TN 2 (10-15)

Citations:

20 CFR 404.911, 404.705 416–1411, and 416.916

If an administrative law judge (ALJ) concludes that he or she needs a consultative examination (CE), the ALJ sends the HA-4489-U2 (Request for DDS Assistance in Obtaining Consultative Examination(s)) directly to the Disability Determination Services (DDS) with pertinent background evidence attached.

If the ALJ did not attach any background evidence, follow local procedures to gain the background materials. The ALJ decides what background evidence we provide to the CE source. The DDS provides the other information for the source, described in DI 22510.015.

The background evidence contains any relevant evidence the ALJ identified as related to the type of examination(s) ordered along with the most recently completed disability report form SSA-3441-BK (Disability Report-Appeal).

The ALJ indicates in the Remarks section of the HA-4489-U2 if he or she needs an updated SSA-827 (Authorization to Disclose Information to the Social Security Administration (SSA)).

A. DDS actions when an ALJ requests a CE

The DDS takes the following actions when an ALJ requests assistance in obtaining a CE.

• Arrange for the CE following normal DDS guidelines and the instructions in DI 22510.000, Development of Consultative Examinations (CE) – Table of Contents.

• Include the relevant medical background evidence that the ALJ forwarded, if any.

• If the ALJ requests that a certain medical specialty perform the CE, make every reasonable effort to comply with the special request. If you encounter or anticipate any difficulty in securing services by the requested medical specialty, you may propose an appropriate alternative source to the ALJ.

• If a DDS medical or psychological consultant (MC/PC) believes the test or other diagnostic procedure is medically adverse, return the request to the ALJ with a cover letter explaining why the claimant should not have the specific test performed. If the ALJ does not agree, the Regional Chief ALJ's office will attempt to resolve the difference with the Regional Center for Disability.

• Pay the prevailing fee for the CE in accordance with the local DDS established fee schedule. For information on establishing local fee schedules, see DI 39545.600.

See Details:

DI 81020.100 Electronic Assistance Requests

B. DDS notifications and evidence

The DDS takes the following actions when scheduling a CE for the ALJ:

1. Notify the claimant and the appointed representative (if any) that the ALJ requested a CE.

2. Inform the CE provider that the examination is for an SSA hearing.

3. Include in the information sent to the CE provider:

   • the relevant medical background evidence forwarded by the ALJ,

   • any special forms provided by the ALJ for the CE provider’s medical opinion of the claimant’s functional capacity, and

   • a signed and dated SSA-827 (Authorization to Disclose Information to the Social Security Administration (SSA)) provided by the hearing office (HO) or a blank SSA-827. If sending a blank SSA-827, ask that the CE provider have the claimant sign and date it at the time of the CE. Instruct the CE provider to retain the signed and dated SSA-827.

4. Follow up for the report within 15 calendar days after the CE date.

For paper cases only:

• Send a copy of the request for the CE to the ALJ at the same time you make the request to the CE provider.

• Provide the ALJ a copy of the follow up letter or telephone report of contact.

C. Claimant does not attend or refuses to undergo a CE or test

If a claimant does not attend or refuses to undergo a CE or test requested by an ALJ, assess whether the claimant had good reasons for doing so. 

• Contact the hearing office (HO) to determine if the claimant or appointed representative communicated a good reason for missing the appointment.

• Consider the claimant’s physical, mental, educational, and linguistic limitations when determining whether good reasons exist for failing to attend a CE.

• For residents of the Fourth Circuit (Maryland, North Carolina, South Carolina, Virginia, and West Virginia), see Acquiescence Ruling 90-4(4).

1. Good reasons established for not attending a CE or test

If the claimant can establish good reasons for failure or refusal, reschedule the CE or test.

Examples of good reasons for failure to attend or refusal to undergo a CE include:

• personal illness,

• death or serious illness in the family, or

• transportation problems.

NOTE: The items in this list are only examples. You must exercise judgment and take into account the facts of each claim.

2. Good reasons not established for not attending a CE or test

If the claimant cannot establish good reasons, or the claimant does not attend or refuses to undergo a rescheduled CE or test, respond to the assistance request (AR) and include the documentation in eView.

For paper cases only, return the request to the ALJ, along with the reason(s) the claimant provided, if any, for missing the CE or test.  The ALJ will associate any documentation from the DDS with the claim(s) file. 

NOTE: If the ALJ determines the claimant had good cause for not attending or refusing to undergo the CE or test (and the claimant does not oppose attending or undergoing a CE or test), the ALJ will submit a new AR requesting the DDS schedule another CE or test as soon as possible. 

D. References

• DI 22510.015 Information for Consultative Examination (CE) Source

• DI 23007.009 Refusal to Attend a Consultative Examination (CE) Appointment

• DI 23007.010 Failure to Attend a Consultative Examination (CE) Appointment

• DI 81020.100 Electronic Assistance Requests (AR)