TN 28 (09-16)
GN 04440.401 Resolving Deficiency Disagreements between the Adjudicating and Reviewing Components
A. Introduction to resolving deficiency disagreements
There are three methods of resolving deficiency disagreements between adjudicating and reviewing components:
Informal Resolution Request (IRR),
Request for Program Consultation (RPC), and
The Office of Quality Review (OQR) rebuttal process.
The process for resolving deficiency disagreements between an adjudicating
component and a reviewing component differs depending on a variety of
factors, to include whether the case is:
a certified electronic folder (CEF),
an electronic folder (EF) with a prior paper folder, or
a modular disability folder (MDF) paper case.
The Office of Policy Consultation and Analysis (OPCA) administers the Request for Program Consultation (RPC) process, which resolves deficiency disagreements for CEF cases without a prior paper folder. For an explanation of the RPC process, see Request for Program Consultation (RPC), subchapter DI 30007.000.
The Office of Quality Review (OQR) rebuttal process is for MDF paper cases, EF cases involving a prior paper folder, and some cases excluded by the RPC process. For an explanation of the OQR rebuttal process, see The Office of Quality Review (OQR) Rebuttal Process, section GN 04440.410.
B. Policy for resolving deficiency disagreements
When the adjudicating component disagrees with any cited group I or group II deficiency in a fully electronic case, they are encouraged to resolve the disagreement on an informal basis by submitting an IRR via the Office of Disability Policy’s (ODP) IRR web-based tool.
NOTE: RPC will not accept submissions when the disagreement involves a change in deficiency type only, otherwise known as a wrong deficiency situation, unless the case has first been through the IRR process. A wrong deficiency situation occurs when one type of deficiency is cited but program instructions support a different type; e.g., documentation vs. decisional, or group I vs. group II. In these situations, there is no rescission of the deficiency, but the reviewing component codes the correct deficiency in the OQR legacy system. This still only results in one chargeable deficiency against the adjudicating component.
EXAMPLE: The reviewing component cites a decisional deficiency, changing an allowance determination to a denial determination, but fails to recognize in doing so, that the adjudicating component must first develop all allegations or medical sources prior to denying the claim. The adjudicating component requests that the reviewing component change, or replace, the decisional deficiency to a documentation deficiency, agreeing that the evidence does not currently support an allowance, but acknowledging the adjudicating component must develop all allegations or medical sources before making a denial determination. The reviewing component corrects the OQR legacy system to reflect a documentation deficiency, thus there is only one chargeable deficiency for the adjudicating component.
If the adjudicating component chooses not to resolve the disagreement through the IRR process, or if they cannot resolve the deficiency after the IRR process, the adjudicating component may submit an:
RPC to OPCA for a fully electronic case (see Submitting a Cease for Request for Program Consultation (RPC) in DI 30007.125); or
OQR rebuttal for a case that is not fully electronic (see The Office of Quality Review (OQR) Rebuttal Process in DI 30005.510).
If the adjudicating component does not resolve the deficiency through the IRR process, or submit an RPC or OQR rebuttal, they must complete the request for corrective action on the deficiency transmittal form.
C. The IRR process for adjudicating components
The adjudicating component uses the IRR process to:
resolve disagreements in group I or group II deficiencies for a fully electronic case;
request a rescission of a group I or group II deficiency in a fully electronic case; or
resolve disagreements, within the appropriate time frames, regarding cases with group II deficiencies routed directly from the reviewing component to the Field Office (FO).
When the adjudicating component prepares an IRR, the adjudicating component:
cannot use the Federal quality review administrative procedure of probability of reversal (POR), as defined in GN 04440.110 and GN 04440.112, as the basis for an IRR for a documentation deficiency;
can use substitution of judgment (SOJ), as defined in GN 04440.118 and GN 04440.119, as a basis for an IRR for a decisional deficiency;
cannot use SOJ as the basis for an IRR for a documentation deficiency; and
is not required to perform any development actions requested on the SSA-1774-U5, Request for Corrective Action, or the SSA-847, SSA Request for Case Action, prior to submitting an IRR, except for those development actions not in dispute.
NOTE: The reviewing component will not accept IRRs for the following:
The adjudicating component must initiate an IRR through the Office of Disability Policy’s (ODP) IRR web-based tool to try to resolve any disagreement, or to request a rescission of any group I or group II deficiency. The adjudicating component must:
submit the IRR request in the web-based tool within 20 calendar days beginning with the date the reviewing component sent the deficiency, and
include a narrative explaining the basis for the IRR.
NOTE: For any IRR submitted after the 20-calendar day timeframe, the adjudicating component must provide an explanation of the unusual circumstances causing the delay. The reviewing component determines whether to accept the IRR due to the unusual circumstances.
If the reviewing component disagrees with the IRR rationale for policy compliance, the adjudicating component will take corrective actions OR submit an RPC (for a fully electronic case) or OQR rebuttal (for a not fully electronic case).
D. When not to use the IRR process
When the adjudicating component does not request rescission of a deficiency or is not in disagreement with the deficiency citation, they may email or phone the reviewing component contact informally, without submitting an IRR, to discuss the issues of the case and the required actions necessary in the following instances:
clarify the actions required in the Form SSA-1774-U5 (Request for Corrective Action);
ask a specific question about the deficiency; or
ask for a policy citation(s)
E. The IRR process for reviewing components
After receiving the IRR notification, the designated reviewing component staff contact takes the following actions:
identifies the original program leader (PL) who approved the deficiency, and
assigns the IRR in the IRR web-based tool to the PL or other designated OQR staff that was not involved in the original return.
The reviewing component has 10 calendar days to respond to the IRR. When the review is complete, the reviewing component staff will:
code the IRR web-based tool,
prepare a narrative response to the IRR in the IRR web-based tool, and
include policy and procedural references to support the response.
When the IRR response is ready for review, the PL, or staff designee, will inform the Branch Chief (BC) or other designated OQR manager. The BC, or other designated OQR manager, will return the IRR to the PL, or staff designee, if declining to sign the IRR response. The PL, or staff designee, will make the requested changes and resubmit the IRR to the BC, or other designated OQR manager, until achieving concurrence. The BC, or other designated OQR manager, will close the IRR in the IRR web-based tool. This action uploads the IRR response to the CEF and the tool notifies the adjudicating component by email that it is available to review.
If the reviewing component agrees that the adjudicating component’s determination was policy compliant, the reviewing component will rescind the deficiency, code and clear the case according to normal business processes.
If the reviewing component disagrees with the adjudicating component’s IRR rationale for policy compliance and affirms the deficiency, the adjudicating component will take corrective actions or prepare an RPC or OQR Rebuttal.
If the adjudicating component decides to complete the required corrective action, the adjudicating component will return the case to the reviewing component after completing the actions. The reviewing component will code and clear the case according to normal business processes.
If the reviewing component rescinds or corrects the deficiency, the IRR web-based tool will send a system-generated email notification to the OQR Reports Branch to ensure that it is recorded.