DI 24501.001: The Disability Determination Services (DDS) Disability Examiner (DE), Medical Consultant (MC), and Psychological Consultant (PC) Team, and the Role of the Medical Advisor (MA)

changes
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~~Effective Dates: 12/05/2017 - Present~~
Effective Dates: 12/07/2017 - Present
TN 10 (08-17)
DI 24501.001 The Disability Determination Services (DDS) Disability Examiner (DE), Medical Consultant (MC), and Psychological Consultant (PC) Team, and the Role of the Medical Advisor (MA)
A. Introduction to the roles and responsibilities of the DE, MC, PC, and MA
A disability determination requires the DE, MC, and PC to collaborate as the adjudicative team. Not all team members participate in the development and evaluation of all claims, as outlined in DI 24501.001B in this section.
All team members have training in the disability process. MAs are not part of the adjudicative team but can provide analysis of medical issues.
B. Adjudicative roles and responsibilities of the DE, MC, PC, and MA
1. General role of the DE
The role of the DE in the disability determination process includes, but is not limited to a responsibility to:
a. Develop the case
* Obtain evidence from the claimant, medical sources, entities that maintain medical sources’ evidence, and nonmedical sources;
* Contact claimants, applicants, appointed representatives, and other appropriate parties for additional information;
* Consult with MCs, PCs, and other staff members to resolve problems in getting evidence from medical sources, entities that maintain medical sources’ evidence, and nonmedical sources;
* Initiate requests for consultative examinations (CE) when medical evidence of record (MER) is not sufficient to make a determination of disability and all available medical information has been obtained; and
* Follow up to obtain CE reports when necessary.
b. Prepare the case for MC, PC, or MA review
* Prepare cases for MC, PC, and MA review, including highlighting the relevant period to consider such as the date last insured, prescribed periods, or prior adjudicated periods; and
* Assist MCs and PCs with the completion of any applicable residual functional capacity (RFC) assessments as appropriate.
c. Evaluate the vocational aspects of the case
* Determine whether a claimant can perform past relevant work given his or her RFC at step 4 of the sequential evaluation process; and
* Determine whether a claimant can adjust to other work given the applicant’s RFC, age, education, and work experience at step 5 of the sequential evaluation process.
d. Prepare the determination
* Prepare rationales and determinations, including Forms SSA-831 (Disability Determination and Transmittal) or Title XVI SSA-832 and Title II SSA-833 (Cessation or Continuance of Disability or Blindness Determination and Transmittal;
* Prepare disability determination notices; and
* Make every reasonable effort to ensure that the following sources completed the medical portion of the case review and completed all applicable RFC assessment:
* A qualified physician (where a physical impairment is alleged);
* A psychiatrist or psychologist (where a mental impairment is alleged); or
* Both (where both a physical impairment and mental impairment are alleged).
2. Signature responsibilities of the DE
The DE alone may make the disability determination without an MC or PC signature in the following situations:
* The DE has single decision-maker (SDM) authority in a prototype or SDM II DDS and the claimant meets SDM requirements as explained in DI 12015.100B.1.;
* The DE has the authority to use the procedures for the quick disability determination (QDD) process or the compassionate allowance process (CAL) determinations as explained in DI 23023.001; and
* The current file or any prior file contains no medical evidence and despite making every reasonable effort, the DDS is unable to obtain medical evidence that exists and one or more of the following situations exists:
* The claimant refuses or fails without good reason to attend a CE as explained in DI 23007.009 and DI 23007.010;
* The DDS curtails CE development after establishing the claimant’s failure or refusal to cooperate as explained in DI 23007.004E and DI 23007.005H; or
* The date last insured or other technical factor is in the past, and there is no possibility of setting an onset prior to the end of the entitlement period.
NOTE: Effective December 28, 2018, SDM, QDD, and CAL authority ends.
3. General role of the MC and PC
This section provides information about the MC or PC role in the disability process. The MC or PC role in the determination process includes, but is not limited to the responsibility to:
a. Evaluate the sufficiency of the evidence and need for further testing
* Evaluate the evidence in the case to determine its adequacy to complete the medical portion of the case review;
* Review requests for CEs in specific claims to ensure they are necessary, are not contraindicated based on the evidence in file, and resolve the issues as intended; and
* Provide alternatives to the purchase of a CE.
b. Act as a liaison between the DDS and the medical community
* Resolve problems in obtaining MER through discussions with DEs and other staff members;
* Review CE reports for deficiencies in content and recommend ways to avoid deficient reports;
* Evaluate and respond to medical questions;
* Improve relations with the medical community, enlarging consultative examiner panels, and minimizing CE processing time by working closely with staff members and CE providers; and
* Improve DE understanding and use of medical evidence by working with training staff.
c. Determine severity, whether the claimant meets or equals a listing, or for a Title XVI child whether the claimant’s impairment functionally equals the listings
* Assess the existence and severity of impairments at step 2 of the sequential evaluation process;
* Determine whether an impairment meets or equals the requirements of a listing in the Listing of Impairments (Listings) at step 3 of the sequential evaluation process; and
* Determining whether a claimant’s impairment(s) functionally equals the Listings at step 3 of the sequential evaluation process in childhood disability claims.
d. Assess RFC and other specific medical issues
* Assess and determine RFC in adult disability determinations;
* Participate in other specific medical determinations in a claim (such as whether drug addiction or alcoholism is material to the determination), as appropriate; and
