TN 48 (06-17)

A. Policy for medical evidence of capability

Medical evidence of capability is evidence of a medical nature that sheds light on a beneficiary’s ability to manage or direct the management of benefits.

To be evidence “of a medical nature”, the evidence must come from a medical source (physician, psychologist, or other qualified medical practitioner) who is in a position to provide a meaningful assessment of the beneficiary’s ability to manage benefits.

When a beneficiary’s capability is questionable, you must develop medical evidence (if available).

1. What is medical evidence of capability?

Medical evidence is a statement offered by a medical source (physician, psychologist, or other qualified medical practitioner), based on his or her evaluation, examination, or treatment of the beneficiary that gives insight on the beneficiary’s ability to manage or direct the management of benefits.

This evidence usually takes the form of a statement signed by the medical source who conducted the examination or a person authorized to sign such certifications (e.g., a medical records librarian). For instructions regarding unsigned medical evidence, see GN 00502.050B.4.

The Form SSA-787 (Physician’s/Medical Officer’s Statement of Patient’s Capability to Manage Benefits) is the usual vehicle for obtaining medical evidence of capability. However, you may use other forms or summary reports from the medical source if they include the information as described above.

Medical evidence must have a signature of the medical source who conducted the evaluation, examination, or provided the treatment, or a person authorized to sign such certifications.

The field office (FO) sends the Forms SSA-787 and SSA-827 (Authorization to Disclose Information to the Social Security Administration) directly to the medical source.

If the medical source does not mail the completed SSA-787 directly back to the Social Security Administration (SSA) with a wet signature or a rubber stamp signature, the FO may accept the completed SSA-787 if the medical source:

• Directly mails the completed SSA-787 with a wet signature or a rubber stamp signature to the beneficiary instead of SSA;

• Faxes the completed SSA-787 directly to SSA; or

• Provides a completed photocopy of the SSA-787 directly to SSA.

If the FO questions the authenticity of the SSA-787, follow GN 00502.040A.2, in this section.

You must scan all completed SSA-787’s you obtain, and any other paper medical evidence obtained for your capability determination, into NDRed or eView per GN 00502.050B.1.

2. Procedure if the FO questions the authenticity of the SSA-787

If the FO questions the authenticity of the SSA-787, the FO must contact the medical source, or medical source’s representative, to confirm the SSA-787’s authenticity and verify the contents. You must document the details of contacts with medical sources as follows:

a. Case established in the electronic Representative Payee System (eRPS)

A payee application is taken or will be taken, whether the application is denied or approved or there is an established beneficiary’s case in eRPS:

On the Beneficiary Details page, using the “Add Report of Contact” link, complete the RPOC. In the “Subject” section, write “SSA-787 CONFIRMATION” before adding your details in the “Report” section see, MS INTRANETERPS 016.002.

b. Case not established in eRPS

Follow these procedures for all beneficiary cases not established in eRPS.

EXAMPLE: The state Disability Determination Services (DDS) suggested there may be a possibility the beneficiary needs a payee, however you do capability development and determine the beneficiary is capable (there is no payee application) or the representative payee does not have an SSN and there is no prior beneficiary’s case established in eRPS:

• Title II or Concurrent--Complete the Report of Contact (RPOC). In the “Report” section, write “SSA-787 CONFIRMATION” before adding your details (see MS MCS 008.007).

• Title XVI--Complete the Report of Contact (DROC). In the “Report Text” section write “SSA-787 CONFIRMATION” before adding your details (see MS MSSICS 022.010).

NOTE: If you are unable to establish a RPOC in MCS or DROC in MSSICS, use the paper Form SSA-5002 (Report of Contact) for your documentation and scan into NDRED or eView.

You must:

• Scan the SSA-787, and any other paper medical evidence, into NDRED or eView; and

• Note in your “Report of Contact” in eRPS, MCS, or MSSICS, you scanned the SSA-787 and any other paper medical evidence used in your capability determination, into NDRED or eView.

3. How much consideration should I give to medical evidence?

Medical evidence is a very important factor in determining a beneficiary’s capability. You must develop for up-to-date (based on an evaluation, examination, or treatment within the last year) medical evidence in every case when capability is questionable.

Although a major factor, medical evidence is not the definitive, determining factor of capability. You must evaluate medical evidence, along with lay evidence, in order to make a sound capability determination.

It is important to use good judgment to weigh the value of the medical evidence before you make a determination based on it. For example, a medical statement of capability from a consultative examiner or another medical source based on limited contact with the beneficiary is less convincing than a statement from the beneficiary’s own medical source. Likewise, a medical statement based on an evaluation, examination, or treatment of more than a year ago would not be as valuable as medical evidence that is more recent.

To arrive at a sound and well-reasoned capability determination, you must carefully evaluate the medical evidence in each case (see GN 00502.050B), along with all other evidence (namely, lay evidence, see GN 00502.030 and GN 00502.050A.)

4. What if the state Disability Determination Services (DDS) offers an opinion regarding a beneficiary’s capability?

In disability cases, the DDS often gives an opinion regarding the beneficiary’s capability. The DDS is not responsible for making capability determinations. The DDS opinion is lay evidence of capability; it is NOT a determination on capability.

In cases where capability development is initiated by the DDS (see GN 00502.050B.6), the DDS enters its opinion in the remarks section of the Forms SSA-831-U3 (Disability Determination and Transmittal), SSA-832-U3 (Cessation or Continuance of Disability or Blindness Determination and Transmittal) for Title XVI, or the SSA-833-U3 (Cessation or Continuance of Disability or Blindness Determination and Transmittal) for Title II.

If the file contains a completed SSA-831-U3, SSA-832-U3, or SSA 833-U3 from the DDS with no opinion on capability, do not seek a DDS opinion on capability even if you have doubts about the beneficiary’s capability. Develop capability using other information.

5. What is the significance of disability listings?

Disability listings appear on the SSA-831-U3, in item 23. They may be referred to in Administrative Law Judge or Appeals Council decisions. A disability allowance under disability listing 12.05A is medical evidence only of incapability and you must consider the medical evidence along with lay evidence. Evaluate it as you would any other piece of medical evidence. For more information on DDS procedures for developing capability, see DI 23001.005.

6. What if the Social Security Administration (SSA) is asked to pay for medical evidence?

SSA does not pay for medical evidence used solely to decide capability, see GN 00502.050B.5.