cause exception(s) applies.

F. Excluded Medical Source Fails to Provide a Written Statement of Exclusion

NOTE: 

All actions described in this sub-section (HALLEX HA 01320.036F) are only required if the excluded medical source has failed to provide a written statement of exclusion. If a written statement of exclusion is associated with the evidence, standard case closing procedures will apply.

If no written statement of exclusion is included with the evidence, the AC should generally conclude that the evidence did not come from an excluded medical source. However, if the AC knows or has sufficient reason or information to believe that the source of the evidence is an excluded medical source, and no written statement of exclusion is associated with the evidence, AC staff will take the following actions:

  • •

    Before submitting the case to the adjudicator, send an email to the Executive Director's Office (EDO) at ^DCDA OAO with a copy to the branch chief, with the subject line: Excluded Medical Source – No Statement of Exclusion. Include an attachment to the email containing the proposed action document. The body of the email will contain the name and social security number of the claimant, the exhibit and page number(s) of the evidence from the excluded medical source (if the evidence is not exhibited, indicate that it is not exhibited and provide other descriptions that will allow the EDO to determine its location in claimant's file), the name of the excluded medical source, and an explanation of how the source was determined to be an excluded medical source.

  • •

    Annotate the case processing system with the following statement: Excluded medical source violation email sent to the EDO on [mm/dd/yyyy].

  • •

    Do not send the case to the adjudicator until the EDO replies to the email confirming that the source is an excluded medical source and that the action document contains any necessary language specified in HALLEX HA 01320.036E. The EDO will only confirm that required language from HALLEX HA 01320.036E is present but will defer to the AC regarding whether to exclude or consider the evidence based on any good cause exception. The EDO will copy the adjudicator and branch chief on the confirmation email and request that the adjudicator expedite the case and that the branch chief advise the EDO by email when the case is closed. The EDO will also request the adjudicator or AC staff inform the EDO if changes are made to the action document which impact the language found in HALLEX HA 01320.036E.

Upon case closure, the EDO will:

  • •

    Refer the non-compliant excluded medical source to the Office of Inspector General (HALLEX HA 01130.030 and POMS DI 23060.040).

  • •

    Send the required notice to the excluded medical source based on the failure to provide a written statement of exclusion as required by the regulations. A copy of the notice must also be sent to ^ODP BBA 812 with the excluded medical source's name and date of violation of the failure to provide a written statement of exclusion (POMS DI 23060.020G and DI 23060.040A.2.).

  • •

    Maintain a record of the excluded medical source violation by retaining a copy of the notice sent, the excluded sources name and the date of violation of the failure to provide a written statement of exclusion (POMS DI 23060.020G).

  • •

    Document these actions in the case processing system.

G. Reopening Due to Incorrect Inclusion or Exclusion of Evidence

A determination or decision may be reopened if a previous adjudicator incorrectly considered evidence from an excluded medical source, or incorrectly excluded evidence from a source that the adjudicator misidentified as an excluded medical source. In such situations, a determination or decision may be reopened at the request of the claimant, appointed representative, or on SSA's own initiative pursuant to reopening timeframes described in 20 CFR 404.988 and 416.1488 (see also HALLEX HA 01390.000).

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/2501320036
HA 01320.036 - Excluded Medical Sources of Evidence (I-3-2-36) - 06/28/2022
Batch run: 01/28/2026
Rev:06/28/2022