TN 13 (12-10)
GN 04440.135 Medical Review Process
A. Roles and responsibilities of the review component quality reviewer
1. Quality reviewer's role
The quality reviewer’s role in the medical referral process is to:
Identify medical issues that require medical advice or clarification;
Clearly state and frame the issues for the medical contractor (MC) or psychological contractor (PC); and
Review the MC or PC responses to ensure they adequately address all medical issues identified, are consistent with SSA disability policy and procedures, and are in conformance with the program guidelines for medical evaluation.
For an explanation of the MC and PC role in the review process, see GN 04440.135B.
In addition, the quality reviewer should ensure the medical review findings are in conformance with SSA regulations and rulings, POMS, and the documented facts of the case, i.e., the quality review standard.
2. Quality reviewer’s responsibilities
The quality reviewer’s responsibilities include, but are not limited to, the following actions:
Requesting medical review, if necessary, using Form SSA-448 (Request for Medical Advice);
Reviewing the medical comments provided on the following forms, or elsewhere, including the disability determination explanation:
Form SSA-416 (Case Analysis),
Form SSA-392 (Medical Contractor’s Review of Physical Residual Functional Capacity Assessment),
Form SSA-392-SUP (Medical Contractor’s Review of Mental Residual Functional Capacity Assessment),
Form SSA-536 (Medical Contractor’s Review of Childhood Disability Evaluation Form), and
Form SSA-3023 (Medical Contractor’s Review of Psychiatric Review Technique Form).
Ensuring the MC or PC coding accurately reflects the medical review findings;
Ensuring the original Psychiatric Review Technique Form (PRTF) and Residual Functional Capacity (RFC) remain in file as part of the audit trail when the review component assumes jurisdiction (Annotate the original assessment “Do Not Process”); and
Rationalizing the use of medical opinions when conflicts in MC assessments exist in file.
3. Reviewing medical comments
The regional MC or PC prepares an SSA-392 or SSA-392-SUP if the adjudicating component prepared an RFC assessment and a medical/vocational determination is appropriate. The MC and PC generally use an SSA-416 to provide medical comments if the determination should have been on a medical onset basis (i.e., non-severe impairment or meets/equals) or the case has a medical documentation deficiency.
The quality reviewer is responsible for reviewing the medical comments on the SSA-416 and requesting clarification or additional information, when necessary. If multiple body systems are involved, the quality reviewer should ensure that the SSA-392(s) reflects the medical opinions for all body systems involved.
The quality reviewer should not request that the MC or PC provide clarification on an SSA-416 if the information has been provided elsewhere in file. For example, if the SSA-392 is sufficiently complete, i.e., it thoroughly describes the nature of the RFC disagreement and the reason(s) why the adjudicating component’s RFC was incorrect; no SSA-416 is required. However, in most instances, you need a supplemental SSA-416 for a full explanation of the issues surrounding the RFC disagreement. The important point is that the file fully explains the discrepancy or disagreement with the adjudicating component, regardless of what form you use to do so.
4. Retaining MC and PC input
Retain all of the final forms completed by the MC or PC in the case file. If a discrepancy exists between specialties or contractors, the quality reviewer must explain which opinion he or she chose and why the other opinion was not supported. For example, the use of an SSA-5002 (Report of Contact) for the explanation is appropriate.
B. Roles and responsibilities of the medical staff
1. The medical staff's role
The MC and PC's role in the review process is to review and evaluate the medical evidence in file, following the standard for medical evaluation in subchapter DI 24500.000, and to make judgments on the review issues listed in GN 04440.130A.3.
In addition, the MC and PC have other duties as listed below.
2. MC and PC duties
The MC and PC's responsibilities include, but are not limited to, the following actions:
Reviews all electronic or paper medical documentation in file;
Prepares an SSA-416 to explain any deficiencies or medical issues. The MC and PC generally uses an SSA-416 to provide medical comments if the determination should have been on a medical-only basis (i.e., non-severe impairment or meets/equals) or the case has a medical documentation deficiency;
Prepares an SSA-3023, when necessary;
Prepares an SSA-392 and SSA-392-SUP, when necessary. The regional MC and PC generally prepare an SSA-392 or SSA-392-SUP if the adjudicating component prepared a residual functional capacity (RFC) assessment and a medical/vocational determination is appropriate;
Prepares an SSA-536, when necessary;
Prepares and signs additional forms, electronically or on paper, as needed; e.g., Form SSA-4734-BK (Physical Residual Functional Capacity Assessment) or Form SSA-2506-BK (Psychiatric Review Technique), when the review component assumes jurisdiction of a case. The original PRTF and RFC should remain in file as part of the audit trail. The quality reviewer should annotate the original adjudicating component documents with “Do Not Process”. For editing incorrect adjudicating component forms, or annotating documents in the certified electronic folder, see GN 04440.237.
Responds to SSA-448 (Request for Medical Advice) from quality reviewers requesting physician review, medical advice, or clarification of a medical issue;
Codes medical review results on screen or provides coding for the medical portion of the data input form; and
Consults with quality reviewers, when necessary, to ensure clear communications.
NOTE: When the MC or PC prepares an SSA-416 requesting additional medical documentation, explain in detail what information is needed. Do not direct the purchase of a consultative examination or specify how or from whom the documentation should be obtained. Instead, describe the specific evidence that is needed (e.g., x-rays, range of motion studies, follow-up evaluations, or functional information) without directing the method the adjudicating component should use to obtain the documentation.
3. Probability of reversal (POR) determinations
Reviewing MCs and PCs have a limited role in the POR determination process. The quality reviewer may ask them to provide an opinion on the potential effect of missing documentation on the severity assessment or RFC, or, on occasion, they may include such an opinion as part of their conditional severity rating. However, that opinion is not binding on the quality reviewer, who has the responsibility for making the final POR determination. MCs and PCs must limit their opinions to the potential effect of missing documentation on impairment severity or RFC only.
4. Review MC or PC signature on determination forms
When the review component assumes jurisdiction and prepares a new determination form, the reviewing MC’s or PC's signature is required. For a further discussion on when the MC or PC signature is required, see GN 04440.244 and GN 04440.245. “The MC or PC must complete and sign an acceptable medical assessment form and that form must be cited on the SSA-831. See instructions in DI 24501.002C.1. and POMS DI 26510.090.” See Signing Electronic Documents for Signatures in the CEF DI 81030.100.