TN 12 (09-16)

DI 30005.501 Introduction to the Office of Quality Review (OQR) Rebuttal Process

A. Introduction to resolving deficiency disagreements

There are three different methods of resolving deficiency disagreements between adjudicating and reviewing components:

  1. Informal Resolution Request (IRR),

  2. Request for Program Consultation (RPC), and

  3. The Office of Quality Review (OQR) rebuttal process.

  4. The process for resolving deficiency disagreements between an adjudicating component and a reviewing component differs depending on a variety of factors, to include whether the case is:

    • a certified electronic folder (CEF),

    • an electronic folder (EF) with a prior paper folder, or

    • a modular disability folder (MDF) paper case.

The Office of Policy Consultation and Analysis (OPCA) administers the Request for Program Consultation (RPC) process, which resolves deficiency disagreements for CEF cases without a prior paper folder. For an explanation of the RPC process, see Request for Program Consultation (RPC), subchapter DI 30007.000.

The Office of Quality Review (OQR) rebuttal process is for MDF paper cases, EF cases involving a prior paper folder, and some cases excluded by the RPC process. For an explanation of the OQR rebuttal process, see The Office of Quality Review (OQR) Rebuttal Process, in section GN 04440.410.

B. Policy for resolving deficiency disagreements

When the adjudicating component disagrees with any cited group I or group II deficiency in a fully electronic case, they are encouraged to resolve the disagreement on an informal basis by submitting an IRR via the Office of Disability’s (ODP) IRR web-based tool.

NOTE: RPC will not accept submissions when the disagreement involves a change in deficiency type, otherwise known as a wrong deficiency situation, unless the case has first been through the IRR process. A wrong deficiency situation occurs when one type of deficiency is cited but program instructions support a different type, e.g., documentation vs decisional or group I vs group II. In these situations, there is no rescission of the deficiency, but the reviewing component codes the correct deficiency in the OQR legacy system. This still only results in one chargeable deficiency against the adjudicating component.

EXAMPLE: The reviewing component cites a decisional deficiency, changing an allowance determination to a denial determination, but fails to recognize in doing so, that the adjudicating component must first develop all allegations or medical sources prior to denying the claim. The adjudicating component requests the reviewing component change, or replace, the decisional deficiency to a documentation deficiency, agreeing that the evidence does not currently support an allowance, but acknowledging the adjudicating component must develop all allegations or medical sources before making a denial determination. The reviewing component corrects the OQR legacy system to reflect a documentation deficiency, thus there is only one chargeable deficiency for the adjudicating component.

If the adjudicating component chooses not to resolve the disagreement through the IRR process, or if they cannot resolve the deficiency after the IRR process, the adjudicating component may submit an:

  • RPC to OPCA for a fully electronic case (see DI 30007.125 – Submitting a case for Request for Program Consultation (RPC)); or

  • OQR rebuttal to the reviewing component for a case that is not fully electronic (see DI 30005.510 The Office of Quality Review (OQR) Rebuttal Process).

If the adjudicating component does not resolve the deficiency through the IRR process, or submit an RPC or OQR rebuttal, they must complete the request for corrective action on the deficiency transmittal form.

C. The IRR process for adjudicating components

The adjudicating component uses the IRR process to:

  • resolve disagreements in group I or group II deficiencies for a fully electronic case;

  • request a rescission of a group I or group II deficiency in a fully electronic case; or,

  • resolve disagreements, within the appropriate time frames, regarding cases with group II deficiencies routed directly from the reviewing component to the Field Office (FO).

When the adjudicating component prepares an IRR, the adjudicating component:

  • cannot use the Federal quality review administrative procedure of probability of reversal (POR), as defined in GN 04440.110 and GN 04440.112, as the basis for an IRR for a documentation deficiency;

  • can use substitution of judgment (SOJ), as defined in GN 04440.118 and GN 04440.119, as a basis for an IRR for a decisional deficiency;

  • cannot use SOJ as the basis for an IRR for a documentation deficiency; and,

  • is not required to perform any development actions requested on the SSA-1774-U5, Request for Corrective Action, or the SSA-847, SSA Request for Case Action prior to submitting an IRR, except for those development actions not in dispute.

NOTE: The reviewing component will not accept IRRs for the following:

The adjudicating component must initiate an IRR through the Office of Disability Policy’s (ODP) IRR web-based tool to try to resolve any disagreement, or to request a rescission of any group I or group II deficiency. The adjudicating component must:

  • submit the IRR request in the web-based tool within 20 calendar days beginning with the date the reviewing component sent the deficiency; and

  • include a narrative explaining the basis for the IRR.

