TN 48 (06-17)

A. Procedure for developing lay evidence

Absent evidence of legal incompetence (see GN 00502.023), lay evidence must be developed and considered in every capability determination, as discussed in GN 00502.030. Use your judgment to determine how much lay evidence you need to make the correct capability determination.

1. What is the best source for developing lay evidence?

A face-to-face interview with the beneficiary (if practicable) is the best source for lay evidence of capability because it gives you the opportunity to observe the beneficiary's behavior, ability to reason, ability to function with others, and effectiveness with which he or she pursues the claim. The face-to-face interview with the beneficiary is an invaluable tool for determining capability, see GN 00502.030A.1.

To guide you through the issues you will want to learn about and to help you formulate an assessment of the beneficiary's capability, here are some sample questions you might pursue in the interview. Not all of these questions will be appropriate in every case. During the interview, you may think of other questions that you deem fit.

Suggested questions:

a. Financial management

Evidence of real-world financial performance is the most reliable basis for making a capability determination. The answers to the following questions demonstrate the beneficiary’s self-awareness and ability to address current needs, understanding of the value of money, independence, self-sufficiency, and ability to handle problems:

• What are the most important things you spend money on?

• What bills do you pay each month? When you live on your own, what bills do you pay (rent/utilities/food/transportation)?

• Do you pay these bills or does someone else pay them for you?

• Do you ever forget to pay some bills?

• If you forgot to pay a bill, what did you do about it? How did you find out about it?

• Do you have any problems with making change?

• Do you go to the bank? If yes, how often?

• Do you have a bank account? If yes, is it a checking or savings account? Do you write checks? Do you handle online banking transactions? If not, does someone else write checks on your account or handle your online banking transactions? Is there anyone else named on any of your bank accounts?

• Did you write a check for insufficient funds (“bounced” a check)? Did you ever get charged a fee for an overdrawn account? How often has this happened? Why do you think this happened, and what did you do when it happened?

• How often do you get a statement from the bank? What do you do with the statement? Do you read and understand it?

b. Shelter

The following questions provide essential information in determining the beneficiary’s ability to meet basic daily needs, stability in living arrangements, and existing support network:

• In what type of housing do you live?

• How long have you lived there? If less than one year, where did you live before?

• Do you live alone? If not, who lives with you?

c. Food

The quality and nutritional value of food could be a significant clue regarding the beneficiary’s ability to meet basic daily needs. Assistance in these tasks could be significant regarding support network and independence:

• How many meals per day do you usually eat?

• What kind of food do you usually eat?

• Do you go to the store to buy groceries? If not, does anyone else buy groceries for you? Who?

• Do you decide what groceries you need to buy? If not, who decides?

• If you go to the store to buy groceries, how do you get there?

• What would you do if you ran out of food before your check comes?

d. Medical

The following questions could provide essential information regarding the beneficiary's ability to meet basic medical needs:

• Do you see a doctor? If so, where do you go and how often? If not, why not?

• Do you take medication? If yes, do you need help remembering when and how much to take?

• How do you pay the doctor's bill or pay for medicine?

e. Support network

The following questions attempt to provide insight into the beneficiary's existing family, friends, acquaintances, or social service workers whom the beneficiary can count on to help:

• Do you have any relatives who live nearby?

• Do you have any friends or other people you can trust?

• Do your friends or relatives help you in any way? Do you ask your friends or relatives for help when you need it?

• Is there a community center or other group that helps you or teaches you how to budget your money and pay bills each month?

• Do your friends or family help you figure out how to manage your benefits and other funds?

f. Questions to evaluate a beneficiary’s thought process

The following questions could provide insight into the beneficiary's thought processes, ability to reason, or value system, and could give clues regarding a beneficiary's vulnerability to predators:

• What things besides food do you shop for each month?

• Do friends or family borrow money from you and not pay you back?

• Do people borrow things you own and not give them back?

• Have you ever lived with people that did not pay their share of the rent or other expenses?

• If, in the last year, you lived with friends or family, did they charge you for the rent? If yes, how much?

NOTE: When the beneficiary has limited English proficiency (LEP), see Language Assistance Required GN 00203.011.

2. What other lay evidence can I develop?

You can develop lay evidence in the form of statements from third-party sources with direct knowledge of facts or circumstances regarding how the beneficiary manages finances to meet his or her basic needs. Sources of such information include the beneficiary’s custodian, relatives, social workers, therapists, clergy, representatives of community service groups, adult protective services workers, friends, neighbors, and landlords. Consider obtaining statements from a third-party source other than the payee applicant. While it is preferable that you obtain statements signed by the source, do not delay a capability determination merely to obtain a signature.

a. Ask the third party the following questions to obtain specific information about the beneficiary’s financial performance:

• Do you have direct knowledge of how the beneficiary manages finances to meet basic needs? NOTE: The third party must have direct knowledge of the beneficiary’s real world financial performance to provide a statement.

