TN 20 (04-13)
GN 04440.501 Completion of the SSA-1774-U5, Request for Corrective Action
A. Use of an SSA-1774-U5
The Office of Quality Review (OQR) uses an SSA-1774-U5 to return group I and group II deficiencies (and other technical corrective actions which may affect the disability determination or the period of disability) to the adjudicating component.
B. Procedure for completing an SSA-1774-U5
The sections below explain how to complete the SSA-1774-U5 form.
1. How to complete the fields
On the SSA-1774-U5, we electronically propagate sections 1 – 9 from information in the OQR legacy system. For complete and correct data propagation, complete all OQR legacy system coding prior to creating the SSA-1774-U5.
Following completion of the review screens:
Review the propagated fields for accuracy and make any necessary changes on both the eForm and in OQR’s legacy system. NOTE: If the return is part of a special study, you must check “Other” in block 4, Type of Review. Complete block 8, Deficiency, to reflect the type of deficiency identified during the quality review although these returns are “informational only”; i.e., do not count towards the adjudicating component’s performance accuracy.
Annotate block 10 “See Narrative.” Incorporate references into the case discussion. Do not list policy references in this section.
Select the “yes” or “no” block for the folder attached section of the SSA-1774-U5, if applicable.
Select the box for “Medical Review” and “Med Note in File”, if applicable.
2. How to format and organize the narrative discussion
The following sections explain how to complete the narrative fields on the SSA-1774-U5.
a. Narrative fields
We consider the “narrative fields” on the SSA-1774-U5:
Item 11 (Action Requested and Rationale) on the first page, and
Continuation pages (4 total) provided when you select the [More] button.
In item 11, summarize the relevant facts of the case and clearly state
To explain or justify the deficiency do not use
Office of Disability Policy’s policy memorandums,
PolicyNet Questions and Answers, or
other similar written guidelines that are not part of National policy.
Acceptable references include:
Follow the appropriate format when completing each section of the narrative discussion on the SSA-1774-U5 as explained below:
b. The header section of the SSA-1774-U5
The OQR legacy system automatically propagates the header section onto the form. The heading will differ based on the type of review and deficiency code.
For cases with Type of Review “Other” in block 4, OQR’s legacy system automatically propagates a header of “Informational Only”.
For cases with a deficiency code between 10 and 85, OQR’s legacy system automatically propagates a heading that includes the deficiency group, type, OQR’s legacy system code, and a narrative description of the deficiency code. The information will be correct if the reviewer completes OQR’s legacy system coding prior to creating the SSA-1774-U5. For example, Group I Decisional – 11 – Incorrect Impairment Severity Decision.
NOTE: If you change the Type of Deficiency or deficiency code after the heading propagates, you must manually correct the header to match your cited deficiency.
c. How to complete the “Issue” section
Provide a statement to describe the nature of the deficiency. Make sure you clearly and briefly state why the case is deficient.
d. How to complete a case discussion including relevant policy citations
Follow the Federal Plain Language Guidelines as enacted by the Plain Language Act of 2010 when writing the narrative discussion of the SSA-1774-U5. Compose the body of the SSA-1774-U5 in typeface Courier New, Arial Regular, or Times New Roman, font size 10-14 points.
If applicable to the return, the section should:
Include a brief statement of the claimant's allegations and the alleged onset date.
Discuss the vocational issues and include specific policy references to support any deficiency findings.
Discuss medical issues with respect to sufficiency of documentation or medical severity, as it relates to listings requirements or consequent impact on the claimant's residual functional capacity (RFC). Include specific policy references.
Discuss symptom evaluation, medical source statements, all opinion evidence, and any related policy.
DO NOT merely cut and paste POMS sections into the return without providing a discussion of the policy interpretation; and how it specifically applies to the deficiency.
DO NOT provide a list of references, or cite a range of POMS chapters.
DO NOT cite a POMS table of contents or introductory section, unless the introductory section contains specific instructions related to the deficiency (e.g., introductory text in specific Listings of Impairments).
NOTE: Be very specific. Adjudicating components, the Request for Program Consultation staff and subsequent reviewers must be able to identify the incorrectly applied policy to determine the proper course of corrective action.
e. How to complete the “Request for corrective action” section
Explicitly state the action necessary to correct the deficiency.
If documentation is necessary, specify the type of documentation. Do not direct the adjudicating component to purchase a consultative examination or tell them how to otherwise obtain the evidence. For routing and correcting deficient cases, see GN 04440.201E.1.
If the return does not require corrective action by the adjudicating component, include the statement “No corrective action required”.
NOTE: Check the box “Continued on Attached Sheet,” if you need an additional page to explain the reason for the return. If you need more than the allotted four continuation pages use an SSA-1774-U5 Continuation sheet.
3. Accessing the continuation pages of the SSA-1774-U5
There are five pages built into the eForm SSA-1774-U5 (i.e., the first page and four possible continuation pages). Item 11 on the first page and each continuation page is recognized as a separate narrative field. At times, you must “work around” the space limitation (displayed in the “current field” attributes in each of the narrative fields) by selecting and moving some of the text to a continuation page.
To access continuation page 2, scroll down, and select the [More] button located at the bottom of page 1.
To access continuation pages 3 through 5, scroll down, move the cursor to the far right margin, and select the [More] button.
IMPORTANT: After creating the continuation pages, use the page number toggle on the tool bar to switch between pages.
4. Signing the SSA-1774-U5
Complete the “signatures” blocks appropriately and date the form with the date you release the form to the adjudicating component.
The quality reviewer may “sign” and “unsign” the SSA-1774-U5 up until the time the case clears OQR’s legacy system. “Unsigning” the SSA-1774-U5 deletes all signatures on the form. The SSA-1774-U5 is locked at case clearance and you cannot make any changes to the form after that point. For information regarding signing electronic documents, refer to DI 81030.100.
NOTE: The review component’s management determines when and who signs the SSA-1774-U5.
5. Uploading the SSA-1774-U5 to the certified electronic folder (CEF)
To upload the final version of the SSA-1774-U5 to the CEF select the form for upload at OQR’s legacy system clearance.
6. Distributing the SSA-1774–U5
Appropriate parties will be able to view the eForm SSA-1774–U5 in the CEF. .
OQR generates and distributes a National Weekly Deficiency Report to regional offices, CDs, and review components.
You should immediately distribute this weekly report to notify the adjudicating component of deficiencies or other actions taken by the review component. NOTE: The National Weekly Deficiency Report serves as OQR's official notification to the adjudicating components.
The FO receives an electronic alert for claims we return to them, as well as notification of all claims we return to the adjudicating component for corrective action.