TN 10 (02-11)

A. Definition of a essential evidence

Essential evidence is any evidence that is needed to make a determination whether the claimant is disabled or to resolve any material conflicts.

NOTE: What constitutes essential evidence differs from case to case.

For a further explanation of a crucial missing evidence technical corrective action (TCA), see GN 04440.242.

B. Background on cases with essential evidence that is missing or illegible

When evidence that is essential to the current determination is missing or illegible, the reviewing component is unable to complete their review of the case. The review component returns the case to the adjudicating component to obtain the missing evidence.

For a further explanation of review component corrective action procedure, see GN 04440.242B.

1. Certified electronic folder

Cases that have a certified electronic folder (CEF) must have all information and evidence for the disability evaluation stored in the CEF.

2. Background on paper folders

Cases that are officially paper (i.e., cases that are not CEF) must have all information and evidence for the disability evaluation stored in the paper modular disability folder (MDF). Official paper cases may also have an electronic folder containing documents the adjudicating component receives in an electronic format. It is the responsibility of the adjudicating component to print the electronic evidence and add it to the MDF

See Details:

DI 81020.130F, DDS actions when closing a CEF that was converted to paper

3. CEF with prior paper or prior CEF folder

In some instances, evidence that is essential to a current determination in a CEF may be contained in a prior folder (i.e., evidence required to adjudicate the current determination correctly in the CEF).

Using evidence from the prior folder:

• If prior folder evidence is relevant to the current CEF and reopening is applicable, the adjudicating component does not add the evidence to a current CEF unless their legacy system is at version 13.0. Until the adjudicating component is at version 13.0, do not process reopenings of prior adjudicating component’s determinations electronically and revert to paper processing. Refer to DI 81020.115, Processing Reopenings.

• If prior folder evidence is relevant to making a determination in the current CEF, but does not result in a reopening of the prior application or disability determination, the adjudicating component should add the essential evidence from the prior folder to the current CEF.

See Also:

DI 81020.030, Prior Folder Material

C. Policy for cases with essential evidence that is missing or illegible

A missing essential evidence TCA exists when essential evidence is missing from the case file and:

• The missing evidence is listed on the case development summary as obtained;

• It is otherwise apparent from references in file that we obtained the missing evidence; or

• The CEF contains an illegible image of a document that is essential evidence necessary to make a current determination.

Refer to guidelines in GN 04440.235, Correcting Other Technical Corrective Actions (TCAs) in General.

D. Procedure for correcting cases with essential evidence that is missing or illegible

1. Paper folders with missing or illegible essential evidence

If the case file consists of a paper MDF only, contact the adjudicating component to obtain the missing evidence and ask the adjudicating component to email or telephone the review component after faxing or sending the missing evidence to the review component.

If the case also has an electronic folder and it contains the missing evidence, the review component should print and place the evidence in the MDF.

If the review component determines that a particular office frequently does not print electronic documents for the official paper folder, contact the regional center for disability (CD).

2. CEF with prior folder (prior paper or prior CEF) that is missing prior essential evidence

When a prior folder exists and the adjudicating component failed to add essential evidence to the current CEF, the review component should take action to add the essential evidence to the CEF.

NOTE: The review component is not responsible for adding essential evidence to the CEF from a prior folder or adding documents that other offices created or received. Nevertheless, during the course of quality review, if the review component determines that an office failed to add either essential evidence from a prior folder or their documents to the CEF, the review component must add the essential evidence and documents to the CEF. For instructions on adding documents to the CEF, see DI 81030.055.

If the review component determines that a particular office frequently does not add essential evidence or documents to the CEF, contact the regional CD.

3. CEF is missing essential evidence

When evidence that is essential to the current determination is missing from the CEF, but the adjudicating component’s case development summary lists the evidence as obtained, or it is otherwise apparent from references in the CEF that the adjudicating component obtained it, prepare an assistance request (AR) as follows:

• Prepare an eForm SSA-883-U3 (Request for Evidence or Assistance (Disability Case)), and indicate the necessary corrective action. Inform the adjudicating component that you are not charging a deficiency at this time because the evidence is missing from the file. Also, inform the adjudicating component that once you receive the missing evidence and review the case, citing a deficiency is possible.

• Print and fax the eForm SSA-883-U3 into the CEF.

• Do not clear the case in the Office of Quality Review’s legacy system. The case remains on the pending list.

• Create the AR and select reason code 18 – Missing Essential Evidence.

• Enter text in the Note field, as needed.

• Send the AR and follow up with the adjudicating component as needed. Refer to DI 81030.018, Initiating and Processing Electronic Assistance Requests (AR) and DI 81020.100, Electronic Assistance Requests (AR).

When the adjudicating component responds to the review component's AR with completed development, the review component completes the review in the usual manner. The review component cites a deficiency if, after reviewing the missing evidence, the case now contains a deficiency.

4. CEF has an illegible image in eView

When the CEF contains an illegible image of a document that is essential to the current determination, the review component prepares an AR as follows:

• Prepare an eForm SSA-883-U3, and indicate the necessary corrective action.

• Inform the adjudicating component that citing a deficiency is not possible at this time because the evidence is illegible.

• Inform the adjudicating component that citing a chargeable deficiency is possible once the evidence is legible and the review component reviews the case.

• Print and fax the eForm SSA-883-U3 into the CEF.

• Create the AR and select reason code 18 – Missing Essential Evidence.

• Enter text in the Note field, as needed.

• Send the AR and follow up with the adjudicating component as needed. Refer to DI 81020.100, Electronic Assistance Requests (AR).

NOTE: The case remains on the review component’s pending list during this process.

When the adjudicating component responds to the review component's AR with the requested development, the review component completes the review in the usual manner. The review component cites a deficiency if, after reviewing the legible evidence, the case now contains a deficiency.