BASIC (01-08)

A. General – Medical Evaluation

In addition to following current policies and procedures pertaining to case review and medical evaluations, Medical Consultants/Psychological Consultants (MC/PC) must evaluate electronic cases by reviewing imaged documents stored in the Certified Electronic Folder (CEF).

B. Medical Consultant/Psychological Consultant (MC/PC) Evaluation

1. Preparing Medical Assessment Forms

To complete the medical evaluation of an electronic case, process the applicable medical evaluation eForm(s) electronically through the DDS case processing system (see eForms - DI 81020.105). The Disability Examiner (DE) or the MC/PC prepares the eForm(s). Initial physical impairment assessments may be signed by the MC or the DE in Single Decision Maker (SDM) and prototype states. However, initial mental impairment assessments in denials must be signed by the MC psychiatrist or PC. Reconsideration, Childhood Disability and Continuing Disability Review (CDR) claims must have all eForm(s) electronically signed by the MC/PC. Prepare the following forms electronically using eForms and save them to the CEF:

• SSA-538 – Childhood Disability Examination Form (CDEF);

• SSA-2506-BK – Psychiatric Review Technique Form (PRTF);

• SSA-4734-F4 – Residual Functional Capacity (RFC) Assessment; and

• SSA-4734-F4-SUP – Mental Residual Functional Capacity (MRFC) Assessment.

NOTE: If completing the paper version of the form in lieu of using eForms, it must contain the hand-written (wet) signature of the person that completed the form and be scanned into the CEF.

2. Modifying Previously Made Medical Assessment on the Same Case

An eForm cannot be altered or modified once it has been uploaded into the CEF. If, due to additional evidence being received, or other reason, a change is needed to a medical assessment form already uploaded to the CEF (but before the case is closed by the DDS), the DDS may use an SSA-416, or similar eForm to record the change in the original medical assessment. After completing and uploading the SSA-416, or similar eForm, add a note to both documents in the “Case Documents” section of eView to cross refer each document to the other as follows:

• For the Medical Assessment form - ‘See SSA-416 (or similar eForm) dated xx/xx/xx.’

• For the SSA-416 (or similar eForm) – “Revises SSA-4734 (or appropriate medical assessment form) dated xx/xx/xx.”

NOTE: The SSA-416, or similar eForm can not be used to make a change to the SSA-538, a new SSA-538 must be created to reference the initial SSA-538. See DI 25230.001B.4. for more information SSA-538.

3. Using Scanned Tracings in Medical Evaluation

Images of tracings (electrocardiogram, pulmonary function study tracings, etc.) are acceptable to use for medical evaluation, even if the image somewhat distorts the actual scale, as long as the scale is displayed on the image and the grid lines are viewable. (See Electronic Case Documentation - DI 81020.065, for information about scanning the tracing into the CEF.)

C. Affirming Medical Assessments on Reconsideration Cases

The MC/PC may affirm any of the initial level medical assessment(s) when evaluating reconsideration cases. For affirming electronic reconsideration cases, see Processing Reconsiderations - DI 81020.025C.