TN 13 (12-10)

A. Definition of essential evidence

Essential evidence is any evidence that you need to determine whether the claimant is disabled or to resolve any material conflicts in file.

NOTE: What constitutes essential evidence differs from case to case.

B. Background on cases with essential evidence that is missing or illegible

Accomplish case review and evaluation actions by reviewing documents in eView or in the paper folder. When evidence that is essential to the current determination is missing or illegible, the reviewing component is unable to complete the review of the case.

1. Certified electronic folder (CEF)

Cases that have a CEF must have all information and evidence for the disability evaluation stored in the CEF.

2. Paper folder

Cases that are officially paper (i.e., cases that are not CEF) must have all information and evidence for the disability evaluation stored in the paper modular disability folder (MDF). Official paper cases may also have an electronic folder containing documents the adjudicating component receives in an electronic format. It is the responsibility of the adjudicating component to print the electronic evidence and add it to the MDF (see DI 81020.130F).

3. CEF with prior folder (prior paper or prior CEF)

In some instances, evidence that is essential to a current determination in a CEF (i.e., evidence that is needed to correctly adjudicate the current determination in the CEF) may be contained in a prior folder.

Using evidence from the prior folder:

• If prior folder evidence is relevant to the current CEF and reopening applies, the adjudicating component does not add the evidence to a current CEF unless their legacy system is at version 13.0. Until the adjudicating is at version 13.0, reopenings of prior adjudicating component’s determinations cannot be processed electronically and must revert to paper processing. Refer to “Processing Reopenings” DI 81020.115.

• If prior folder evidence is relevant to making a determination in the current CEF, but will not result in a reopening of the prior application or disability determination, the adjudicating component should add the essential evidence from the prior folder to the current CEF.

See Also:

DI 81020.030 - Prior Folder Material

C. Policy for cases with essential evidence that is missing or illegible

A missing essential evidence technical corrective action (TCA) exists when essential evidence is missing from the case file and:

• The missing evidence is listed on the case development summary as obtained;

• It is otherwise apparent from references in file that the missing evidence was obtained; or

• The CEF contains an illegible image of a document that is essential evidence to make a current determination.

Refer to guidelines in “Correcting Other Technical Corrective Actions - General” GN 04440.235.

D. Procedure for correcting cases with essential evidence that is missing or illegible

1. Paper folder

If the case file consists of a paper MDF only, contact the adjudicating component to obtain the missing evidence and ask the adjudicating component to notify the review component by email or telephone after faxing or sending the missing evidence to the review component.

If the case also has an electronic folder and it contains the missing evidence, the review component should print and place the evidence in the MDF.

If the review component determines that a particular office frequently does not print electronic documents for the official paper folder, contact the regional center for disability (CD).

2. CEF with prior folder (prior paper or prior CEF) that is missing prior essential evidence

When a prior folder exists and the adjudicating component failed to add essential evidence to the current CEF, the review component should take action to add the essential evidence to the CEF.

NOTE: It is not the responsibility of the review component to add essential evidence from a prior folder or documents created or received by other offices to the CEF. Nevertheless, during the course of quality review, if you determine that an office has failed to add essential evidence from a prior folder or their documents to the CEF, the review component must take action to add the essential evidence and documents to the CEF. For instructions on adding documents to the CEF, see DI 81030.055.

If the review component determines that a particular office frequently does not add essential evidence or documents to the CEF, contact the regional CD.

3. CEF is missing essential evidence

When evidence that is essential to the current determination is missing from the CEF, but the adjudicating component’s (AC) case development summary lists the evidence as obtained, or it is otherwise apparent from references in the CEF that the AC obtained it, prepare an assistance request (AR) as follows:

• Prepare an eForm SSA-883-U3 (Request for Evidence or Assistance (Disability Case)) using the Office of Quality Performance (OQP) legacy system and indicate the necessary corrective action. Inform the adjudicating component that you are not charging a deficiency at this time because the evidence is missing from the file. Also, inform the adjudicating component that, once you receive the missing evidence and review the case, citing a deficiency is possible.

• Print and fax the eForm SSA-883-U3 into the CEF.

• Do not clear the case in OQP’s legacy system. The case remains on the pending list.

• Create the AR and select reason code 18 – Missing Essential Evidence.

• Enter text in the Note field, as needed.

• Send the AR and follow up with the adjudicating component, as needed. Refer to “Initiating and Processing Electronic Assistance Requests (AR)” DI 81030.018 and “Electronic Assistance Requests (AR)” DI 81020.100.

When the adjudicating component responds to the review component's AR with completed development, complete the review in the usual manner. Cite a deficiency if, after reviewing the evidence that was missing, the case now contains a deficiency.

4. CEF has an illegible image in eView

When the CEF contains an illegible image of a document that is essential to the current determination, prepare an AR as follows:

• Prepare an eForm SSA-883-U3 using OQP’s legacy system, and indicate the necessary corrective action.

• Inform the AC that citing a deficiency is not possible at this time because the evidence is illegible.

• Also, inform the adjudicating component that citing a chargeable deficiency is possible once the evidence is legible and the review component reviews the case.

• Print and fax the eForm SSA-883-U3 into the CEF.

• Do not clear the case in the OQP legacy system. The case remains on the pending list.

• Create the AR and select reason code 18 – Missing Essential Evidence.

• Enter text in the Note field, as needed.

• Send the AR and follow up with the adjudicating component, as needed. Refer to DI 81020.100.

When the adjudicating component responds to the review component's AR with the requested development, complete the review in the usual manner. Cite a deficiency if, after reviewing the legible evidence, the case now contains a deficiency.