Consultative Exams: A DDS Option to Gather Additional Information
In the process of collecting medical evidence, the DDS examiner may decide that there is insufficient information to make a determination about disability. In this case, the DDS examiner can request an evaluation from an outside source called a Consultative Exam (CE).
About Consultative Exams (CE)
A CE is an evaluation conducted by a contracted provider, scheduled and paid for by DDS, so DDS can obtain additional information as needed. CEs are not required with every application.
Who Conducts the CE?
The regulations indicate that the CE must be conducted by “an acceptable medical source.”
- This includes physicians (psychiatrists or others), psychologists, and some other medical providers
- DDS maintains a list of providers they contract with in the community willing to conduct CEs
- The CE can be conducted by the person’s treating physician or psychologist if the individual provider is a contracted CE provider
- The advantage is that the person will likely feel more comfortable with someone they know
- A person’s own physician can provide an update in the context of past treatment
CEs can provide valuable information to support a claim.
- Provide an up-to-date evaluation
- Helpful when no- or low-cost assessments or evaluations are not available in the community
- Can take the form of psychological or neurological testing or medical diagnostic testing (such as laboratory work, radiology assessments, evaluations by specialists)
CEs tend to be cursory; typically, they are not holistic evaluations of the individual.
- CEs can delay the process, increasing the amount of time before the individual receives benefits
- Applicants often act out of character with an interviewer who is new to them
- They may want to impress the new doctor, so they dress their best and respond in ways that show only their strengths
- They may be uncomfortable and therefore not forthcoming with information
- People may try to hide or mask symptoms
- The full picture of mental illness usually emerges over time
- Many symptoms of mental illnesses are episodic
- The professional administering a CE can only provide information about one visit
- This may provide little information of value
- People who are homeless often miss CE appointments due to logistical problems
- Applicants can be denied for missing the appointment
How Can the SOAR Case Manager Help?
If the case manager is the applicant’s representative, he or she will receive notification of the CE and the date.
- It is critical that the appointment is kept – after one or two missed appointments and no follow up, DDS will generally deny the application
- Do what you can to help the person keep the appointment and accompany them if possible
- Fully explain the purpose of the CE to the applicant – what it is and why it is important
- Encourage the applicant to “tell your struggles” to the consultative examiner
- Advise applicants that no special preparation or dress is required
- With appropriate releases, bring your Medical Summary Report to share with the examiner
SSA's Green Book
- SSA offers additional information in their “Consultative Examinations: A Guide for Health Professionals” also known as the “Green Book”
- Know what the examiner will be assessing for by reviewing the content requirements for CE reports on adult claimants (Part IV of the Green Book).
Elements of a CE Exam
- For more information about how the examination is conducted and the information the examiner is seeking, see Elements of a Consultative Exam (CE) Report for a Disability Based on a Mental Disorder.
- February, 2013
- Medical Records and HIPAA