BASIC (04-08)

A. Background

Case review and evaluation actions must be accomplished by accessing the CEF and reviewing documents on screen. All information and evidence for the disability evaluation should be stored in the CEF.

1. CEF with Prior Folder (Prior Paper or Prior CEF)

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

Per DI 81020.030, Prior Folder Material:

• If prior folder evidence is relevant to the current CEF and reopening is applicable, the disability determination services (DDS) will not add the evidence to a current CEF unless their case processing system has been upgraded to version 13.0. Until the DDS is at version 13.0, reopenings of prior DDS determinations cannot be processed electronically and must revert to paper processing. Refer to DI 81020.115, Processing Reopenings.

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

2. CEF Only or CEF with Missing Prior Paper Folder - Missing Essential Evidence

Refer to DI 81030.023A.1. for the definition of essential material. In some instances, evidence that is essential to the current determination is missing from the CEF; and

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

• It is otherwise apparent from references in the CEF that the missing evidence was obtained.

When evidence that is essential to the current determination is missing, the disability quality branch (DQB) is unable to complete their review of the case.

3. CEF Only or CEF with Missing Prior Paper Folder - Illegible Image in eView

In some instances, a document in the CEF displays as an illegible image in eView. When evidence that is essential to the current determination is not legible, the DQB is unable to complete their review of the case.

B. Policy

Essential evidence is any evidence that is needed to make a current determination as to whether the claimant is disabled or to resolve any material conflicts in file. A missing essential evidence deficiency exists when:

• Evidence that is essential to the current determination is missing from the CEF, and

• The missing evidence is listed on the DDS case development summary as obtained, or

• It is otherwise apparent from references in the CEF that the missing evidence was obtained, or

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

Deficiencies involving missing essential evidence or illegible images are non-recorded deficiencies; i.e., an incorrect action that is not recorded as a deficiency to Disability Case Adjudication and Review System (DICARS). Refer to general guidelines in GN 04440.125, Recording Deficiencies, GN 04440.235, Correcting Non-Recorded Deficiencies, and GN 04440.242, Correcting Cases with Essential Missing Evidence.

C. Procedure

1. CEF with Prior Folder (Prior Paper or Prior CEF)

When a prior folder exists and the DDS failed to add essential evidence to the current CEF, DQB should take action to add the essential evidence to the CEF.

NOTE: It is not the responsibility of the DQB to add essential evidence from a prior folder or documents that are created or received by other offices to the CEF. Nevertheless, during the course of quality review, if it is determined that an office has failed to add essential evidence from a prior folder or their documents to the CEF, in order to ensure that the CEF is appropriately documented, DQB takes action to add the essential evidence and documents to the CEF.

If it is determined that a particular office is frequently not adding essential evidence or documents to the CEF, contact the regional Center for Disability.

2. CEF Only or CEF with Missing Prior Paper Folder - Missing Essential Evidence

When evidence that is essential to the current determination is missing from the CEF, but the evidence is listed on the DDS case development summary as obtained, or it is otherwise apparent from references in the CEF that it was obtained, prepare an assistance request (AR) as follows:

• Prepare an eForm SSA-883 (Request for Evidence or Assistance (Disability Case)) using Web eForms, and:

  • Indicate the necessary corrective action;

  • Inform the DDS that no deficiency is being charged at this time because the evidence is missing from the file. Also inform the DDS that once the missing evidence is received and the case is reviewed, a chargeable deficiency may be given.

• Fax the eForm SSA-883 into the CEF.

• Do not clear the case in DICARS. The case remains on the pending list.

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

• Text may be entered in the Note field as needed.

• Send the AR and follow-up with the DDS as needed. Refer to DI 81030.018 Electronic Assistance Requests (AR) – DQB and DI 81020.100, Electronic Assistance Requests (AR).

When the DDS responds to DQB's AR with completed development, complete the review in the usual manner. A deficiency may be charged if, after reviewing the evidence that was missing, the case now contains a chargeable deficiency.

3. CEF Only or CEF with Missing Prior Paper Folder - Illegible Image in eView

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

• Prepare an eForm SSA-883 using Web eForms, and:

  • Indicate the necessary corrective action;

  • Inform the DDS that no deficiency is being charged at this time because the evidence is illegible. Also inform the DDS that once the evidence is legible and the case is reviewed, a chargeable deficiency may be given.

• Fax the eForm SSA-883 into the CEF.

• Do not clear the case in DICARS. The case remains on the pending list.

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

• Text may be entered in the Note field as needed.

• Send the AR and follow-up with the DDS as needed. Refer to DI 81020.100.

When the DDS responds to DQB's AR with the completed development, complete the review in the usual manner. A deficiency may be charged if, after reviewing the legible evidence, the case now contains a chargeable deficiency.