Medical Evidence to Support SSI Applications

Revised on August 31, 2016

Special Report for SSI Hearing Purposes

This is medical evidence used at an administrative hearing when an ABD recipient is involved in the Social Security disability determination appeal process. These reports are a supplement to medical evidence already obtained by the Department and any consultative exams obtained by DDDS. A Special Report from a medical provider is defined as:

  1. Verbal information provided to the attorney, followed by a written report; or
  2. In person testimony at an administrative hearing.

Reimbursement for special reports must be pre-approved by the Exception to Rule (ETR) process in Barcode.

Medical Evidence at the SSI Initial, Reconsideration, or Hearing Level

When an additional evaluation or testing is necessary to support a SSI application at any level of the determination process, and DDDS will not pay per their policy, use the following procedures:

  1. If payment is within the medical evidence fee schedule, generate a referral in ICMS using the appropriate DSHS 14-150 to authorize payment, and document the reason for the referral in ICMS case notes.
  2. If payment for medical evidence is outside of the medical evidence fee schedule, submit a request for an expenditure approval through the ETR process in Barcode. Please include the following information in the request:
    1. The specific evaluation or testing being requested, including the credentials of the provider needed to perform or author the evidence (e.g. physician, psychologist, neurologist, etc.);
    2. An explanation of why the evaluation is necessary;
    3. An explanation of why DDDS will not pay for the evaluation or testing; and
    4. If the SSI application was denied, the reason(s) for the denial.
  3. If approval is obtained from CSD Headquarters through the ETR process, clearly document the approval in ICMS case notes.
  4. In order to receive reimbursement for an approved evaluation or additional testing, the provider must send the CSO an invoice for the services being billed.  Upon confirmation that the medical evidence has been received and is complete, social services staff will submit the reimbursement request through SSPS using the appropriate service codes detailed in the CSD Procedures Handbook.

EXAMPLE: An ABD recipient with a mental illness has missed multiple DDDS consultative exams despite coordination with DDDS to arrange transportation. DDDS has refused to schedule another consultative examination. Submit an expenditure request through the Barcode ETR process for an evaluation that meets DDDS consultative examination criteria.

EXAMPLE: The SSIF receives a phone call from an attorney asking DSHS to pay for copies of medical records from the local community hospital. The attorney asks for the complete medical records (e.g. "all records" or "all history") and says that they are being used to "prepare the case for hearing." The SSIF asks what specific records are needed, why those specific records are needed, and if all or part of them are included in the DDDS or CSO records already provided to the attorney. The attorney responds by saying they just want to make sure they have everything. The SSIF denies the request because the need for the records has not been clearly demonstrated.