There are two methods of resolving deficiency disagreements between adjudicating and review components:

1. 1. 

   The IRR process, administered by Quality Review (QR), attempts to resolve deficiency disagreements informally between the adjudicating and review components. The adjudicating component directs the IRR submission to the review component that cited the deficiency for another impartial review of the case facts and applicable policies in contention. The review component will prepare a policy-based IRR resolution to address the adjudicating component's deficiency disagreement.

2. 2. 

   The RPC process, administered by the Office of Policy Consultation and Analysis (OPCA), resolves deficiency disagreements between the adjudicating and review components through an RPC Panel Discussion. For an explanation of the RPC process, see DI 30007.000.

When the adjudicating component disagrees with any cited group I deficiency, group II deficiency, or technical corrective action (TCA), in a fully electronic case, they are encouraged to attempt to resolve the disagreement on an informal basis by submitting an IRR via the Office of Disability Policy’s (ODP) IRR web-based tool.

NOTE: RPC will not accept submissions when the disagreement involves a change in deficiency type only, otherwise known as a "wrong deficiency cited", unless the case has first been through the IRR process. A wrong deficiency citation occurs when one type of deficiency is cited, but program instructions support a different type; e.g., documentation vs. decisional, or group I vs. group II. In these situations, there is no rescission of the deficiency, but the review component updates the QR case processing system database with the correct deficiency. This still only results in one chargeable deficiency against the adjudicating component.

EXAMPLE: The review component cites a decisional deficiency, changing an allowance determination to a denial determination, but fails to recognize in doing so, that the adjudicating component must first develop all allegations or medical sources prior to denying the claim. The adjudicating component requests the review component change, or replace, the decisional deficiency to a documentation deficiency, agreeing that the evidence does not currently support an allowance, but acknowledging the adjudicating component must develop all allegations or medical sources before making a denial determination. The review component updates the QR case processing system database with the correct deficiency, thus there is only one chargeable deficiency for the adjudicating component.

NOTE: The QR case processing system allows displaying of more than one deficiency code if applicable as a result of the Federal quality review. However, only the deficiency marked as "Primary" is counted against the adjudicating component. Deficiencies marked as "Other" do not count against the adjudicating component unless they subsequently become "Primary" as a result of the IRR or RPC.

If the adjudicating component chooses not to attempt to resolve the disagreement through the IRR process, or if they cannot resolve the deficiency after the IRR process, the adjudicating component may submit an RPC, if the criteria is met, to OPCA for a fully electronic case (see DI 30007.125 - Submitting a Case for RPC). The adjudicating component may not simultaneously submit an IRR and RPC.

If the adjudicating component does not resolve the deficiency through the IRR process, they must complete the request for corrective action(s) noted on the Request for Corrective Action, or Request for Case Action, or submit an RPC, if the case meets the criteria for RPC submission (see DI 30007.125 - Submitting a Case for RPC).

For subsequent returns, which are precluded from the IRR/RPC process, the adjudicating component may choose to contact reviewing component directly to discuss concerns informally prior to completion of the action(s) noted on the Request for Corrective Action or Request for Case Action. (see GN 04440.205 and DI 30005.205 - Quality Review Subsequent Returns).

The adjudicating component uses the IRR process to:

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  resolve disagreements in group I deficiencies, group II deficiencies, or TCAs, in a fully electronic case;

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  request a rescission of a group I deficiency or group II deficiency, in a fully electronic case; or

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  resolve disagreements, within the appropriate time frames, regarding cases with group II deficiencies routed directly from the review component to the Field Office (FO).

When the adjudicating component prepares an IRR, the adjudicating component:

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  cannot use the federal quality review administrative procedure of probability of reversal (POR), as defined in GN 04440.110 and DI 30005.110, as the basis of an IRR for a documentation deficiency;

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  can use substitution of judgment (SOJ), as defined in GN 04440.118, as the basis of an IRR for a decisional deficiency;

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  cannot use SOJ as the basis of an IRR for a documentation deficiency; and

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  is not required to perform any development actions requested on the Request for Corrective Action or the Request for Case Action, prior to submitting an IRR, except for those development actions not in dispute.

NOTE: The review component will not accept IRRs for the following:

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  subsequent returns (See GN 04440.205); or

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  closed cases, with the exception of group II deficiencies routed directly to the FO.

