TN 152 (11-23)

GN 04440.130 Medical Review in the Office of Quality Review (OQR)

A. Medical review in the federal review component

The review component performs quality reviews of all sampled cases to ensure policy compliance and to determine whether a medical contractor (MC) or psychological contractor (PC) review is required or is discretionary.

B. MC and PC review criteria

Based on the instructions below, the reviewer determines whether a case requires review by, and input from, an MC and/or PC.

1. Cases requiring medical review

The reviewer is required to obtain a review by an MC or PC for:

  1. a. 

    any case with a group I medical deficiency, unless the file contains NO medical evidence or the case is a continuing disability review (CDR) case without any current medical evidence;

  2. b. 

    any case or workload required per instructions from the Associate Commissioner of the Office of Quality Review, or designee;

  3. c. 

    any case where OQR assumes jurisdiction. (See GN 04440.244 Assuming Jurisdiction.)

2. Discretionary medical review

If review by an MC or PC is not required, reviewers may use their judgment in deciding whether to seek medical consultation.

  1. a. 

    The reviewer may obtain review by an MC or PC in cases with questions or issues regarding:

    • impairment severity

    • inconsistencies in the evidence

    • the claimant’s ability to sustain a normal workday or workweek

    • medical improvement

    • duration, onset, end or cessation dates, or closed periods

    • whether the medical evidence in file is sufficient

    • symptom evaluation and limitations to function

    • psychiatric review technique (PRT), residual functional capacity (RFC) or mental residual functional capacity (MRFC) assessment(s)

  2. b. 

    The reviewer generally does not need review by, or input from, an MC or PC for cases with:

    1. 1. 

      Group I non-medical deficiencies such as:

      • clear evidence that the individual is engaging in substantial gainful activity (SGA) (code 10)

      • incorrect determination regarding vocational factors (code 20)

      • incorrect determination regarding onset relative to Title II eligibility period (code 23)

      • incorrect determination regarding collateral estoppel (code 26)

      • unresolved work activity that could affect the determination (code 30)

      • insufficient vocational documentation to determine the claimant’s age (code 51)

      • insufficient vocational documentation to determine the claimant’s education (code 52)

      • insufficient vocational documentation to determine the claimant’s work history (code 53)

      • failure to obtain a prior folder or copy of an administrative law judge or appeals council ruling when required by an acquiescence ruling (code 60)

      • whereabouts unknown procedures not compliant with SSA policy (code 65)

      • failure or refusal to cooperate procedures not compliant with SSA policy (code 66)

    2. 2. 

      Cases with group II onset deficiencies such as:

      • documented period of SGA after proposed onset (code 71)

      • failure to reopen a prior determination when onset falls within a previously adjudicated period and there is no medical issue to address (code 71)

      • clear-cut onset date errors involving traumatic onset (code 71)

      • incorrect onset decision based on vocational factors where the medical assessment is correct (e.g. borderline age (code 71))

      • incorrect cessation date (CDR involving failure to cooperate or whereabouts unknown)(code 73)

      • unresolved work activity that could affect onset (with no unresolved medical issue) (code 85)

      See GN 04440.950 - Exhibit of Group I and Group II Deficiency Codes in the Office of Quality Review (OQR) Case Processing System for additional deficiency code information.

    3. 3. 

      Cases with technical corrective actions (TCA) such as:

      • 12-month medical evidence of record

      • diary entry

      • notice

      • collateral estoppel documentation

      See GN 04440.230 - Introduction to Technical Corrective Actions (TCAs) for more information.

C. Preparing the medical referral(s) for review by an MC or PC

Once the reviewer has determined a case requires review by an MC or PC, the reviewer will submit a medical referral(s) through the case processing system. The referral should:

  • identify medical issues in the case that require medical advice or clarification,

  • state specific questions or frame issues for the MC or PC to review and address, and

  • include information about technical issues or work issues only as they relate to the medical aspects of the case.

D. Medical review by an MC or PC

A medical review includes assessing impairment severity, the RFC, and related medical issues. The MC or PC reviews the adjudicating component's medical assessment and may independently arrive at a different assessment of impairment severity or RFC than the adjudicating component. It is NOT a “de novo” review. If the adjudicating component’s assessment complies with SSA disability program policy, and the evidence in file fully supports and documents the assessment, the MC or PC must not substitute his or her judgment.

As part of their medical and response, the MC or PC should:

  • respond to the medical referral completed by the quality reviewer requesting MC or PC review, medical advice, or clarification of a medical issue and offer an explanation or guidance as to the course of action recommended. The advice or recommendation should be more detailed when it is not consistent with the reviewer’s guidance or possible expectations,

  • provide an opinion on probability of reversal (POR) determinations, as needed. MCs and PCs must limit their opinions to the potential effect of missing documentation on impairment severity or RFC only,

  • complete appropriate forms to respond to the medical referral,

  • code results of a medical review in the case processing system.

The documentation in the file must fully explain the discrepancy or disagreement with the adjudicating component. MCs and PCs may prepare a SSA-3023-F3 (Medical Consultant's Review of Psychiatric Review Technique Form), SSA-392 (Medical Consultant's Review of Physical Residual Functional Capacity Assessment), or SSA-392-SUP (Medical Consultant's Review of Mental Residual Functional Capacity Assessment), to express findings of agreement or disagreement with an adjudicating component’s proposed PRT, RFC, or MRFC assessment(s).

MCs and PCs generally prepare a SSA-416 to provide medical comments if a determination should have been made on a medical-only basis (i.e., non-severe impairment(s) or impairment(s) meets/equals a listing) or the case is insufficient to establish a severe medically determinable impairment.

NOTE: For a discussion of “de novo” review and substitution of judgment, see GN 04440.003 - Explanation of Quality Review Terms and GN 04440.118 - Substitution of Judgment (SOJ) in the Quality Review Process.

E. Reviewer actions after MC or PC review

Once the MC or PC completes the medical review, the reviewer is responsible for:

  • reviewing all medical responses and requesting clarification or additional information, when necessary,

  • ensuring the responses adequately address all medical issues identified and the findings by the MC or PC comply with SSA regulations, rulings, POMS, and the documented facts of the case, i.e., the quality review standard (GN 04440.003G., Explanation of Quality Review Terms),

  • confirming the MC or PC adequately explained their findings and prepared any necessary medical assessment forms,

  • leaving all original forms completed by the adjudicating component (i.e. PRT, RFC) in the file, as part of the audit trail, even when the review component assumes jurisdiction of a case,

  • ensuring that MC or PC coding in the case processing system accurately reflects the findings by the MC or PC,

  • uploading all of the final forms completed by the MC or PC into eView,

  • resolving discrepancies between MC or PC review findings by explaining the basis for supporting one opinion over another, and

  • confirming MC or PC signatures on the determination forms are correct when assuming jurisdiction.

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GN 04440.130 - Medical Review in the Office of Quality Review (OQR) - 11/29/2023
Batch run: 11/29/2023