TN 19 (03-15)

Citations:

20 CFR 404.1520b and 416.920b

A. When to request evidence by telephone from a medical source

You may use the telephone to expedite development of medical evidence to:

• Obtain evidence quickly for an expedited processing claim (e.g., a claimant alleges end-stage renal disease and you need documentation on form CMS-2728 (ESRD Medical Evidence Report Medicare Entitlement and/or Patient Registration).

• Verify a diagnosis on a medical report (e.g., a treatment note states claimant has small cell carcinoma but you need to clarify a non-definitive pathology report).

• Resolve an inconsistency or discrepancy in a medical report.

• Clarify what is hand-written in a medical report.

• Initiate medical or psychological consultant (MC/PC) contact with a medical source.

B. Procedure for requesting medical evidence by telephone and fax

These procedures apply to medical evidence that you request by telephone initially, and any medical evidence that supplements medical evidence that you received initially over the telephone or in writing. For instructions on developing supplemental evidence see DI 22505.008.

1. Telephone contact with a medical source’s support staff to obtain MER

In most cases, you do not need to speak directly to the medical source for evidence. An office secretary, office manager, receptionist, hospital medical records technician, or other person who has access to the claimant’s medical records may be able to provide the needed information. Call the source’s office and:

1. Explain the need for the requested medical evidence.

2. Determine whether the office can receive and send faxes.

   1. If the source can receive and send faxes:

      • Fax the medical source the request for medical evidence, the invoice, and an SSA-827 (Authorization to Disclose Information to the Social Security Administration (SSA)), if he or she has not already received one.

      • Ask the medical source to fax the requested evidence back to the certified electronic folder (CEF), using the fax number for your region by placing the bar-coded cover sheet on top of the first page of the document to ensure accurate placement in the case file. For information on faxing documents into the CEF see DI 81010.090C.

        NOTE: It is not necessary for the source to fax the SSA-827.

   2. If the source cannot receive and send faxes, you may request and receive evidence by U.S. mail or other delivery services.

2. Telephone contact with a medical source

IMPORTANT: You are not required to send an SSA-795 to the source for signature if the supplemental contact produced no new evidence, or simply confirmed evidence already received. However, you must still document the supplemental contact.

If you need to speak directly with a medical source in order to complete a medical assessment, telephone contact is appropriate. If the medical source provides new and material evidence:

1. Explain to the source that you will:

   • document the information provided on form SSA-795 (Statement of Claimant or Other Person) for his or her review; and

   • send it for his or her review, date, and signature.

2. Document the information the medical source provides on form SSA-795.

3. Request the medical source sign and return the completed form to document the file.

4. Determine whether the office can receive and send faxes.

   1. If the office can receive and send faxes:

      • Fax the medical source the SSA-795, and an SSA-827, if he or she has not already received one.

      • Ask the medical source to fax the requested evidence back to the certified electronic folder (CEF), using the fax number for your region by placing the bar-coded cover sheet on top of the first page of the document to ensure accurate placement in the case file. For information on faxing documents into the CEF see DI 81010.090C. It is not necessary for the source to fax the SSA-827.

        EXCEPTION: For Electronic Disability Collect System (EDCS) exclusions ask the source to fax you the evidence directly.

   2. If the office cannot send and receive faxes, you may request and receive evidence by U.S. mail or other delivery services.

REMEMBER: Document all development actions using the electronic claims analysis tool (eCAT). For electronic processing exclusions, document development in the case summary.

C. Completing the SSA-795

Discuss and record the relevant information on the SSA-795. To view this form, go to SSA-795.

EXCEPTION: The SSA-795 will be available to all Disability Determination Services (DDSs) upon rollout of the Disability Case Processing System (DCPS). DDS legacy systems may not have the capacity to generate an SSA-795. If your legacy system cannot generate the SSA-795, use the appropriate locally available format.  Include all of the information detailed in this section.

1. Identification

In the applicable blocks on the top of the SSA-795 enter all the following:

• The claimant’s name and social security number.

• The complete name of the person making the statement (i.e. the person to whom you are speaking) and their relationship to the claimant (e.g., Jane Jones, Dr. Smith’s office manager). Indicate the person’s medical credentials, if any.

2. Body of evidence

The statement content begins after the established lead-in language, “Understanding that this statement is for the use of the Social Security Administration, I hereby certify that -.”

In the body of the SSA-795, document the evidentiary information provided. Use the person’s own words to the extent possible.

3. Administrative note

Explain who documented the telephone conversation and when.

Example of an administrative note: “This statement was initially provided to John Doe, State DDS by telephone on 01/21/2015.”

D. Documenting determinations using SSA-795 evidence

Document all SSA-795 issues on the electronic claims analysis tool disability determination explanation (eCAT DDE).

1. SSA-795 required prior to adjudication

If you don’t have other acceptable medical evidence that addresses the issue(s), you must wait for a signed telephone report (SSA-795) to document a:

• partially favorable allowance, or

• denial.

For example, the medical evidence establishes that the claimant received hemodialysis while hospitalized subsequent to a traffic accident. There is no evidence regarding the necessity for chronic hemodialysis. To satisfy the requirements in Listing 6.03, you contact the source to confirm chronic kidney disease (CKD), current dialysis, and that dialysis will be ongoing. However, the source indicates that the claimant suffered acute kidney failure that resolved prior to discharge. Assessment of the claimant’s impairment(s) directs a durational denial. You must wait for the signed SSA-795 to document the issue of kidney failure.

2. SSA-795 not required prior to adjudication

You do not need to wait for the signed SSA-795 if the claim is a fully favorable allowance. Document the case file with the issue(s) that the signed SSA-795 resolves. Place the signed SSA-795 in the file post-adjudicatively.

For example, the medical evidence establishes that the claimant received hemodialysis while hospitalized subsequent to a traffic accident. There is no evidence regarding the necessity for chronic hemodialysis. To satisfy the requirements in Listing 6.03, you contact the source to confirm chronic kidney disease (CKD), current dialysis, and that dialysis will be ongoing. The source indicates that the claimant’s traumatic kidney failure did not resolve. The claimant is currently receiving dialysis, and the source opines the need for chronic hemodialysis or transplant. If the established onset date (EOD) is fully favorable, you do not need to wait for the signed SSA-795 that documents the issue of CKD and chronic hemodialysis.

E. References

• DI 22505.008 Developing Supplemental Evidence

• DI 22505.035 Follow-up on Requests for Medical Evidence of Record (MER)

• DI 81020.020 Electronic Case Development

• DI 81020.035 Document Management Architecture (DMA) Barcodes and Document Indexing

• DI 81020.060 Receiving Evidence in Disability Determination Services (DDS)

• OS 15010.425 SSA-795, Statement of Claimant or Other Person