Effective Dates: 05/14/2019 - Present Previous | Next

TN 7 (05-19)

DI 30007.135 Actions Prior to the Request for Program Consultation (RPC) Panel Discussion

A. Receiving the RPC submission

When a DDS requests an RPC, the RPC tool automatically:

  1. 1. 

    Assigns a case number;

  2. 2. 

    Enters the date of the submission; and

  3. 3. 

    Adds the case to the Workload Management screen.

B. RPC actions prior to panel discussion

Upon receipt of an RPC submission:

  1. 1. 

    The RPC technical expert reviews the submission for personally identifiable information (PII). If the DDS submission contains PII, the technical expert returns the submission to the DDS for correction.

  2. 2. 

    If there is no PII in the RPC submission, or after the DDS corrects the submission, the technical expert accepts the submission and the RPC tool automatically emails the DDS, the DQB, and the CD, notifying them of the acceptance of the RPC submission.

  3. 3. 

    The technical expert assigns the submission to an RPC reviewer who serves as the ODP panel member in the RPC panel discussion.

C. ODP, ODD, and OQR RPC panel member actions prior to the RPC panel discussion

1. All three panel members (ODP, ODD, and OQR):

  • •

    Review the DDS's RPC submission and the DQB's SSA-1774 (Request for Corrective Action) for the involved policy issues and policy references.

  • •

    Review the entire case record and prepare to resolve the policy issues in question.

2. The ODP panel member:

  • •

    Completes the DDS and DQB data screens in the RPC tool.

  • •

    Reviews the RPC tool database for cases with similar issues.

  • •

    Determines the need for additional medical or policy component expertise. If the panel member finds additional expertise is necessary, the panel member will not schedule the case for panel discussion. The panel member will provide a synopsis of the case issues to the RPC Technical Expert (TE) and request the appropriate policy guidance. The TE will forward the request to the consulting component. Upon the policy component response, the panel member may expedite the case or schedule it for discussion.

  • •

    Expedites the claim when appropriate. If the panel member finds the case record supports using the expedited process, the panel member applies the procedures for DI 30007.135F. and DI 30007.135G. in this section.

  • •

    Schedules the RPC panel discussion using the RPC tool, allowing two business days’ notice to all interested parties, if the case record does not support use of the expedited process. When the RPC panel discussion is scheduled, the RPC tool automatically sends an email to the involved DDS, DQB, and CD, notifying them of the date and time of the RPC panel discussion.

    NOTE: RPC makes every attempt to schedule RPC panel discussions in a timely manner. If RPC has not resolved a submission within 21 calendar days of the DDS’s RPC request, the DDS may request status using the “^ODP OPCA Controls” mailbox. In the email subject line, enter “RPC Status Request” and the RPC case number.

D. DQB wishes to rescind a deficiency

1. Submitting a rescission request to RPC

When a DQB chooses to rescind a deficiency prior to the RPC panel discussion, the DQB uses the RPC tool to notify RPC they wish to rescind the deficiency. The RPC tool automatically informs the DDS by e-mail when RPC accepts the DQB rescission request.

2. RPC accepts or rejects the rescission request

  • •

    If the DQB submits the request prior to RPC panel discussion and the DQB does not make the rescission contingent upon a DDS action, RPC generally accepts the DQB rescission request.

  • •

    If the DQB makes the rescission contingent on a DDS action, the technical expert will contact a DDS RPC liaison to see if the component will agree to DQB’s terms.

  • •

    If a proposed rescission would clearly result in an incorrect determination, RPC will reject the rescission. When RPC rejects a rescission request, RPC notifies the DQB and the DDS, and schedules the case for RPC panel discussion following the regular RPC process.

The following chart clarifies the process RPC uses in accepting or rejecting DQB requests for deficiency rescission:

If …

then …

the DQB asks to rescind a deficiency without requiring any subsequent DDS actions, RPC accepts the rescission request and emails confirmation of the rescission,

DQB removes the deficiency from the OQR database.

