BASIC (10-10)

Citations:

Title II – Federal Old-Age, Survivors, and Disability Insurance 20 CFR 404.1512 Evidence, 404.1520a Evaluation of mental impairments, 404.1527 Evaluating opinion evidence, 404.1529 How we evaluate symptoms, including pain,404.1546 Responsibility for assessing your residual functional capacity,404.1602 Definitions, 404.1615 Making disability determinations, 404.1616 Medical or psychological consultants, 404.1619 Quick disability determinations process.Title XVI – Supplemental Security Income for the Aged, Blind, and Disabled 416.912 Evidence, 416.920a Evaluation of mental impairments, 416.927 Evaluating opinion evidence, 416.929 How we evaluate symptoms, including pain, 416.946 Responsibility for assessing your residual functional capacity, 416.1002 Definitions, 416.1015 Making disability determinations, 416.1016 Medical or psychological consultants, 416.1019 Quick disability determination process.

A. Disability examiner authority for quick disability determinations and compassionate allowance initiative cases

1. Authority

This authority is separate and distinct from single decisionmaker (SDM) authority in Prototype States and SDM II States.

a. Regulatory

Regulations effective November 12, 2010 temporarily permit disability examiners (DEs) in the disability determination services (DDS) to issue fully favorable determinations on claims adjudicated under the quick disability determination (QDD) and compassionate allowance initiative (CAL) procedures. The procedures in this subchapter apply to all qualified adjudicators in all States (see DI 23023.001E in this section).

b. Applicability

The authority applies to QDD and CAL cases at the initial level, and to CAL cases at the reconsideration level. The policy and procedures for QDD and CAL cases generally apply, except as provided in this subchapter.

NOTE: These changes do not apply to claims for Supplemental Security Income payments under Title XVI for persons under age 18. Section 1614(a)(3)(I) of the Social Security Act requires that we make reasonable efforts to ensure that a qualified pediatrician or other individual who specializes in a field of medicine, appropriate to the disability of the individual, evaluates the case.

See Details:

• DI 23022.000 Processing Quick Disability Determination (QDD) and Compassionate Allowance (CAL) in the Disability Determination Services (DDS)

• DI 25201.020 Determinations for Childhood Impairments – Role of Qualified Pediatrician or Other Specialist in the Evaluation – Policy (Section 416.903(f))

2. DE authority to make QDD and CAL determinations

Disability examiners who are authorized to use the procedures in this subchapter are solely responsible for their determinations. Regardless of the basis of the determination (meets a listing, medically equals a listing, or medical-vocational), medical or psychological consultant (MC/PC) signoff is not required for a fully favorable determination. DEs may consult with MCs or PCs but, except in one case, are not required to do so. For the exception, see DI 23023.001H.2. in this section.

B. Cases in which the authority applies

You may make a fully favorable determination without MC or PC input or signoff in the following QDD or CAL cases, if your DDS Administrator authorizes you to do so (and if the cases are not excluded from the authority in this subchapter per DI 23023.001C in this section):

• Initial-level cases assigned to you and identified as QDD or CAL; and

• Reconsideration-level cases assigned to you and identified as CAL.

C. Cases in which the authority does not apply

Even if you are authorized to make fully favorable QDD and CAL determinations, your authority does not apply to:

• Cases removed from QDD processing for any reason, unless they also meet a CAL criterion or they had been removed from QDD in error and QDD was reinstated before case closure;

• Cases removed from CAL processing, unless they are also identified as QDD cases or the case had been removed from CAL in error and CAL was reinstated before case closure;

• Continuing disability reviews (CDRs);

• Title XVI claims for persons under age 18;

• Age-18 redeterminations under Title XVI;

• Individual claims in which the determination is not fully favorable;

• Closed periods, even if the claimant alleges only a closed period; and

• Multiple claims in which any determination is not fully favorable (see DI 23023.001D.1. in this section).

D. Multiple claims

If a QDD or CAL case contains a claim that is not within the authority in this subchapter, route the case to an appropriate medical or psychological consultant (MC/PC) for processing and signoff, as described in DI 23022.000.

1. Fully favorable and less than fully favorable claims

The authority in this subchapter applies only when all claims receive fully favorable determinations. If you cannot use this authority for every claim, you cannot use this authority for any claim. Route these cases to an appropriate MC or PC for processing and signoff, as described in DI 23022.000.

EXAMPLE: The evidence establishes that the claimant was disabled on the date of the application for Title XVI benefits but not on or before the date last insured for purposes of DIB.

Since the determination on the Title II claim is not fully favorable (in this case, a denial), forward both claims to an appropriate MC or PC for processing and signoff, as described in DI 23022.000.

2. Adult and Title XVI childhood disability claims

In rare instances, you may receive a QDD or CAL case in which the claimant must have a determination for both a Title XVI childhood and an adult disability claim. For example, the claimant files a Title XVI application before attaining age 18, but attains age 18 before you make the determination. Since the authority does not apply to the Title XVI child claim, forward the case(s) to the appropriate MC or PC(s) for processing and signoff, as described in DI 23022.000.

E. Minimum DE qualifications

The minimum qualifications for QDD and CAL adjudicators and the authority for DEs to make QDD and CAL determinations under this subchapter are the same. See DI 23022.020.

Each DDS Administrator may also require a DE to have additional experience. The authority in this subchapter applies only to cases assigned to a qualified DE.

