TN 13 (12-10)

GN 04440.003 Explanation of Quality Review (QR) Terms

A. Adjudicating component

An adjudicating component is a State or SSA component that adjudicates disability claims (e.g., disability determination services or a Federal disability-processing branch).

B. Another returnable deficiency

A case is considered to have "another returnable deficiency" if, in addition to the group I or group II work activity documentation deficiency, there is a returnable technical corrective action (TCA) that requires adjudicating component development or action. This is a rare occurrence. The development or action the adjudicating component takes is in addition to the field office (FO) development or action and is unrelated to the work activity documentation deficiency. The FO development or action pertains to the cited group I or II work activity documentation deficiency.

It is never appropriate to cite more than one group I or II deficiency for a claim. However, it is possible that when the development for the cited group I or group II deficiency is completed, there is additional medical or vocational development or documentation necessary. We do not consider that as “another returnable deficiency.”

C. Deficiencies

Deficiencies are specified instances of noncompliance with SSA policies and procedures we classify into two groups according to their impact, or potential impact, on the disability determination. We categorize deficiencies as either group I or group II. We further categorize group I and group II deficiencies as either decisional deficiencies or documentation deficiencies. There are also TCAs that we do not categorize as deficiencies.

1. Group I deficiencies

Group I deficiencies are substantive deficiencies that affect, or have the potential to affect, the basic decision to allow or deny, or to continue or cease, disability benefits. There are two categories of group I deficiencies:

  • Group I decisional deficiencies indicate that the adjudicator should have made an opposite or different disability determination based on a fully documented case; and

  • Group I documentation deficiencies necessitate the development of additional evidence to make the correct disability determination.

For the categories of group I decisional deficiencies, see DI 30005.121 and for group I documentation deficiencies, see DI 30005.123.

2. Group II deficiencies

Group II deficiencies are substantive deficiencies that affect only the onset date, ending date, or cessation date. There are two categories of group II deficiencies:

  • Group II decisional deficiencies indicate that the adjudicator should have determined a different period of disability based on a fully documented case; and

  • Group II documentation deficiencies require the development of additional evidence to establish the correct period of disability.

For the categories of group II decisional deficiencies, see DI 30005.125 and for group II documentation deficiencies, see DI 30005.126.

3. TCAs

TCAs, formerly called group III deficiencies, involve instances of adjudicating component noncompliance with procedural requirements for effective program administration with claimants and beneficiaries.

TCAs are incorrect actions:

  • Identified during the review process, but not covered by the formal group I or group II definitions; or

  • Identified in a non-sample case, regardless of whether the group I or group II definitions cover the incorrect action.

TCAs may be either substantive or non-substantive.

For the categories of TCAs, see DI 30005.127.

D. De novo review

Black’s Law Dictionary (6th ed. 1990) defines “de novo” as, “Anew; afresh; considering a matter anew, the same as if it had not been determined before and as if no decision previously had been rendered.”

A de novo review looks at the case as if no determination previously had been made; to re-adjudicate the claim as if it previously had not been adjudicated.

Quality reviewers do not perform a de novo review, but administrative law judges do.

E. Documentation

The term “documentation” refers to the record SSA establishes and maintains of its determination of a claimant’s benefit rights and the evidence supporting that determination.

See Details

GN 00301.285, Statements and Other Documentation

F. Federal quality reviewer

The Federal quality reviewer is the disability examiner (DE) or program leader (PL) in the review component who reviews the QR sample case to determine if the evidentiary record supports the determination and if the evidence and determination conform to SSA operating policies and procedures.

G. Performance accuracy

Performance accuracy is the percentage of sampled cases that the quality reviewer does not have to return to the adjudicating components for further development or correction of determinations, based on the evidence in file; it represents the reliability of the adjudicating component’s determination. The definition of performance accuracy includes the measurement of factors with a potential for affecting a determination and the correctness of the determination. See 20 CFR § 404.1643 .

We use only group I deficiencies in initial quality assurance sample cases in computing the adjudicating component’s performance accuracy rates.

H. Probability of reversal (POR)

POR is an administrative tool used by quality reviewers to distinguish returnable group I or group II documentation deficiencies from TCAs. The determining factor is whether obtaining the missing documentation is unlikely to reverse the disability determination or change the period of disability.

For a complete explanation of the POR rule and application, see GN 04440.110.

I. QR team

The QR team is made up of the DE and PL in the review component and the Federal review physician/psychologist (or other specialist) on the medical consultant (MC) staff in the regional office who performs the medical review portion of the QR when medical review is necessary.

J. Substantive change

Per DI 40115.005, a substantive change is a change that alters the conclusions as to:

  • Whether an individual is disabled or not disabled,

  • When disability begins or ends, or

  • The basis for a determination, even when there is no change that affects benefits.

K. Substitution of judgment (SOJ)

One of the principles of QR is that Federal quality reviewers, Federal MCs, and Federal psychological consultants (PC) must not substitute their judgment for that of the adjudicating component’s MCs, PCs, and DEs. Federal MCs, PCs, and Federal quality reviewers must be aware of the SOJ concept. MCs and PCs must be aware of SOJ as a review principle to ensure they do not perform a de novo case review.

For a description of medical consultation review, see GN 04440.130B.

Quality reviewers must be aware of SOJ as a review principle in their decisional deficiency deliberations.

If the adjudicator fully documented the case, the adjudicator's assessment complies with SSA policy, and the evidence in file supports it, the QR does not cite a decisional deficiency even though the reviewer may have arrived at a different, equally supportable conclusion.

For a complete explanation of SOJ, see GN 04440.118 - GN 04440.119.

L. Determination is supported or supportable

The term “supported” or “supportable,” means conforming to SSA disability program policy and procedures. Within this context, not being supported or not supportable is linked to the presence of substantive deficiencies (e.g., the medical evidence consists only of a diagnosis without any acceptable clinical or laboratory findings to support it).

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GN 04440.003 - Explanation of Quality Review (QR) Terms - 12/23/2010
Batch run: 12/23/2010