TN 16 (09-16)

A. Policy for Initial review of CE reports

When a CE report is received, review the CE report as explained in DI 22510.020B in this section.

If the report is inadequate, request and obtain a corrected report.

B. Procedure for processing a CE report review

1. Receiving CE reports

The disability determination services (DDS) may receive CE reports through Electronic Records Express (ERE), by mail, or by facsimile (fax). If there is any question about whether the CE source transmitted faxed evidence:

• Telephone the CE source to verify that the CE source did in fact send the CE report received via fax.

• Document the telephone contact in the case development summary.

NOTE: For ERE, mail, and fax CE report signature policy refer to DI 22510.015C.

2. Reviewing CE report for required information

Review each CE report for the following required information:

1. Does the document properly identify the claimant as required by DI 22510.015A.3.?

2. Is the CE report complete?

   1. Does it contain the information we requested in the CE order?

   2. Does it document other evidence that the claimant provided at the CE appointment?

   3. Is it internally consistent?

      • Are all the diseases, impairments, and complaints described in the history adequately assessed and reported in the clinical findings?

      • Do the conclusions correlate with the findings from the medical history, the clinical examination, and laboratory tests, and explain all abnormalities?

   4. Did the report fail to mention an important or relevant complaint (within the scope of the requested exam) noted in other evidence in the file (e.g., blindness in one eye, amputations)?

3. Did the CE provider properly sign the CE report? For signature requirements, see DI 22510.015C.

4. Did the CE provider submit a copy of any records provided to them directly from the claimant at the examination as outlined in DI 39542.240?

3. Inadequate CE report process

If information in DI 22510.020B.2. in this section is missing or inadequate, contact the CE source to:

1. Explain what is inadequate about the report; and

2. Request the missing information or a revised and corrected report and document the case development summary about the telephone contact.

4. Referral of CE reports

With the claimant’s permission, or where the examination discloses new diagnostic information or test results that reveal potentially life-threatening situations, take the following actions.

a. Claimant has a medical source

Refer the CE report to the claimant's medical source. Put a copy of the cover letter to the medical source in the file or annotate the case development summary indicating you sent a copy of the CE report to the claimant’s medical source.

“Model language for cover letter”

[Claimant First Name and Last Name] has asked us to provide you with a copy of the enclosed Social Security consultative examination/test report. We hope that it will be of use to you.

Under HIPPA, your patient has a right of access to inspect and obtain a copy of this report regardless of whether you created this report or not.

[Disability Examiner First Name and Last Name]

Notify the claimant if you send the CE report to the medical source without the claimant's permission. Put a copy of the letter in the claim file.

b. Claimant does not have a medical source

Advise the claimant in a letter to see a physician for consideration of any additional testing that may be appropriate. If the claimant is unable to pay for such services, inform the claimant of any local welfare agency or medical facility where he or she can obtain the required medical services at no cost. Put a copy of the letter in the claim file.

C. Procedure for processing cases with unsigned or improperly signed CE reports

These procedures apply to both written (“wet”) and electronic signatures. For more information on signature requirements for CE reports see DI 22510.015C.

1. Unsigned or improperly signed CE report for fully favorable determination

If the CE report is unsigned or improperly signed and the determination is fully favorable:

• Adjudicate and release the case.

• Obtain a properly signed CE report post adjudication, unless the medical source who performed the original CE has died.

• Forward the properly signed CE report to associate with the file.

2. Unsigned or improperly signed CE report for other determinations

If the CE report is unsigned or improperly signed and the determination is not fully favorable, do not make a determination. Wait until the adjudicator receives a properly signed CE report (including any telephone supplement).

If the signature of the medical source who performed the original examination cannot be obtained because that source is out of the country for an extended period of time, on an extended vacation, seriously ill, or deceased, or for any other reason, reschedule the CE with another medical source.

D. References

DI 22510.065 Sending the CE Report to the Claimant’s Medical Source

DI 39545.375 Claimant Complaints of Consultative Examination (CE) Provider

DI 81020.070 Consultative Examinations (CE)

DI 22510.015 Information for Consultative Examination (CE) Source