NOTE: For any IRR submitted after the 20-calendar day timeframe, the adjudicating component must provide an explanation of the unusual circumstances causing the delay. The reviewing component determines whether to accept the IRR due to the unusual circumstances.

If the reviewing component disagrees with the IRR rationale for policy compliance, the adjudicating component will take corrective actions OR submit an RPC (for a fully electronic case) or OQR rebuttal (for a not fully electronic case).

D. When not to use the IRR process

When the adjudicating component does not request rescission of a deficiency or is not in disagreement with the deficiency citation, they may email or phone the reviewing component contact informally, without submitting an IRR, to discuss the issues of the case and the required actions necessary in the following instances:

  • Clarify the actions required in the SSA-1774-U5 – Request for Corrective Action, from the reviewing component;

  • Ask a specific question about the deficiency; or,

  • Ask about a policy citation(s)

E. Policy for the OQR rebuttal process

  1. Objectives of the OQR rebuttal process

    The main objective is to resolve deficiency disagreements between the adjudicating and the reviewing components quickly. Other objectives include:

    • Protect claimants and beneficiaries from incorrect determinations;

    • Protect the Social Security Disability Insurance program and the Supplemental Security Income program from incorrect determinations;

    • Identify and rescind incorrectly cited deficiencies;

    • Achieve a consistent review process;

    • Ensure OQR review policies are clear;

    • Enable OQR to obtain clarifications from other policy components in a timely manner; and

    • Ensure a credible and objective review.

  2. Division of Disability Quality (DDQ) review process

    DDQ is part of OQR’s central office operations and is separate from the DQBs, which are under OQR’s field operations. DDQ will receive all rebuttal cases for final resolution when the reviewing component affirms the deficiency. The DDQ reviewer consults with other policy components as necessary, prior to presenting the case for the DDQ policy team discussion. The purpose of this discussion is to provide a consistent resolution.

    DDQ reviews:

    • Rebuttals affirmed by the reviewing component;

    • Evidence available at the time of the adjudicating component’s determination, to determine whether the deficiency cited by the reviewing component is supported,

    • Subsequent documentation, which is not used to determine whether the deficiency citation was appropriate, and

    • All appropriate policy guidance.

  3. The DDQ resolution

    DDQ resolves all deficiency citation disagreements and issues. If DDQ determines a deficiency is present, but the reviewing component cites the incorrect deficiency, e.g., wrong deficiency type, the reviewing component corrects the deficiency citation to reflect the appropriate deficiency type (e.g., the reviewing component cites a decisional deficiency when the evidence supports a documentation deficiency). This correction will still not result in more than one chargeable deficiency on the case.

    There is no appeal of the DDQ findings and resolution including:

    • Requests for specific adjudicating component development, documentation, or determination as a part of the case resolution;

    • Requests for other adjudicating component action; or

    • Affirmations, modifications, or rescissions of the deficiencies.

  4. When the adjudicating component prepares a rebuttal

    The adjudicating component:

    • Should not use the Federal quality review administrative procedure of probability of reversal, as defined in GN 04440.110 and GN 04440.112, as a basis for rebuttal of a documentation deficiency;

    • May use substitution of judgment, as defined in GN 04440.118 and GN 04440.019, as a basis for the rebuttal of a decisional deficiency, but not as a basis for the rebuttal of a documentation deficiency;

    • Is not required to take the development actions requested on the SSA-1774-U5, Request for Corrective Action, or SSA-847, SSA Request for Case Action, prior to submitting a rebuttal, except for those development actions not in dispute; but

    • Is required to take all development actions addressed in the DDQ resolution.

    See Details

    • GN 04440.110, The Probability of Reversal (POR) Rule and Clarifying Documentation Deficiencies

    • GN 04440.112, When the Probability of Reversal (POR) Rule Cannot be Used

    • GN 04440.118, Substitution of Judgment (SOJ) in the Quality Review (QR) Process

    • GN 04440.119, Determining Whether Substitution of Judgment (SOJ) is at Issue

  5. Specified time frames for submitting and processing OQR rebuttals

    The adjudicating and reviewing components will strive to meet the following time frames:

    • Adjudicating component rebuttal submittals

    • The adjudicating component’s goal is to submit a rebuttal to the reviewing component within 30 calendar days beginning with the date the reviewing component sends the deficiency. The reviewing component will accept rebuttals submitted after the 30-calendar day time frame expires only when the adjudicating component provides a full explanation of the unusual circumstances, and the reviewing component determines that the delay results from the unusual circumstances.

    • Rebuttal responses

    • The goal for the reviewing component and DDQ is to resolve rebuttals within 30 calendar days after receipt of the rebuttal by the reviewing component. However