TN 1 (04-89)

GN 04442.110 Medical Review Policy

A. Operating Policy

1. GENERAL

The medical consultant staff in the Chicago Regional Office participates with the DRS in the adjudication of railroad claims and also with the DQB in the quality assurance review of the same claims.

2. CHICAGO RMCS FUNCTIONS

Since the Chicago Regional Medical Consultant Staff (RMCS) will have already evaluated the medical evidence, impairment severity, and when applicable, residual functional capacity, it will not routinely review railroad claims selected for quality review.

3. DQB REVIEWER FUNCTIONS

During the quality review process, DQB reviewers:

  1. Can refer any claim to the RMCS for further evaluation.

  2. Must obtain RMCS concurrence in all claims in which the DQB cites a medically based deficiency.

B. Related Procedure - RMCS Action

1. FORMS COMPLETION

When a RMCS physician reviews the quality of a railroad disability determination, the physician will:

  1. Code the Data Verification Form.

  2. Prepare the following forms, if necessary:

    • SSA 416-U4, Medical Report

    • SSA 4734-F4, Residual Functional Capacity Assessment

    • SSA-2506-BK, Psychiatric Review Technique

    • SSA-4734 SUP, Mental Residual Functional Capacity Assessment

2. COMPLETION OF SSA-416-U4

The physician reviews the quality of the determination. If the medical evidence is inadequate, the SSA-416-U4 is completed.

  1. The physician evaluates what the missing evidence might show within the limits established by the medical evidence already in the folder.

  2. This evaluation of the probable impact of the missing medical evidence is criticalto the decision to obtain (or not obtain) additional medical evidence.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0204442110
GN 04442.110 - Medical Review Policy - 07/29/1994
Batch run: 01/27/2009
Rev:07/29/1994