TN 10 (02-11)

DI 30005.001 The Quality Review Process

A. Introduction to the quality review process

This subchapter provides the adjudicating components with a description of:

  • SSA quality reviews (QR),

  • definitions of deficiencies,

  • instructions for correcting deficient cases SSA returns, and

  • instructions for rebutting SSA deficiency findings.

B. Description of QR process

1. Office of Quality Review (OQR) review criteria

The OQR reviews QR sample cases to ensure that the evidentiary record supports the decision and that the evidence and the decision conform to SSA operating policies and procedures. For an explanation of the various QR samples, see DI 30005.005.

2. OQR return criteria

OQR may return a deficiency to the adjudicating component when correcting the deficiency could affect the disability determination, the period of disability, or could affect whether they conformed to certain technical requirements. For the definition of specific types of deficiencies and other technical corrective actions (TCAs), see DI 30005.121- DI 30005.127. For a description of the procedures for correcting deficiencies, see DI 30005.201 through DI 30005.241.

3. Adjudicating component rebuttal criteria

The adjudicating component may use the rebuttal procedure (for paper cases) or file a Request for Program Consultation (RPC) (for fully electronic cases) for any group I or group II deficiency, or TCA when the adjudicating component does not agree with the review component.

For instructions on rebuttal procedures, see DI 30005.501DI 30005.510.

For RPC procedures that only apply when the case reviewed is a certified electronic folder, see DI 30007.000.

C. Glossary of terms

1. Deficiencies

Deficiencies are specified instances of noncompliance with SSA policies and procedures and we classify them into two groups according to their impact, or potential impact, on the disability determination. We categorize deficiencies as either group I or group II. We further categorize group I and group II deficiencies as either decisional deficiencies or documentation deficiencies. There are also TCAs that we do not categorize as deficiencies.

2. Categories of group I and group II deficiencies

We categorize group I and group II deficiencies as either:

  • Decisional deficiencies in which the adjudicating component should have made an opposite or different disability determination or period of disability determination based on a fully documented case, or

  • Documentation deficiencies that require the development of additional evidence to make the correct determination or to determine the correct onset, ending, or cessation date.

The review component records these incorrect actions as deficiencies and reports them on the QR report, if they occur in a QR sample case.

3. Differences in determination form data

On occasion, the entries on the adjudicating component-prepared disability determination form in the case file differ from those on the electronic record transmitted to the review component; i.e., the adjudicating component inputs the data at the time they clear the case that pass on to the review component electronically. Unless the difference is due to an obvious keying error, the review component bases their review on the electronic record and cites any deficiency based on a disagreement with the electronic record. This is so even if the review component agrees with the entries on the disability determination that is in the case file, as explained in GN 04440.007B.3.

4. Group I deficiencies

Group I deficiencies affect, or have the potential to affect, the basic decision to allow, deny, continue, or cease disability benefits. There are two categories of group I deficiencies:

  • Group I decisional deficiencies indicate that the adjudicating component should have made an opposite or different disability determination; and

  • Group I documentation deficiencies require the development of additional evidence to establish the correct disability determination.

For types of group I decisional and documentation deficiencies, see DI 30005.121 and DI 30005.123.

5. Group II deficiencies

Group II deficiencies are substantive deficiencies that affect only the onset date, ending date, or cessation date. There are two categories of group II deficiencies:

  • Group II decisional deficiencies in which a different period of disability should have been determined; and

  • Group II documentation deficiencies requiring the development of additional evidence in order to make the correct period of disability determination.

6. TCAs

TCAs, formerly called group III deficiencies, involve instances of adjudicating component noncompliance with procedural requirements for effective program administration with claimants and beneficiaries.

TCAs are incorrect actions:

  • Identified during the review process but not covered by the formal group I or group II definitions; or

  • Identified in a non-sample case regardless of whether the group I or group II definitions cover the incorrect action.

TCAs may be either substantive or non-substantive.

For the TCA categories, see DI 30005.127.

7. Performance accuracy

Performance accuracy refers to the percentage of cases not returned to adjudicating components for further development or correction of determinations based on the evidence in file, and represents how reliable the adjudicating component’s determination is. The definition of performance accuracy includes the measurement of factors with a potential for affecting a determination, as well as the correctness of the determination, as explained in 20 CFR, §404.1643.

OQR uses only group I deficiencies in initial quality assurance sample cases for computing the adjudicating component’s performance accuracy rates, as explained in 20 CFR §404.1645.

8. Probability of reversal

Probability of reversal (POR) is an administrative tool quality reviewers use to distinguish returnable group I or group II documentation deficiencies from TCAs. The determining factor is whether obtaining the missing documentation is unlikely to reverse the disability determination or change the period of disability. For a complete explanation of the POR rule and application, see DI 30005.110 and GN 04440.110.

9. Review component

A review component is any SSA component that reviews disability determinations; e.g., the disability quality branch.

10. Substitution of judgment in the QR process

One of the principles of QR is that Federal quality reviewers, Federal medical consultants (MC), or Federal psychological consultants (PC) must not substitute their judgment for that of the adjudicating component's MCs, PCs, and disability examiners. Federal MCs, PCs, and Federal quality reviewers must be aware of the substitution of judgment (SOJ) concept. MCs and PCs must be aware of SOJ as a review principle to ensure that they do not perform a de novo case review. (For an explanation of de novo review, See GN 04440.003D.) Quality reviewers must be aware of SOJ as a review principle in their decisional deficiency deliberations.

If the adjudicating component fully documents a case, and the adjudicator's assessment complies with SSA policy and supports evidence in file, the QR does not cite a decisional deficiency even though the Federal reviewer(s) arrived at a different, equally supportable conclusion.

For a complete explanation of SOJ, see GN 04440.118 - GN 04440.119. For an explanation of SOJ and the medical review, see GN 04440.130B.

11. Determination supported or supportable

The term “supported” or “supportable,” means conforming to SSA disability program policy and procedures. Within this context, not being supported or supportable links to the presence of substantive deficiencies (e.g., the medical evidence consists only of a diagnosis without any acceptable clinical or laboratory findings to support it).

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DI 30005.001 - The Quality Review Process - 02/09/2011
Batch run: 01/15/2014