TN 13 (03-15)

DI 27520.026 Improper Effectuation of an Allowance Determination before the Office of Quality Review Completes Its Review

Citations:

Social Security Act §§ 221(c) and 1633(e)

A. Federal quality review of disability determinations

The Social Security Act requires us to review at least half of all favorable disability determinations in initial claims for benefits made by State disability determination services (DDS) before we take any action to effectuate the determination.

The Office of Quality Review (OQR) conducts this preeffectuation review, as well as ongoing quality assurance reviews, to ensure the accuracy of the determination. These reviews also protect the integrity of the disability programs by preventing erroneous payments.

As part of these reviews, OQR may find a documentation or decisional error on an uneffectuated allowance determination that results in a denial determination. Sometimes, the field office (FO) improperly effectuates the allowance determination.

NOTE: Effective August 23, 2014, we added a system fix to prevent the FO from effectuating initial and reconsideration allowance determinations in the electronic folder if the case is pending in OQR. This safeguard will remain in place until we input a final disability determination into the disability system.

B. Reopening improperly effectuated allowance determinations

When the FO improperly effectuates an incorrect allowance determination before OQR completes its review, the DDS will reopen the allowance determination.

NOTE: We will not consider an improperly effectuated allowance determination as a prior determination for purposes of applying the medical improvement review standard (MIRS) if the DDS reopens the determination promptly, as explained in DI 27520.026C in this section.

C. How the MIRS applies

1. Reopening within 60 days from date of notice

Do not apply the MIRS if the DDS reopens the allowance determination promptly within 60 days from the date of the improper award notice. See DI 27520.026D in this section.

2. Reopening more than 60 days from date of notice

Apply the MIRS to an adverse reopening if the DDS reopens the allowance determination more than 60 days from the date of the improper award notice. See DI 27520.026E in this section.

NOTE: The MIRS does not apply to adverse reopenings to a later onset date per DI 28005.001D.2.c.

D. Reopening within 60 days from the date of the improper award notice

The DDS should take the following actions if it is reopening the allowance determination within 60 days from the date of the improper award notice:

  • apply the current rules for reopening per DI 27505.000;

  • use the 1-year “for any reason” rule as the basis for reopening. See DI 27505.001A.1.;

  • do not apply the MIRS;

  • follow due process notification instructions in DI 27525.015B; and

  • follow reopening processing instructions in DI 81020.115.

E. Reopening more than 60 days from the date of the improper award notice

The DDS should take the following actions if it is reopening the allowance determination more than 60 days from the date of the improper award notice:

  • apply the current rules for reopening per DI 27505.000;

  • use the 1-year “for any reason” rule as the basis for reopening if you can reopen the allowance determination within 1 year from the date of the award notice;

  • if more than 1 year has elapsed since the date of the award notice, consider if you can reopen the determination for “good cause.” See sections DI 27505.001 and DI 27505.010.

    NOTE: Do not use “clerical error