TN 13 (12-10)

GN 04440.007 Quality Review (QR) Standard

A. Standard used in QR

The review standard for QR cases is that the adjudicating component's determination must conform to:

  • Social Security regulations and rulings;

  • Other written guidelines, such as the Program Operations Manual System (POMS); and

  • The documented facts in each case, including the medical and administrative documentation in file, the rationales or explanations in all administrative forms, and notices in file. For an explanation of what constitutes documentation and documentation requirements, see GN 00301.285.

When evaluating if the evidence in file supports the disability determination, the quality reviewer follows the preponderance of evidence standard. Establishment of preponderance is that piece or body of relevant evidence that is more convincing when weighed against the evidence in opposition.

For a complete explanation of the preponderance of evidence standard see DI 23025.001B.5.

NOTE: If you are a quality reviewer who receives a case from the adjudicating component and the evidence is insufficient, even if the adjudicating component inadvertently cleared the case, contact the adjudicating component and request the missing evidence. If the adjudicating component does not fax the evidence necessary to make a disability determination into the folder, or the review component does not receive it within a reasonable amount of time, the quality reviewer may cite a deficiency. If the file references the missing essential evidence, follow the instructions in “Correcting Cases with Essential Evidence that is Missing or Illegible” GN 04440.242, and “Correcting Cases with Essential Evidence that is Missing or Illegible” DI 30005.241.

B. Procedure for deficiency citation and support

1. Deficiency citation

Cite a deficiency if the evidence:

  • is insufficient to support a determination; or

  • clearly contradicts the determination.

Determine the sufficiency of the documentation. Be sure the file contains sufficiently detailed reports on history, physical and mental examinations, laboratory studies, and any prescribed therapy and response to permit the quality reviewer to assess impairment severity and duration.

2. Deficiency support

Support the deficiency citation with specific references to:

  • the evidence in file;

  • the needed evidence; and

  • the specific, relevant POMS section(s).

NOTE: Regional POMS supplements are authorized policy/procedural vehicles for the region for which they are issued. A review component can cite a regional supplement as the basis for a return to an adjudicating component within the region that issued the supplement.

The quality reviewer should not use Office of Disability Policy memorandums, PolicyNet Questions & Answers, adjudicating component’s Administrative Letters, Request for Program Consultation responses, or other similar written guidelines to justify or explain a deficiency. Emergency messages and administrative messages carry the weight of POMS and you may reference them in support of a deficiency citation.

3. Entries on case file SSA-831-C3/U3 (Disability Determination and Transmittal), SSA-832-C3/U3 (Cessation or Continuance of Disability or Blindness Determination and Transmittal-Title XVI), or SSA-833-C3/U3 (Cessation or Continuance of Disability or Blindness Determination and Transmittal-Title II) different from entries on the Office of Quality Review’s (OQR) legacy system

If the entries on the SSA-831-C3/U3, SSA-832-C3/U3, or SSA-833-C3/U3 in the case file differ from those on the download record (i.e., the data input by the adjudicating component when they clear the case that are passed on to OQR’s legacy system database), base your review on OQR’s legacy system record, unless the difference is due to an obvious keying error.

Base the citation of any deficiency on a disagreement with OQR’s legacy system record. Even if you agree with the entries on the disability determination that is in the case file, still cite a deficiency.

C. Use of queries

To properly document work history, the adjudicating component must address all material inconsistencies in a claimant’s work history. The adjudicating component:

  • May use SEQY, DEQY, or DISCO queries to address material work history inconsistencies.

  • Should only obtain a query when it is likely that the information the query contains will be useful in addressing the issue at hand