TN 36 (01-19)

GN 04440.007 Quality Review Standard

A. Standard used in federal quality reviews

The standard for quality reviews is that the adjudicating component's determination must:

  • Conform to Social Security regulations, rulings and other written guidelines, such as the Program Operations Manual System (POMS); and

  • Be supported by facts, including the medical and administrative documentation, rationales, explanations, and/or notices in file. For an explanation of administrative documentation requirements, see GN 00301.285. For an explanation of medical documentation requirements, see DI 24501.000.

When evaluating whether the evidence in file supports the disability determination, the quality reviewer follows the preponderance of evidence standard. This term means that a piece or body of relevant evidence is more convincing when weighed against the evidence in opposition is accepted as fact in support of a determination. However, unless expressly permitted by POMS instructions, subsequent adjudicators/reviewers cannot make presumptions about information not documented in the claims file. Facts not recorded in the claims file cannot be considered as evidence.

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

B. Procedure for deficiency citation and support

1. Deficiency citation

Determine the sufficiency of the documentation. Ensure the file contains policy compliant reports of the individual’s medical history, physical and mental examinations, laboratory studies, any prescribed therapy, and any responses to therapy needed to establish one or more medically determinable impairments, assess severity of the impairment(s) and determine the duration of the impairment(s).

Cite a deficiency if the evidence:

  • is programmatically insufficient, including establishing the onset date of disability;

  • does not support the determination; or

  • contradicts the determination.

2. Deficiency support

Support the deficiency citation with specific references to:

  • evidence in file;

  • programmatically required evidence; and

  • specific, relevant policy.

NOTE: Regional POMS supplements are authorized policy/procedural vehicles applicable only in the region where issued. A review component can cite a regional supplement as the basis for a return within the region that issued the supplement; however, cannot use to support a deficiency in another region.

The quality reviewer must not use Office of Disability Policy memorandums, PolicyNet Questions & Answers, adjudicating component’s Administrative Letters, Request for Program Consultation Resolution 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 Disability Determination and Transmittal forms

The entries on forms SSA-831-C3/U3 (Disability Determination and Transmittal) and SSA-832/833-C3/U3 (Cessation or Continuance of Disability or Blindness Determination and Transmittal - Title XVI/Title II) in the case file may differ from those on the download record (i.e., the adjudicating component data input that is passed on to OQR). If this occurs, base your review and the citation of any deficiency on OQR’s legacy system record. In other words, cite a deficiency even if you agree with the entries on the disability determination form(s) in the case file.

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 (e.g., a material inconsistency in the claimant’s work history or in determining if a job is relevant).

  • Must place into the case file any query obtained to address material inconsistencies in the claimant’s work history.

  • Must explain the use of a query, if obtained or referenced.

  • Must address all material inconsistencies raised by a query, regardless of the reason the adjudicating component obtained or referenced the query.

  • Must address all material inconsistencies raised by a query that the adjudicating component did not obtain but are present in the case file.

1. Procedure when there is no query referenced or in file

When there is no query referenced or in file, the review component:

  • must not obtain a query, even if it appears that information from the query could resolve a material inconsistency in the claimant’s work history;

  • should return the case when material work history inconsistencies exist, specifying for the adjudicating component the inconsistencies they must resolve and explain; and

  • must not instruct the adjudicating component to obtain a query nor specify how the adjudicating component should address any material inconsistency identified by the review component.

2. Procedure when there is a query referenced or in file

When a query referenced is in file or referenced by the adjudicating component, the review component:

  • may use the query that is already in file or identified by name (but only the same query that is in the file, or a query the adjudicating component obtained, referenced, or used) to conduct their case review; and

  • may cite deficiencies based on the information the query contains.

NOTE: If the query the adjudicating component used is not in file, identified, or clear from the case record, then the review component may use the Summary Earnings Query (SEQY), Detail Earnings Query (DEQY) or Disability Insured Status Calculator Online (DISCO) in conducting the case review and may cite deficiencies based on the information the queries contain.

See Also:

DI 22515.020 – Resolving Insufficient Vocational Evidence using a Detail Earnings Query (DEQY) or a Summary Earnings Query (SEQY)

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GN 04440.007 - Quality Review Standard - 07/24/2018
Batch run: 01/17/2019