TN 44 (03-19)

GN 04440.003 Explanation of Quality Review Terms

A. Adjudicating component

An adjudicating component is a state or federal 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 technical corrective action (TCA) that requires adjudicating component development or action. This is a rare occurrence.

The development or action required by the adjudicating component 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 group II work activity documentation deficiency.

NOTE: Never cite more than one group I or group II deficiency for a claim. However, it is possible that when development for a cited group I or group II deficiency is completed, the need for additional medical or vocational development or documentation may become apparent. Return this additional request for correction to the adjudicating component as a subsequent return, not “another returnable deficiency.”

C. Deficiency

A deficiency is a specific instance of noncompliance with SSA policies and procedures classified according to its impact, or potential impact, on the disability determination. We categorize deficiencies as group I or group II. We further identify group I and group II deficiencies as decisional or documentation . There are also TCAs that require correction, but 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 occur when the evidence in file supports an opposite or different disability determination based on policy compliant documentation.

  • Group I documentation deficiencies occur when the evidence in file is insufficient to make a correct, policy compliant determination and when the file is not documented in accordance with SSA policy.

For more information on 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 the evidence in file supports a different period of disability based on a policy compliant documentation.

  • Group II documentation deficiencies occur when the evidence in file is insufficient to establish the correct, policy compliant period of disability and when the file is not documented in accordance with SSA policy.

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

3. Technical Corrective Actions (TCAs)

TCAs, are instances of noncompliance with procedural requirements for effective program administration and programmatic, documentation requirement deficiencies that do not have the potential to affect the determination or the period of disability.

TCAs are :

  • 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 substantive or non-substantive.

For more information on the categories of TCAs, see DI 30005.127.

D. De novo review

 

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 and quality review medical contractors do not perform de novo reviews.

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 in GN 00301.285, Statements and Other Documentation

 

F. Federal quality reviewer

The federal quality reviewer is the reviewer or program leader (PL) in the review component who evaluates the quality review sample case to determine if the evidentiary record and determination conform to SSA operating policies and procedures.

G. Preponderance of the evidence

Preponderance of the evidence is such relevant evidence that as a whole shows the existence of the fact to be proven is more likely than not. See20 CFR §405.5. The SSA bases determinations at all levels on the preponderance of the evidence.

Preponderance of the evidence is the greater weight of evidence that, when weighed against other evidence, is more convincing of the truth. It does not represent any specific quantity or volume of evidence, only that which is more probable of its truth and accuracy.

See also DI 23025.001B5 for more on preponderance of the evidence.

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 missing documentation is likely 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. Quality review team

The quality review team is made up of the quality reviewer and PL in the review component and the federal review physician/psychologist (or other specialist) on the medical contractor (MC) staff in the regional office who performs the medical review portion of the quality review .

J. Substantive change

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

  • Whether an individual is 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 the quality review is that federal quality reviewers, federal MCs, and federal psychological contractors (PC) must not substitute their judgment for that of the adjudicating component’s MCs, PCs, and adjudicators. Federal MCs and PCs must be aware of SOJ as a review principle to ensure they do not perform a de novo case review (see GN 04440.003D above for a definition of de novo review).

For a description of the medical contractors' review process, see GN 04440.130B.

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

If an adjudicator documented a case in accordance with SSA policy, the adjudicator's assessment complies with SSA policy, and the preponderance of the evidence in file supports the determination, the quality reviewer must not cite a deficiency even though the reviewer may have arrived at a different, equally supportable conclusion (see GN 04440.003G above for a definitio of preponderance of the evidence.

For a complete explanation of SOJ, see GN 04440.118.

L. Supported or supportable determination

A determination is supported or supportable if it complies with SSA policy and procedural requirements, does not conflict internally, and is substantiated by a preponderance of the evidence in file. A quality reviewer may find a determination not supported if it does not comply with specific SSA policy or documentation requirements.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0204440003
GN 04440.003 - Explanation of Quality Review Terms - 02/19/2019
Batch run: 03/21/2019
Rev:02/19/2019