BASIC (10-01)

A. Introduction

In all CDRs involving medical issues, except as noted in DI 13005.035, a personal contact with the individual is recommended, but not required.

The purpose of the personal contact is to alleviate the individual’s or payee’s apprehension about the medical review by providing a thorough and understandable explanation of the CDR process, including the beneficiary’s role in the process. The preferred method of doing this is a face-to-face contact. However, telephone contact is appropriate when more convenient to the beneficiary or when the CDR is being initiated from a central point. A complete and accurate record of the individual’s condition, treating medical sources, vocational information and any observable information relevant to his/her impairment(s) should be thoroughly documented.

B. Policy

The overview of the CDR process and the explanation of rights and responsibilities provided the beneficiary at the personal contact must include an explanation of the disability hearing process to which the beneficiary is entitled at reconsideration. The disability hearing is a result of the implementation of sections 4 and 5 of P.L. 97-455.

Sections 4 and 5 of P.L. 97-455 provide for an evidentiary disability hearing (known as a disability hearing) at the reconsideration level of appeal for title II medical cessations. The regulations implementing this statute extend the disability hearing process to comparable title XVI and concurrent title II/XVI cases.

The beneficiary should be made aware that, if he/she is dissatisfied with the outcome of the CDR, he/she may request a reconsideration. The DDS will perform a folder review and develop the reconsideration as it has in the past. However, as a result of P.L. 97-455, if the DDS cannot make a fully favorable determination after its review, the beneficiary will be entitled to a disability hearing before an unfavorable determination is issued. The explanation of the disability hearing should include a brief overview of the items covered in DI 12026.001 - DI 12026.020.

C. Procedures

1. General

Complete a Form SSA-454-BK (Continuing Disability Review Report) and SSA-827s (Authorization to Release Medical Information to the Social Security Administration) or local authorization form. Obtain SSA-827s according to DI 11005.055 and regional policy. The DDS will initiate medical development.

Explain that the individual/payee is responsible for submitting evidence to prove that disability continues. SSA will assist in obtaining this information but the individual must submit the names and addresses of treating sources and give permission for SSA to obtain the evidence.

Explain that a prompt response is required to any later DDS contact or request to appear for a consultative examination (CE). Careful attention should be given to the possibility, however, that the very nature of the individual’s impairment (i.e. psychiatric) may hinder cooperation. Annotate the file to alert the DDS. Failure to cooperate issues should be handled in accordance with DI 13015.001 ff. The file should document all efforts made to gain the individual’s cooperation.

The individual should be informed that the CDR can be a lengthy process. Medical sources do not always respond promptly. The DDS needs time to evaluate the evidence and, should the file not contain sufficient evidence for a decision, a CE would be required.

Upon completion of the interview the SSA-454-BK and the SSA-827s should be prong filed on the right side of the claims folder (if the FO has the folder), folder movement should be documented in the Disability Control File (DCF), and the folder should be sent to the DDS via an SSA-408 unless the CDR is deferred and the folder returned to ODO/PSC-DRS.

2. Title XVI Childhood Disability Cases

1. In addition to the SSA-454-BK, also complete:

   • Form SSA-3881-BK (Questionnaire for Children Claiming SSI Benefits). (If using a version printed before 08/94, also ask the question in DI 11005.030B.2., to obtain the name of someone else who could help SSA obtain evidence about the child.)

     NOTE: It is extremely important that the FO make every effort to obtain the name of an “other responsible adult” when completing the SSA-3881-BK, or to document the file if no such third party is available.

   • The appropriate Function Report-Child (SSA-3375-BK through SSA-3379-BK).

2. Advise the payee that he/she may be asked to provide evidence to show that the child is and has been receiving treatment, to the extent considered medically necessary and available, for the condition(s) that was the basis for providing benefits. Advise the payee that, if he/she refuses to comply with this requirement without good cause, we will decide if benefits should go to another payee, at which time the child’s record may be placed in administrative suspense until another payee can be found, or if the child should receive his/her own benefits directly.