The adjudicating component must initiate an IRR through ODP's IRR web-based tool to attempt to resolve any disagreement or to request a rescission, if applicable, of any group I deficiency, group II deficiency, or TCA. The adjudicating component must:

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  submit the IRR request in the web-based tool within 20 calendar days, beginning with the date the review component returned the deficient case, and

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  include a policy-based narrative, with applicable citations, explaining the basis for the IRR.

NOTE: For any IRR submitted after the 20-calendar-day time frame, the adjudicating component must provide an explanation of the unusual circumstances that caused the delay. The review component determines whether to accept the IRR due to the unusual circumstances.

If the review component disagrees with the IRR rationale for policy compliance submitted by the adjudicating component, the adjudicating component must complete the requested corrective action(s) noted on the Request for Corrective Action, or Request for Case Action, or submit an RPC, if the case meets the criteria for RPC submission (see DI 30007.125 - Submitting a Case for RPC).

When the adjudicating component does not request rescission of a deficiency or is not in disagreement with the deficiency citation, the adjudicating component may email or phone the review component contact found on the Request for Corrective Action or Request for Case Action, without submitting an IRR, to discuss the issues in the case, and/or the necessary required actions:

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  to clarify the requested corrective action(s) noted on the Request for Corrective Action or Request for Case Action;

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  to ask a specific question about the deficiency; or

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  to ask for a policy citation(s).

NOTE: The Request for Corrective Action and Request for Case Action are displayed on the first page of the QR Disability Determination Explanation.

After receiving an IRR notification, the designated review component contact:

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  identifies the original program leader (PL) who approved the deficiency and

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  assigns the IRR in the IRR web-based tool to a designated QR staff member who was not involved in the original return.

The review component has 14 calendar days to respond to the IRR. When the review is complete, the review component will:

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  code the IRR web-based tool,

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  prepare a narrative response to the IRR in the IRR web-based tool,

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  ensure that the IRR response addresses all relevant policy concerns or questions raised by the adjudicating component, and

• •

  include policy and procedural references to support the response, unless the review component agrees with the adjudicating component’s IRR, rescinds the deficiency, and no further action is needed.

When the IRR response is ready for review, the QR designated staff member will inform the branch chief (BC) or other designated QR manager. The BC, or other designated QR manager, will return the IRR to the QR designated staff member if they decline to sign the IRR response. The QR designated staff member will make the requested changes and resubmit the IRR to the BC, or other designated QR manager, until achieving concurrence. The BC, or other designated QR manager, will close the IRR in the IRR web-based tool. This action uploads the adjudicating component's IRR submission and review component's IRR response to the certified electronic folder and the tool notifies the adjudicating component by email that the response is available to view.

NOTE: The review component should not obtain medical contractor (MC) or psychological contractor (PC) review(s) during the informal resolution request (IRR) process. MC/PC review results must be coded in the case processing system per GN 04440.130D . The review component’s case processing system does not support coding results of MC/PC reviews during the IRR process.

If the review component agrees that the adjudicating component’s determination was policy compliant, the review component will rescind the deficiency in the IRR web-based tool. Once the case is returned by the adjudicating component, the review component will update the QR case processing system database and clear the case according to normal business processes.

If the review component disagrees with the adjudicating component’s IRR rationale for policy compliance and affirms the deficiency, the adjudicating component must take the requested corrective action(s) noted on the Request for Corrective Action, or Request for Case Action, or submit an RPC, if the case meets the criteria for RPC submission (see DI 30007.125 - Submitting a case for RPC).

If the adjudicating component decides to complete the requested corrective action(s), the adjudicating component will return the case to the review component after completing the actions. The review component will code and clear the case according to normal business processes.

If the review component rescinds or corrects the deficiency within the IRR web-based tool, the QR case processing system database will be automatically updated with the applied revisions to ensure that the rescinded or corrected deficiency is appropriately recorded.

NOTE: When an IRR results in a rescission of a group II decisional deficiency that has been transmitted to the field office for effectuation, and the final outcome of the determination is changed, the case must be reactivated. The review component will follow policy guidance in GN 04440.111 Reopenings Certified Electronic Folders (CEF) for reactivation and reopening.