TN 13 (04-13)

Citations: 20 CFR sections

404.1517,404.1519 through404.1519t,416.917, and416.919 through 416.919t

A. Definitions for CE policy

1. Consultative examination (CE)

A CE is a physical or mental examination or test purchased from a medical source, at the Social Security Administration's request and expense, to provide evidence for a claimant’s disability or blindness claim.

2. Evidence

Evidence is anything relevant to a claim that the claimant or anyone else submits or that we obtain. For a detailed explanation of evidence, see DI 22501.001B.

3. Medical source

For the definition of medical source, see DI 22505.001A.4 Medical and Nonmedical Evidence.

• Acceptable medical source, or

• Other health care provider who is not an acceptable medical source.

4. Claimant’s own medical source

A claimant’s own medical source is a medical source who has provided a claimant with evaluation, examination, or treatment.

• Provides or has provided the person with medical treatment or evaluation, and

• Has or has had an ongoing treatment relationship with the person.

For an explanation of when an acceptable medical source is not a treating source, see DI 22505.001B.1.

5. Qualified CE source

A qualified CE source is a medical source who:

• Is currently licensed (or certified in the case of a psychologist, or otherwise qualified in the case of a speech-language pathologist) in the State in which he or she performs the CE.

• Has the training and experience to perform the type of examination or test requested; and

• Is not barred from participation in Medicare or Medicaid programs or any other Federal or federally assisted programs.

For policy on selecting a qualified medical source for a CE and on the qualifications required of support staff assisting a qualified source in performing a CE, see DI 22510.010.

For details about CE provider licensure, see DI 39569.300.

For details about program integrity considerations, see DI 39569.200A.

B. Policy for approval of CEs

Some disability determination services (DDS) may require supervisory approval for the authorization or purchase of CEs. Follow your DDS business process regarding supervisory approval.

If the CE could involve significant risk to the claimant, see additional approval requirements in DI 22510.006C.

C. Policy for payment for CEs

• We pay for any CE we order for the claimant.

• We do not pay for any medical examination arranged by the claimant or the claimant's representative, unless we approve it in advance.

D. Procedures for ordering a CE

1. Make the decision to purchase a CE on an individual case basis.

2. Purchase only the specific test or examination needed. For example, if you need only an x-ray, EKG, or blood test, do not authorize a comprehensive medical examination.

3. Select an appropriate CE source. (See DI 22510.010.)

4. Notify the CE source in writing. (See DI 22510.017A.)

5. Provide the CE source background information, if appropriate. (See DI 22510.017.)

6. If ordering a CE for a case pending hearing, see additional instructions in DI 29501.010.