TN 1 (05-89)

GN 04447.300 Corrective Actions on Deficient Claims Under GLPSC - DRS Procedures

A. Operating Policy

1. CLASSIFIED DEFICIENCIES

Most deficient determinations are classified by the Group I, II, and III categories. These determinations are returned by the DQB to the DRS for corrective action.

2. NON-CLASSIFIED DEFICIENCES

The DQB may find some situations with incorrect (or potentially incorrect) determinations where the deficient action is not classified by a specific deficiency category. In these situations, the DQB must return the claim to the DRS for corrective action, but no deficiency will be cited.

B. Procedure

1. CORRECTING GROUP I AND II DEFICIENCIES

Take the requested action, and return all claims with group I and II deficiencies to the DQB.

EXCEPTION:Work Activity Deficiencies

  1. Send the claim containing an unresolved issue to the FO.

  2. Correct any other deficiencies after the FO returns the claim to the DRS.

  3. Send the claim to the DQB for review of the corrective action.

2. CORRECTING GROUP III DEFICIENCIES

Correct the following group III deficiencies:

  1. Substantive Notice Deficiencies: The DQB will return the claim using an SSA-5526-U3, Request for Assistance - Disability, if a notice is substantively deficient. You must:

    • Prepare a corrected notice.

    • return the claim to DQB for review of the corrective action.

  2. Technical Notice Deficiencies: The DQB will annotate the SSA-559, Claims Folder/Material Transmittal, used to return the claim to the DRS, “Deficient Notice, Corrected Notice Required,” if a technically deficient notice (i.e., misspelled words, typographical errors, etc.) is the only deficiency. You must:

    • prepare a corrected notice.

    • not return the claim to the DQB if onlythe notice is technically deficient.

    • send a copy of the corrected notice to the DQB.

  3. Unsigned or Incorrectly Signed Consultative Examination Report

    • obtain the signature of the physician who conducted the examination.

    • place the properly signed consultative examination report in the folder.

    • Return the claim to the DQB.

  4. Incomplete or Missing Form SSA-4734-F4, Residual Functional Capacity
    Assessment:The DQB will initiate corrective action directly with the regional medical consultant staff (RMCS)since this form is completed by the RMCS.

3. VOCATIONAL DEFICIENCIES BASED ON EARLIER DQB CONSULTATION

In some cases involving vocational issues, the DQB may have assisted the DRS in adjudicating the claim. If the DQB later finds a deficiency based on the DQB's earlier participation in adjudicating the claim, no deficiency will be cited.

You will be notified of the required corrective action on an SSA-5526-U3. You must:

  1. takethe action necessary to correct the deficiency.

  2. returnthe claim to the DQB.

4. ROUTING CORRECTED DEFICIENT CLAIMS

Send all corrected claims to the DQB for review of the corrective action and completion of a results form. The DQB will return the claim to you for removal of the sample flag and effectuation of the determination.
EXCEPTION: Do not send corrected claims to the DQB when only technical deficiencies were involved.

5. SECOND RETURNS

The DQB may return the claim again to you if:

  1. DQB disagreeswith your action, and

  2. You have notrebutted the deficiency.

In this situation, take the corrective action requested and return the claim to the DQB.

NOTE:Although the DRS may be required to correct additional deficiencies, no additional deficiency will be charged to the DRS.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0204447300
GN 04447.300 - Corrective Act