• What is your relationship with the beneficiary (e.g., parent, spouse, other relative, friend, social worker, therapist, clergy, other)?

• How long have you known the beneficiary? (The longer the time of acquaintance, the more information the source may have.)

• How often do you meet or see the beneficiary (daily, weekly, monthly, quarterly, yearly)? (The more frequent meeting, the more knowledge the source has of the beneficiary.)

• Based on your interaction with and observation of the beneficiary, does he or she have general knowledge of what is happening to his or her money (e.g. the amount he or she receives monthly, what bills are being paid such as rent, utilities, and food, and whether the remainder is saved)?

• Is the beneficiary able to handle a checking/savings account? (Are you aware of any bounced checks issued by the beneficiary or recurring bank fees for overdrawing the account? If yes, why do you think it happened and what did the beneficiary do about it?)

• Is the beneficiary able to pay bills on time? (Does he or she have sufficient understanding of the concept of time in order to pay bills promptly? Are you aware of any occasion a utility company cut off his or her utilities due to non-payment? Did he or she ever receive an eviction notice?)

• Based on your observation of the beneficiary, can he or she successfully manage money to meet basic needs (such as food, shelter, and clothing)? Can you describe how the beneficiary is meeting daily needs?

• Can the beneficiary direct someone else in the management of his or her benefits? Do you know who (if anyone) is helping or would be ideal to help the beneficiary in managing benefits?

• Do you have any other comments or concerns about the beneficiary’s financial performance or financial management capability?

b. You must document your contact with the third party and his or her detailed statement:

• Case established in the electronic Representative Payee System (eRPS)

  A representative 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 “Report of Contact Details” screen. In the “Subject” section write “CAPABILITY-THIRD PARTY STATEMENT” before adding your details in the “Report” section, see MS INTRANETERPS 016.002.

• 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 might be a possibility the beneficiary needs a representative payee, however you do capability development and determine the beneficiary is capable, therefore, there is no new representative payee application, or the representative payee does not have an SSN and the beneficiary has no established case in eRPS):

  • Title II or Concurrent--Complete the “Report of Contact (RPOC)” screen in Modernized Claims System (MCS). In the “Report” section, write “CAPABILITY-THIRD PARTY STATEMENT” before adding your details (see MS MCS 008.007).

  • Title XVI--Complete the “Report of Contact (DROC)” screen in Modernized Supplemental Security Income Claims System (MSSICS). In the “Report Text” section write “CAPABILITY-THIRD PARTY STATEMENT” before adding your details (see, MS MSSICS 022.010).

If you are unable to establish a RPOC in MCS or DROC MSSICS, use the paper Form SSA-5002 (Report of Contact) for your documentation and scan into Non-Disability Repository for Evidentiary Documents (NDRed) or eView (Retention of Paper Material, see GN 00301.322).

If you obtained a signed third party statement:

• Scan the statement into NDRed or eView; and

• Note in the “Report of Contact” in eRPS, MCS, or MSSICS that a detailed third party signed statement used in your capability determination is in NDRed or eView.

NOTE: You must use Form SSA-788 (Statement of Care and Responsibility for Beneficiary) if you contact the beneficiary's custodian and the custodian is different from the representative payee applicant. Scan the completed SSA-788 into NDRed or eView.

These are not the only sources of lay evidence. Any other means of obtaining evidence that indicates the beneficiary's ability to manage or direct the management of benefits is acceptable.

CAUTION: Do not suspend or delay benefits while developing capability. Consider paying current benefits only while resolving the capability issue following the instructions in GN 00504.105.

B. Procedure for developing medical evidence

1. What kind of medical evidence should I get and how should I get it?

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 conducted within the last year, as discussed in GN 00502.040.

You must scan all SSA-787’s, and any other paper medical evidence obtained for use in your capability determination, into NDRed or eView.

The Form SSA-787 (Physician’s/Medical Officer’s Statement of Patient’s Capability to Manage Benefits), is a commonly used instrument to provide this kind of medical evidence. However, other forms or summary reports from medical sources may also be used, see GN 00502.050B.2 EXCEPTIONS, in this section.

To carry the full probative value of medical evidence, the medical source, who conducted the evaluation, examination, or provided treatment, or a person authorized to sign such certifications (e.g., a medical records librarian), must sign the statement.

REMINDER: While the Social Security Administration (SSA) must obtain medical evidence of capability, per GN 00502.020B, it is at SSA’s discretion that we send the SSA-787 to the medical source when developing capability. Receiving a signed SSA-787 from a medical source, along with the Form SSA-11 (Request to be Selected as Payee), does not eliminate the necessity of fully developing lay evidence of capability.

