TN 13 (12-10)
GN 04440.020 The Scope of Quality Review (QR) for Certified Electronic Folder (CEF) Cases
A. Current folder (no prior folder)
Most disability claims are established in the Electronic Disability Collect System (EDCS) and the CEF is the agency's official record.
Fully paper modular disability folders (MDF) will exist as long as there are EDCS exclusions and limitations.
When one or more claims are established in EDCS but one or more claims are EDCS exclusions, an electronic folder exists – but this is not a CEF.
1. CEF cases
Federal quality reviewers, regional medical contractors (MC), and psychological contractors (PC) consider all evidence in the CEF to evaluate the accuracy of the adjudicating component’s disability determinations.
2. Paper MDF cases
Federal quality reviewers and regional MCs or PCs consider all evidence in the paper MDF to evaluate the accuracy of the adjudicating component’s disability determinations. For processing instructions, refer to Federal Quality Review of State Disability Determinations GN 04440.000.
B. Prior folder(s) exists for current claim
1. Prior folder is a CEF case
Review the prior CEF to determine if it affects the review of the current claim.
2. Prior folder is a paper case
If you have not received the prior paper folder, but it is necessary to perform the QR, request the prior paper folder from the adjudicating component. Remember to correct the paper folder indicator (PFI) and prior paper folder indicator (PPFI), if necessary.
If you do not receive the prior paper folder and decide that it is not necessary for the QR, you can correct the PFI and review the case.
If the prior paper folder is necessary and you don’t receive it after contacting the adjudicating component, exclude the case from sample review.
NOTE: For detailed information regarding PFIs and PPFIs, refer to operating instructions in Paper Folder Indicators DI 81020.010.