F. Consultation with an MC or PC in QDD and CAL cases

You have the option of consulting with an MC or PC at any point in the sequential evaluation process, except in one circumstance where it is required (see DI 23023.001H.2. in this section). Regardless of whether you choose to consult with an MC or PC, or are required to do so, you are solely responsible for the disability determination.

G. MC and PC evidence

MC and PC evidence are “administrative medical findings.” Under the regulations, you have the authority to accept or reject MC and PC evidence. However, each DDS Administrator may alter this authority for DEs within his or her DDS. Your DDS Administrator may decide, for example, that you cannot reject an MC’s or PC’s evidence without first discussing the contrary conclusion with the MC or PC or that you cannot reject an MC’s or PC’s s evidence at all.

If your finding on an issue relevant to the fully favorable determination differs from that of the MC or PC, you must provide a rationale for the finding. If your DDS Administrator does not permit you to reject the finding of the MC or PC and you and the MC or PC cannot reconcile your differences, you cannot issue the determination using this authority. You must determine the case as described in DI 24503.000 Evaluating Evidence.

See Details:

• DI 24503.000 Evaluating Evidence

H. Consultation with an MC or PC at Step 3 of the sequential evaluation process (meets or medical equivalence)

1. Meets listing

If you find that a claimant’s impairment meets a listing, MC or PC consultation is not required, but is optional.

For cases involving mental impairments, you have the authority to complete and sign the SSA-2506-BK (Psychiatric Review Technique Form (PRTF)). You may ask an MC or PC to complete and sign a PRTF and may incorporate the findings on the form in your determination. The determination must state that you are adopting the assessment in total or explain any relevant differences between your findings and the MC’s or PC’s assessment to indicate that you are responsible for the entire determination.

2. Medical equivalence

For a finding about medical equivalence, you must consult with an MC or PC about whether a claimant’s impairment(s) medically equals a listing.

You must document in the case file that you requested and considered an MC’s or PC’s findings regarding medical equivalence. The documentation may be on an SSA-416, SSA-5002, in the determination rationale, or on any other appropriate form. For information regarding considering an MC’s or PC’s administrative medical findings, see DI 23023.001G in this section.

NOTE: If you have sufficient documentation to make a fully favorable determination at Step 5, it is unnecessary to obtain additional documentation to determine whether the claimant’s impairment(s) might also medically equal a listing.

See Also:

• DI 24515.001 Evaluating the Evidence

• DI 25220.010 Meets or Medically Equals

I. Consultation with an MC or PC for Steps 4 and 5 of the sequential evaluation process (past relevant work or other work)

You have the authority to assess residual functional capacity (RFC), and may complete and sign Forms SSA-4734-BK (Physical Residual Functional Capacity Assessment) and SSA-4734-F4-SUP (Mental Residual Functional Capacity Assessment). MC or PC consultation is not required, but is optional.

You may ask an MC or PC to complete and sign an RFC assessment form and may incorporate the findings on the form in your determination. The determination must state that you are adopting the assessment in total or explain any relevant differences between your findings and the MC’s or PC’s assessment to indicate that you are responsible for the determination.

If the determination is not fully favorable, forward the case to an appropriate MC or PC for processing and signoff, as described in DI 23022.000.

J. Coding QDD and CAL cases

Under the regulations, the program is scheduled to end on December 28, 2018, unless we end it earlier or decide to extend it. We need information from each DE to evaluate the success of the program properly. You must fully document each QDD and CAL claim.

To make the data as accurate as possible, we need you to provide data about every QDD and CAL case, including cases that are decided by a team (DE and MC/PC).

NOTE: When we refer to “DE determination” in the following list, we mean a determination you make under the authority in this subchapter. When we refer to “team determination,” we mean a determination for which a DE and an MC/PC are jointly responsible.

Enter one of the following disability-related list codes into Item 26D on the Form SSA-831 (Disability Determination and Transmittal) for each claim. The first three codes apply when a DE alone is responsible for the determination. The last two codes apply when a team is responsible for the determination.

• 360 – DE determination, no MC/PC involvement;

• 361 – DE determination, MC/PC consultation only (no disability forms signed by the MC/PC used in the determination);

  NOTE: Use code 361 when you are making the determination with verbal consultation with the MC/PC (e.g., required administrative medical finding regarding medical equivalence, verbal consultation, no decisional documents signed by an MC/PC),

• 362 – DE determination, MC/PC consultation with disability forms signed by the MC/PC.

  NOTE: Use code 362 when asking for consultation for any reason and decisional forms are signed by an MC/PC (DE is still solely responsible for the determination as it is allowed under this subchapter, however; MC/PC signed forms are in file).

• 363 – Team determination, DE authorized to make QDD and CAL determinations under this subchapter, but MC/PC signature required because of statutory or policy requirement for MC/PC involvement (e.g., T16 childhood disability, closed period, CDR, less than fully favorable determination, concurrent with less-than-fully-favorable determination on at least one claim); or

• 364 – Team determination, DE not authorized to make QDD and CAL determinations under this subchapter, MC/PC signature required (any type of claim).

  NOTE: Use code 364 if you are a DE who does not have the authority to make QDD or CAL determinations in any claims and must always make a determination with an MC/PC. If you are such a DE, always use code 364 regardless of the type of claim or whether the determination is favorable or unfavorable.

K. SSA-831 signature requirement

You must sign the SSA-831 when you make fully favorable QDD and CAL determinations using the authority in this subchapter.

See Details:

For instructions on completing the signature blocks for

• electronic cases, see DI 81020.130;

• paper cases, see DI 26510.090.