If you question the authenticity of a completed SSA-787, contact the medical source who submitted the SSA-787 to confirm its authenticity and contents per GN 00502.040A.2.

Absent evidence of legal incompetence, you must make a capability determination, see GN 00502.023, and you must obtain lay evidence in all cases – there are no exceptions even if medical evidence of incapability is in file. For information on developing lay evidence, see GN 00502.050A.

2. What is the best way to get evidence of capability from medical sources?

If the beneficiary had an evaluation, examination, or treatment by a medical source within the past year, you must obtain a signed and dated form SSA-827 (Authorization to Disclose Information to the Social Security Administration (SSA) and send the signed and dated SSA-827 with an SSA-787 to the medical source. (Follow instructions for completing the SSA-827 in DI 11005.055.)

The beneficiary or representative (someone who can act under State law, in making decisions related to beneficiary health care) must sign the SSA-827, or an alternative Health Insurance Portability and Accountability Act (HIPAA)-compliant authorization form, to disclose medical information. If the beneficiary refuses to sign the form, and has no representative, develop capability using other evidence. For developing lay evidence, see GN 00502.050A. For direct payment prohibitions, see GN 00502.001C.

If the beneficiary decides to undergo an evaluation, examination, or obtain treatment on his or her own volition, ask the beneficiary to notify SSA after the examination. Then mail a SSA-787, and signed and dated SSA-827, to the medical source. If the beneficiary is unwilling to undergo an evaluation, examination, or treatment do not compel him or her to do so solely to obtain medical evidence of capability.

REMEMBER: SSA does not pay for medical evidence used solely to decide capability, see Payment for Medical Evidence of Capability in GN 00502.050B.5.

EXCEPTIONS:

• If you developed other methods (which you believe are resistant to fraud) of obtaining accurate statements from medical sources quickly, you may use these rather than mailing the SSA-787 to the medical source. (Follow instructions for completing the SSA-827 in DI 11005.055.)

• If the beneficiary is not in treatment or chooses not to undergo a current evaluation, examination, or obtain treatment, develop other evidence of capability.

3. How can I get evidence of capability from the Department of Veterans Affairs (VA)?

If the medical source works at a VA facility, include a signed and dated SSA-827 (Authorization to Disclose Information to the Social Security Administration (SSA) with your request (e.g., your request may be the SSA-787).

4. What if I receive unsigned medical evidence?

If you have an unsigned SSA-787, contact the medical source of the evidence for confirmation. If the medical source confirms providing the unsigned evidence, treat it as signed and document all pertinent facts. The confirmation may be from the medical source who provided the SSA-787 or the medical source’s representative.

If the medical source cannot confirm providing the evidence, redevelop by sending an SSA-787 and SSA-827 to this medical source, or develop for other evidence of capability.

You must document the details of your contact with the medical source, per GN 00502.040A.2.

If you have medical evidence other than a SSA-787 that is clearly a part of the beneficiary's medical records, especially those submitted as evidence in determining capability, treat them as if the medical source signed them.

5. What if the medical source asks the Social Security Administration (SSA) to pay a fee for medical evidence?

SSA does not pay for medical evidence of capability. If the medical source requests payment for medical evidence of capability, do not honor the request. Explain that since we will not use the evidence in deciding entitlement, SSA cannot pay for it.

If the medical source refuses to provide the evidence without payment, develop capability using other evidence.

6. What about medical evidence of capability from the state Disability Determination Services (DDS)?

The DDS is responsible for providing an opinion regarding a claimant’s capability to manage his or her disability benefits when the field office (FO) identifies a case where it is likely that a claimant may be incapable or where DDS medical development indicates the claimant may be incapable, per DI 23001.001. While the DDS provide an opinion regarding the evidence of capability, the FO is responsible for the final determination of capability. DDS does not complete medical development solely to resolve an issue of capability, per DI 23001.005.

If you are referring your case to the DDS for a disability determination, you can request DDS assistance in obtaining medical evidence of capability by following the instructions:

• DI 11055.215 Resolving Representative Payee Issues;

• DI 11005.045 Completing the SSA-3367;

• DI 23001.001 Disability Determination Services (DDS) Capability Opinion; and

• DI 23001.005 Disability Services (DDS) Procedures for Developing Capability.

For more information on DDS offering an opinion on capability, see GN 00502.040A.4.

If you do not need a disability determination, or if the DDS indicates on the Form SSA-831-U3 (Disability Determination and Transmittal), that capability is unresolved, contact the medical source for medical evidence of capability, per GN 00502.050B.2.

NOTE: If the DDS collected medical information from a medical source, you can use it as medical evidence for your capability determination. For information on medical evidence, see GN 00502.050B.1. For information on lay evidence, see GN 00502.023.

REMEMBER: You must document your capability determination, per GN 00502.065.