TN 13 (12-10)
GN 04440.015 Federal Quality Review (QR) of Certified Electronic Folder (CEF) Cases
A. Introduction to the Federal QR
The Office of Quality Review (OQR) conducts a Federal QR of disability cases in OQR review components located in the 10 regions and OQR Baltimore. The OQR review components were formerly called disability quality branches.
B. Official folder is a modular disability folder (MDF) or CEF
Federal QR of adjudicating component disability determinations provides general QR processing instructions for review components to use when returning or correcting deficient paper MDF cases or CEF cases.
C. QR sample selection
The automated sample selection process selects OQR’s QR sample cases during the adjudicating component’s case closure process and prior to effectuation of the determination.
The adjudicating component receives an alert during the case closure process, via the National Disability Determination Services System (NDDSS), when a CEF case is selected for Federal QR.
Both NDDSS and eView display an indicator when the case has been selected for Federal QR. NDDSS only shows that the case has been selected for review and the original review component as the destination. Some CEF cases are automatically transferred to other review components and this change only shows in eView. The only place to see where a case is being or has been reviewed is eView.
CEF cases selected for Federal QR are electronically transferred to the appropriate review component for quality review (e.g., quality assurance review, preeffectuation review, special studies, etc.).
For information regarding eView, refer to DI 81005.005.
D. Results of OQR QR
Results of Federal QRs are as follows:
1. Non-deficient (correct) cases:
The review component completes the QR and legacy system coding, and clears the CEF case to the field office (FO), program service center, National Records Center, or PC7 for effectuation of the determination.
2. Deficient cases:
The review component returns jurisdiction of the CEF to the adjudicating component for corrective action; or
The review component takes the corrective action and clears the CEF to the FO to effectuate the determination.
Refer to General Rules for Routing and Correcting Deficient Cases GN 04440.201.
3. FO action needed:
The review component may request assistance from the FO for additional development (e.g., substantial gainful activity development) prior to completing the review. Refer to Initiating and Processing Electronic Assistance Requests (AR) DI 81030.018.
E. Process for Federal QR
For paper MDF cases, OQR QR sample selections are directed to the regional review component (i.e., the adjudicating component's “home” region), this includes prior paper folders.
For CEF cases, OQR QR may be electronically redirected to an “out-of-region” review component or the “home” review component.
For further information, refer to Disability Case Adjudication and Review System (DICARS) User Tools: Folder Indicators – Certified Electronic Folder (CEF) DI 81030.115, and Federal Quality Review (QR) DI 81020.135.
F. Adjudicating component and review component disagreement when a paper MDF is the agency's official folder and no EF exists
The adjudicating component follows OQR's established rebuttal process, as described in GN 04440.401 through GN 04440.425 and DI 30005.501 through DI 30005.550.
G. Adjudicating component and review component disagreement when the CEF is the agency's official folder
The adjudicating component follows the Office of Disability Policys' (ODP) Request for Program Consultation (RPC) process, as described in Request for Program Consultation (RPC) DI 30007.000.
H. Adjudicating component and review component disagreement when an EF exists with a paper MDF
ODP accepts, as an RPC, any adjudicating component and review component disagreement case when all evidence used by the adjudicating component and review component is viewable in the EF.
If the EF is not documented with the appropriate evidence, a member of ODP's RPC staff contacts the adjudicating component or review component to clarify.
If ODP denies the request for an RPC, they notify the adjudicating component and the adjudicating component may use OQR's rebuttal process to resolve the disagreement.