* Review determinations to ensure their integrity.
4. Signature responsibilities of the MC and PC
The MC and PC:
* Sign assessments and determinations; and
* Indicate that his or her signature completes the medical portion of the disability determination.
An MC who is a physician takes responsibility for the medical portion of the determination, except in cases where a PC may perform this function.
A PC may perform this function when:
* a mental impairment is the only impairment in the claim; or
* there is a combination of a mental impairment with a physical impairment, but the mental impairment alone justifies a finding of disability.
The MC or PC who is taking responsibility for the medical portion of the determination signs the disability determination forms and all supporting documents relevant to the determination that require a signature.
In cases where there is evidence of mental and physical impairment(s), and a PC reviews the case, the PC evaluates only the mental impairment(s) and the MC evaluates the physical impairment(s).
In cases where the combination of physical and mental impairments may be equivalent to a medical listing, the MC and PC confer, both complete and sign an SSA-416 (Medical Evaluation), and one of the consultants takes overall responsibility to sign the rationale supporting the equivalence. For additional information on the SSA-416, see DI 24501.006.
5. Handle adjudicative team conflicts of interest
If a DDS MC or PC furnishes any of the MER, he or she does not participate in the disability determination of that claim.
For instructions on when a DDS Adjudicative Team Member Furnishes Evidence, see DI 22505.027.
For additional instructions on Conflict of Interest, see DI 39569.100.
6. The general role of the MA
The MA’s role in the determination process includes:
* Help DEs, MCs, and PCs understand specialized issues or evidence in claims; and
* Provide analysis about medical issues related to impairments for which they are qualified to evaluate, as described in DI 22505.003A.
EXAMPLE: A speech-language pathologist (SLP) provides advice in a claim about an issue or evidence related to a speech or language impairment.
The adjudicative team must consider the MA analysis as evidence from an acceptable medical source.
NOTE: Because an MA is an independent medical source that provides evidence in a claim, an MA may provide analyses of the same case at both the initial and reconsideration level of adjudication.
MAs must use the Form SSA-416 to provide their analysis. Use the analysis as evidence in the claim. For specific business process instructions on the role of the MA, see DDSAL 960 “Medical Advisors—Bipartisan Budget Act (BBA) Section 832—INFORMATION.”
7. Signature requirements for MA
The statute prohibits MAs from signing or otherwise taking responsibility for the medical portion of the disability determination. For additional information on MA adding their analysis to a claim, see DI 24501.006.
C. Qualifications for MC, PC, and MA
1. MC
An MC is a licensed physician (medical or osteopathic doctor) who is a member of a DDS or Social Security Administration (SSA) team that makes disability determinations.
2. PC
A PC is a licensed psychiatrist or a psychologist who is a member of a DDS or Social Security Administration (SSA) team that makes disability determinations and:
* is licensed or certified as a psychologist at the independent practice level of psychology by the State in which he or she practices;
* possesses a doctorate degree in psychology from a program in clinical psychology of an educational institution accredited by an organization recognized by the Council for Higher Education Accreditation, formerly the Council on Post-Secondary Accreditation; or
* is listed in a national register of health service providers in psychology that the Commissioner of Social Security deems appropriate; and
* possesses two years of supervised clinical experience as a psychologist in health service, at least one year of which is post master’s degree.
NOTE: The Commissioner has not identified an appropriate national register of health service providers, so a PC must meet the criteria in the first two bullets, or the DDS must be able to check the registry to ensure the psychologist is properly credentialed.
NOTE: The Commissioner has not identified an appropriate national register of health service providers, so a PC must meet the criteria in the first two bullets, or the DDS must be able to check a registry to ensure the psychologist is properly credentialed.
3. MA
An MA is an acceptable medical source who is not an MC or PC.
For claims filed before March 27, 2017, this includes:
* Licensed optometrists, for impairments of visual disorders only (except, in the United States Virgin Islands, licensed optometrists, for the measurement of visual acuity and visual fields only).
* Licensed podiatrists, for impairments of the foot, or the foot and ankle only, depending on whether the State in which the podiatrist practices permits the practice of podiatry on the foot only, or the foot and ankle.
* Qualified speech-language pathologists, for impairments of speech or language only.
For claims with a filing date on or after March 27, 2017, this additionally includes:
* Licensed physician assistants for impairments within the licensed scope of practice only.
* Licensed audiologists for impairments of hearing loss, auditory processing disorders, and balance disorders within the licensed scope of practice only. NOTE: Audiologists’ scope of practice generally includes evaluation, examination, and treatment of certain balance impairments that result from the audio-vestibular system. However, some balance impairments involve several body systems that are outside the scope of practice for audiologists, such as those involving muscles, bones, joints, vision, nerves, heart, and blood vessels.
* Licensed Advanced Practice Registered Nurses (APRN), also known in some States as Advanced Practice Nurse (APN), and Advanced Registered Nurse Practitioner (ARNP) for impairments within his or her licensed scope of practice.
For more information about acceptable medical sources, see Evidence from an Acceptable Medical Source (AMS), DI 22505.003.

POMS Reference

DI 24501.001: The Disability Determination Services (DDS) Disability Examiner (DE), Medical Consultant (MC), and Psychological Consultant (PC) Team, and the Role of the Medical Advisor (MA)