TN 22 (08-14)

GN 04440.004 Quality Review Exclusions

A. Introduction to quality review exclusions

The Office of Quality Review (OQR) conducts reviews on adjudicating component determinations selected for preeffectuation review (PER), quality assurance review (QA), targeted denial review (TDR), and other special samples. OQR may receive incorrectly sampled cases or cases that do not meet the criteria for quality review.

B. Quality review exclusion policy

The first step in the quality review process is to determine if the sampled case is an exclusion. OQR excludes cases that meet the criteria of an exclusion as identified in GN 04440.004C in this section. Cases excluded from quality review require OQR legacy system coding.

C. Exclusion codes and definitions

The following table indicates all OQR legacy system codes for quality review exclusions and a description of each code.

Code

Exclusion Definitions

01

Non-State Cases Selected for Review – If OQR inadvertently receives a case from a non-sampled federal site, we do not conduct the quality review. As we expand review of federal sites, this exclusion will become more rare. Reviewers may refer to management if they are unsure.

02

Number holder attains full retirement age in the waiting period or dies within five months of the alleged onset date and no earlier onset date is possible

03

Supplemental Security Income (SSI) Only – Applicant Dies Prior to Adjudication

05

Number holder/Applicant does not want to continue development of claim – Regulation Basis Codes M7/M8-1516 and N38-916

06

Informal Remands

07

FO Jurisdiction – Whereabouts Unknown (WU) – Exclude a WU case from the QA or PER sample when the field office (FO) has jurisdiction of the case. We do not review a case that is not under the adjudicating component’s jurisdiction.

08

Invalid PER Selection – Claim 1 is aTitle II Denial, Title II CDR, or Titl XVI Disabled Child, Per is composed of adult initial and reconsideration allowances only

09

Reconsideration – continuing disability review (CDR) cessation

10

FO Jurisdiction – No Medical Determination Needed

12

Medicare Only – Death Precludes Entitlement

13

Res Judicata – Refiling of a claim denied for the same period. (For additional information on res judicata see matrix chart in GN 04440.004D in this section.)

14

Adjudication by a Component Other than the Jurisdictional Adjudicating Component – This exclusion code is for cases when Site A has jurisdiction, Site B does the development and makes the determination, but the case clears from Site A. If we do not exclude these cases from review, it may unfairly affect the accuracy rating of Site A.

15

PER only Claim Involving Reconsideration or Reopening of Onset or Ending Date in a Prior Allowance – If the adjudicating component clears an allowance case, and then reopens that case to change the onset or ending date only, we exclude from OQR review.

17

Sample Selection not Received in a 6-Month Timeframe – PER sample cases that are paper only

18

Special Disability Workload (SDW) Claim Without Cadre Involvement

19

QA Reopening of a Prior Reconsideration Determination – In the QA sample, a reopening of a prior reconsideration determination includes appeal rights to a disability hearing and the sampled reopening may actually be a Disability Hearings Officer decision. The level would not be distinguishable from a determination made by an adjudicating component examiner.

20

Concurrent Claim Selected for SSI PER

21

Multi Category Case – SSI recipient filing only to change to another category (e.g. DI to BI)

22

Virtual Case – Non-receipt of essential current or prior paper folder

23

Non CDR Paper Case – OQR does not select paper cases with the exception of the QA CDR sample

88

Other – None of the other exclusion codes apply. Cases excluded with this code are subject to supervisory approval and reviewers MUST explain the reason in the Notes section of the OQR legacy system (e.g., reactivated case sampled and previously reviewed by OQR).

D. Res Judicata matrix for quality review cases

The following matrix provides quality reviewers with instructions on whether to exclude, review, or cite a deficiency on a res judicata case:

Field Office (FO)

Adjudicating Component

OQR

Deficiency or Exclude

Res Judicata

Res Judicata

No Res Judicata

Exclude

Res Judicata

No Res Judicata

Res Judicata

Exclude

No Res Judicata

No Res Judicata

Res Judicata

Exclude

No Res Judicata

Res Judicata

No Res Judicata

Deficiency

Res Judicata

Res Judicata

Res Judicata

Exclude

No Res Judicata

No Res Judicata

No Res Judicata

Regular Review

No Res Judicata

Res Judicata

Res Judicata

Exclude

E. Processing an excluded quality review cases

If a quality reviewer makes a determination to exclude the case, he or she must:

  • Fill out the appropriate fields in the OQR legacy system;

  • Indicate the appropriate exclusion code;

  • Effectuate the determination, when applicable; and

  • Release Personalized Decision Notices (PDNs) in file, if applicable.

F. Handling deficient quality review exclusion cases

If a quality reviewer determines that a case is deficient, but the case meets exclusion criteria, the quality reviewer will not cite a deficiency. OQR must address any issues discovered during the quality review process to protect the integrity of the review.

If a quality reviewer discovers a deficiency in an excluded case, he or she must:

  • Enter deficiency code 99 in the OQR legacy system;

  • Create and complete Form SSA-847-U3 (Request for Case Action) and explain the deficiency;

  • Indicate that the deficiency is information only and is not chargeable;

  • If possible, OQR will make corrective action and route to the FO for processing. If corrections require adjudicating component action, forward the case to the appropriate component for completion; and

  • Effectuate the determination, if appropriate.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0204440004
GN 04440.004 - Quality Review Exclusions - 08/22/2014
Batch run: 08/22/2014
Rev:08/22/2014