TN 1 (04-89)

GN 04442.205 Screening Sample Claims—Quality Review Policy

A. Introduction

Sample claims are selected by the DRS, flagged, and sent to the DQB for review.

B. Operating Policy

1. EXCLUDED CLAIMS

Excluded claims must be returned to the DRS. They are listed in GN 04442.115.

2. FORM SSA-415

The SSA-415 is used to coordinate and exchange information on SSA disability claims filed by railroad workers and their dependents.

3. DRS ACTION - FORM SSA-415

The form is initiated and released by the DRS and serves to:

  1. Coordinate the DRS disability determination with the RRB (the coordination block in section 1 of the form will be checked).

  2. Transmit claims material to the RRB (the information block in section 1 of the form will be checked).

  3. Request consultative examinations from the RRB (the consultative examination block in section 1 of the form will be checked).

C. Procedure - DQB Action

1. FORM SSA-415

Determine that a completed SSA-415 is in every dual eligibility claims folder reviewed. If a completed form is not in the folder:

  1. Stop the review.

  2. Do not charge a deficiency.

  3. Return the folder to the DRS.

  4. Request the DRS on an SSA-559 to:

    • Place a completed SSA-415 in the folder.

    • Return the folder to DQB to complete the QA review.

2. FORM SSA-415, "CONFLICT” BOX CHECKED

When this box is checked, it means that RRB has contested the proposed DRS disability determination. DRS or RRB must obtain documentation to resolve the conflict.

3. NO DOCUMENTATION TO RESOLVE CONFLICT

  1. Return the folder to the DRS via an SSA-559.

  2. Indicate in the remarks sectionof the SSA-559:

    • The SSA and RRB determinations are in conflict.

    • The issue must be resolved.

    • Request the DRS to return the folder to complete the quality review after the conflict is resolved.

4. MISROUTED CLAIMS

Return misrouted claims to the DRS via an SSA-559, explaining the reason for the return.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0204442205
GN 04442.205 - Screening Sample Claims--Quality Review Policy - 11/08/1996
Batch run: 01/27/2009
Rev:11/08/1996