Effective Dates: 01/10/2025 - Present Previous | Next

TN 176 (01-25)

GN 04440.204 Group II Deficiencies

A. Definitions of group II deficiencies

There are two types of group II deficiencies, decisional and documentation. A group II decisional deficiency is a substantive deficiency in which the evidence supports a different onset, ending, or cessation date for a disability determination that is material i.e., the different date has the potential to affect the month of entitlement (MOE), the primary insurance amount (PIA), or the earnings freeze. A group II documentation deficiency is a substantive deficiency in which the evidence is insufficient and obtaining additional evidence has the potential to change the onset, ending, or cessation date for a disability determination.

1. Group II decisional deficiencies

The review component will cite a group II decisional deficiency based on the following issues:

a. Onset date (category 71 )

The adjudicating component allows a disability claim, but evidence supports a different onset date. In potential reopening situations, cite this deficiency when the adjudicating component:

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should have reopened, but did not (even when the established onset date (EOD) is correct),
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should not have reopened, but did (even when EOD is correct), or
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correctly reopened, but established an incorrect onset date that is material.

b. Ending date (category 72)

The adjudicating component allows a disability claim:

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for a closed period, but evidence supports a different ending date,
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for a closed period, but evidence is sufficient to show disability did not end, or
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for an open period, but evidence is sufficient to show disability ended.

c. Cessation date (category 73)

The adjudicating component ceases an individual’s disability benefits, but evidence supports a different cessation date.

2. Group II documentation deficiencies

The review component will cite a group II documentation deficiency based on the following issues:

a. Onset date (category 81)

The adjudicating component allows a disability claim, but evidence is insufficient to support the onset date. This includes situations where the adjudicating component’s EOD falls within a previously adjudicated period, and there is insufficient evidence to determine whether the prior denial determination can be reopened.

The review component should not cite a Group II onset date documentation deficiency when the field office (FO) did not inform the adjudicating component of a prior determination, and there was no indication of a prior determination in the certified electronic folder (CEF).

b. Ending date (category 82)

The adjudicating component allows a disability claim for a closed period, but evidence is insufficient to support the ending date.

c. Cessation date (category 83)

The adjudicating component allows a disability claim, but evidence is insufficient to determine the correct cessation date.

d. Unresolved work activity that has potential to affect the period of disability (category 85)

The adjudicating component allows a disability claim, but evidence is insufficient to determine either the correct onset or ending date because of unresolved work activity.

NOTE:

When sufficient documentation exists to support a different established onset date (EOD) or if there is insufficient evidence to support the EOD, the reviewer's deficiency is based on the potential impact of the adjudicator not following policy. As explained in DI 25501.300, the EOD impacts the PIA, MOE, and the disability freeze.

B. Correcting group II deficiencies

The review component handles group II deficiencies differently depending on the specific deficiency involved and the circumstances of the case. The review component either returns the case to the adjudicating component for correction or corrects the case.

1. Case returned to the adjudicating component for corrective action

Group II documentation deficiencies involving onset or ending date, unresolved work activity that has the potential to affect the period of disability, and all cessation deficiencies are returned to the adjudicating component for correction. In these cases, the review component will:

a. code the deficiency in the case processing system,

b. notify the adjudicating component, via an SSA-1774-U5, Request For Corrective Action, to explain why the determination is not policy compliant and to request the adjudicating component to undertake appropriate development,

c. route the case to the adjudicating component for correction as a controlled return, and

d. follow-up with the adjudicating component in 60 days if the corrected determination has not been returned to the review component.

2. Case corrected in the review component

Group II onset and ending date decisional deficiencies are corrected by the review component. In these cases, the review component will:

a. annotate all of the adjudicating component’s original determination and medical assessment forms, as well as notices, in the CEF as “Do Not Process” or “Do Not Release”, as applicable,

b. code the deficiency in the case processing system,

c. notify the adjudicating component, via an SSA-1774-U5, Request For Corrective Action, to explain why the determination is not policy compliant,

d. correct the onset or ending date,

e. prepare and release any necessary personalized notices, and

f. route the case to the FO for effectuation.

EXCEPTION: If the case has another deficiency or technical corrective action requiring correction by the adjudicating component, or changing the ending date results in an adverse reopening of either an initial or a reconsideration case, the review component will follow the instructions in GN 04440.204B.1 above, to return the case to the adjudicating component for correction.