 

the DQB asks to rescind a deficiency contingent on certain DDS actions and DDS agrees to take those actions, RPC accepts the rescission request,

confirms the DDS will take the agreed-upon action and closes the RPC.

the DQB asks to rescind a deficiency contingent on certain DDS actions and the DDS does not agree to take those actions, RPC rejects the rescission request

schedules the case for RPC panel discussion.

the DQB asks to rescind a deficiency but the rescission will clearly result in an incorrect determination, RPC rejects the rescission request,

notifies the DQB of the action and schedules the case for RPC panel discussion.

RPC receives the DQB rescission notification after the RPC panel discussion results in an RPC resolution, RPC will not accept the rescission request and

the RPC resolution is official.

E. DDS RPC submission withdrawal process

When a DDS chooses to withdraw an RPC request prior to the RPC panel discussion, the DDS sends an email to the “^ODP OPCA Controls” mailbox, indicating “RPC Withdrawal” and the RPC case number in the subject line. Generally, RPC will honor the withdrawal request, unless it is clear the withdrawal will result in an incorrect determination.

F. Expedited RPC process

The purpose of the expedited RPC process is to identify cases where the areas of dispute can be appropriately resolved without the full RPC panel discussion process, as outlined in DI 30007.145.

1. Examples of cases that are appropriate for the expedited process

An RPC staff member decides whether the facts of a case are consistent with the expedited process. Examples of cases that may be appropriate for the expedited process include those in which:

  • •

    The only disputed issue is medical and RPC receives a written medical opinion that resolves the issue. In this case, the ODP panel member enters the written opinion or clarification into the CEF.

  • •

    The DQB cites a documentation deficiency, but the missing documentation is in the CEF.

  • •

    The existing policy on the disputed issue(s) is well defined and the resolution of the case is not in question, considering the case facts and disability policy.

  • •

    RPC has previously provided guidance on the same policy issue in a previous RPC resolution; or

  • •

    Any case where, based on the experience of the RPC reviewer, technical expert, or manager, the resolution of the case is not in question.

2. Case types excluded from the RPC expedited process

  • •

    Quality assurance (QA) reviews.

  • •

    Unresolved informal resolution requests (IRR).

EXCEPTION: A QA or IRR case can only be expedited if OQR, ODD, and ODP all agree that the case facts support RPC expedited processing.

G. Expedited RPC procedure

The expedited RPC procedure:

  1. 1. 

    If ODP/RPC reviews the case evidence and determines the expedited process may apply, the reviewer discusses the case with the RPC technical expert.

  2. 2. 

    The RPC technical expert reviews the case and the recommendation and determines whether the expedited process is appropriate.

  3. 3. 

    Upon receiving approval to expedite, the reviewer prepares an RPC resolution, and puts the resolution into the RPC tool. The resolution will include a notice under both the ODP summary and the ODP narrative stating “Expedited RPC – No RPC Panel Discussion Held.”

  4. 4. 

    The reviewer will code the case as an expedited RPC in the “Categories of Issue” on the RPC tool’s ODP Data Screen.

  5. 5. 

    The reviewer will submit the case to the RPC technical expert for closure in the RPC tool.

H. Center for Disability (CD) actions

A center for disability (CD) is not required to take any action on an initial RPC request submitted within the appropriate timeframe (see DI 30007.125B.). However, CDs have access to the RPC database for use in their ongoing oversight, liaison, training, and leadership responsibilities.

If a CD has comments regarding a DDS’s RPC, the CD should email comments to RPC (include the RPC case number in the subject line) at “^ODP OPCA Controls” with a copy to ODD at “||DCO ODD” and the OQR at ^DCBFQM OQR Controls.

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0430007135
DI 30007.135 - Actions Prior to the Request for Program Consultation (RPC) Panel Discussion - 05/14/2019
Batch run: 05/14/2019
Rev:05/14/2019