TN 24 (09-14)

GN 04440.008 Quality Review Process (Initial Level Claims)

A. Introduction to the quality review process

The Office of Quality Review (OQR) examines a sample of claims selected from adjudicating components prior to effectuation to ensure determinations comply with federal guidelines. Quality reviewers follow the guidelines in GN 04440.008B.

B. Quality review process policy

Follow steps 1 through 8:

  1. 1. 

    Determine whether the case meets the criteria for exclusion (GN 04440.004). If the case is an exclusion and does not warrant quality review, follow these procedures. If the case is not an exclusion, go to step 2.

    • Identify the reason for exclusion;

    • Code the legacy system (for exclusion code 88, an explanation in the note section of the legacy system is required);

    • Effectuate the determination, when applicable;

    • Date and release the Personalized Decision Notice (PDN) in DI 27025.001, if appropriate; and

    • Route the folder to the field office (FO).

  2. 2. 

    Open and review all case documents (the order of review is at the discretion of the quality reviewer).

  3. 3. 

    After initial review, determine if the adjudicating component’s determination complies with the Regulations, Social Security Rulings (SSRs), and other written guidelines such as the Program Operational Manual System (POMS). The evidence in the case must be sufficient and support the adjudicating components determination. If the adjudicating component determination is policy compliant and sufficient, OQR considers this a clean case. If a deficiency is suspected and the case needs additional input, continue to step 4. If the case is clean, clear the case following these procedures:

    • Verify that all determination information is correct on the Form SSA-831-C3/U3 (Disability Determination and Transmittal);

    • Code the legacy system;

    • Effectuate the determination, when applicable;

    • Date and release the PDN, as appropriate; and

    • Route the folder to the field office (FO).

      Potential issues to consider:

      1. a. 

        It is possible that the determination and onset is policy compliant, but the information on the SSA-831 is not correct. In these instances, upload a modified SSA-831 with the correct information. Note any changes made in Item 34 Remarks of the SSA-831.

      2. b. 

        Be sure that the legacy system coding matches the information on the SSA-831.

  4. 4. 

    Determine if you need a consultation from a medical contractor (MC), psychological contractor (PC), or vocational consultant (VC).

    1. a. 

      Address questions on the Form SSA-448 (Request for Medical Advice) pertinent to the medical issues in file. Be sure to address the issues to the MC/PC in a clear and concise manner. Issues that often require review by MC/PC are questions regarding the sufficiency of evidence, onset, weighing of medical opinions, and symptom evaluation completed by the adjudicating components (GN 04440.130).

      NOTE: When the quality reviewer and the MC/PC cannot reach agreement on the medical findings and conclusions, or both, expressed in the formal assessment, that assessment must remain in the official claims folder, even when it is contrary to the final OQR determination made by the quality reviewer. In that situation, prepare a rationale explaining why the medical findings and conclusions or both, in a specific medical assessment(s) not reflected in the final disposition of the case (e.g., the assessment(s) contains incorrect conclusions, it does not address issues that need resolution).

    2. b. 

      Not all cases will require review from a VC. If a group I deficiency code 20, 31 or 53 (GN 004440.950) is cited, a Form SSA-1047 (see GN 04440.140) must be in file. The SSA-1046 and VC review are optional in other cases involving vocational issues. Deciding on whether to seek VC review in optional cases will depend on the experience of the quality reviewer and the field site business process. Refer cases to a VC for complicated vocational matters that need clarification.

    NOTE: Refer cases to a VC or designee per GN 04440.140A.

  5. 5. 

    Determine if any type of deficiency is present. If any deficiency is present, continue the steps in the quality review.

    1. a. 

      Deficiencies fall into three categories:

      1. (1) 

        Group I deficiencies in GN 04440.204, have the potential to reverse the determination from unfavorable to favorable, or from favorable to unfavorable.

      2. (2) 

        Group II deficiencies in GN 04440.216, have the potential to change the period of disability; that is, when disability started, ended, or ceased.

      3. (3) 

        Technical Corrective Actions (TCAs) in GN 04440.230 are instances of non-compliance with procedural requirements that do not influence the basic determination to allow or deny, or the period of disability.

    2. b. 

      Group I and group II deficiencies are further classified as decisional or documentation.

      1. (1) 

        Decisional deficiencies exist when adjudicating components sufficiently document the case to support an opposite determination and the evidence contradicts the determination.

        Potential issue to consider:

        Consider Substitution of Judgment (SOJ) in GN 04440.118, when a group I or group II decisional deficiency exists. MCs and PCs must be aware of SOJ as a review principle to ensure they do not perform a de novo case review. If SOJ is considered, reviewers must document this in the legacy system (note section). For further guidance, see GN 04440.119.

      2. (2) 

        Documentation deficiencies exist when medical evidence in the case is insufficient to support the disability determination or to determine the correct onset or ending date.

        Potential issue to consider:

        It is the quality reviewer’s role to consider the Reversal (POR) in GN 04440.110 when a group I or group II medical or vocational documentation deficiency exists. The reviewing contractors have a limited role in the POR determination process. Reviewers may ask them to provide an opinion, but this opinion is not binding. Quality reviewers make the final POR determination. Reviewers must explain and code all POR determinations in the legacy system.

  6. 6. 

    Provide a clear and concise explanation of the deficiency to the adjudicating component and request or take corrective action. If taking corrective action is appropriate, correct the claim and follow the procedure in step 3 of the quality review process. If not taking corrective action, control the return in GN 04440.202, and code the legacy system to reflect why the case is not policy compliant and continue to step 7.

  7. 7. 

    Send the case back to the adjudicating component. Prepare a summary of the case including an explanation of why the case does not comply with policy. Notify the adjudicating component and FO, when applicable, of the deficiency and required corrective action:

    1. a. 

      Use the Form SSA-1774-U5 (Request for Corrective Action) to return group I and group II deficiencies, and other TCAs which may affect the disability determination or the period of disability to the adjudicating component;

    2. b. 

      Use the Form SSA-5524-U3 (Request for Assistance) to request development from the FO; and

    3. c. 

      Use the Form SSA-847-U3 (SSA Request for Case Action) to return TCAs to the adjudicating component.

  8. 8. 

    When the adjudicating component or FO, as applicable, corrects the deficient case and returns it to OQR for review, re-evaluate the full case record. Evaluate if the adjudicating component has made the requested corrections. Determine if the case is policy compliant or if the case requires a return to the adjudicating component for a second time in DI 30005.405. If the case is policy compliant, clear the case following the procedures in step 3 of the quality review process.

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GN 04440.008 - Quality Review Process (Initial Level Claims) - 07/20/2016
Batch run: 07/20/2016