BASIC (04-08)

DI 81030.021 Routing and Correcting Deficient Certified Electronic Folder (CEF) Cases

A. Introduction

1. General Instructions

The following routing and corrective action instructions apply only to CEF cases. Use these instructions in conjunction with the general processing instructions in GN 04440.201 GN 04440.243.

NOTE: Exceptions and revisions to general processing instructions that are specific for CEF cases are found in DI 81030.021 DI 81030.040.

2. How the Office of Quality Review (OQR) Central Office Notifies the Regional Centers for Disability (CD) of Deficiencies Cited

Effective September 2007, the regional CD accesses a weekly automated report listing the deficiencies cited by the disability quality branch (DQB) during that week.

3. Split Routing

CEF claims, except electronic continuing disability review claims, can be split routed in the Disability Case Adjudication and Review System if certain conditions are met. These conditions are:

  • Case 1 to the adjudicating component with Controlled Return = Y or N and other cases to the field office (FO) with Controlled Return = N; or

  • Case 1 to the FO with Controlled Return = Y and other cases to FO with a Controlled Return = N.

B. Corrective Action - DDS Only

When a case requires corrective action by the DDS only:

  • Code the review screens prior to creating the eForms so the information propagates into the eForm.

  • Prepare an SSA-1774-U5 (Request for Corrective Action) or an SSA-847 (Request for Case Action) using eForms, and:

    • Indicate the necessary corrective action;

    • Inform the DDS which component they should transfer jurisdiction to upon completion of their actions.

  • Control the return, if appropriate.

  • Clear the case to the DDS. This action transfers jurisdiction to the DDS.

  • Send the SSA-1774-U5 or SSA-847 to the CEF during the clearance process.

  • For controlled returns, input results data when the corrected case is returned.

    NOTE: Follow guidelines in GN 04440.201 - GN 04440.243 for instructions regarding whether or not to control the return.

C. Corrective Action - DDS and FO

When a case contains a group I work activity procedural documentation deficiency per GN 04440.211, Correcting Group I Work Activity Procedural Documentation Deficiencies, or a group II work activity documentation deficiency per GN 04440.228, Correcting Group II Work Activity Documentation Deficiencies, and there is another returnable deficiency:

  • Code the review screens prior to creating the eForms so the information propagates into the eForm.

  • Prepare an eForm SSA-5524–U3 (Request for Assistance) and ask the FO to develop work activity and document the CEF.

  • Prepare an SSA-1774-U5 or SSA-847–U3, as appropriate, using eForms and notify the DDS of the deficiency. See DI 04440.201D to determine whether to use form SSA-1774–U5 or SSA-847–U3.

  • Control the return.

  • Clear the case to the FO.

  • Send the SSA-5524 and SSA-1774-U5 or SSA-847–U3 to the CEF during the clearance process.

    NOTE: DQB retains jurisdiction of the CEF in pending status. DQB clearance stops processing time from accruing on the case while the FO completes the requested development.

D. Corrective Action - FO Only

1. Group I Substantial Gainful Activity (SGA) Decisional Deficiency

When there is clear evidence of SGA, and a FO SGA determination is required per GN 04440.210, Correcting Group I Substantial Gainful Activity Decisional Deficiencies, take the following action:

  • Code the review screens prior to creating the eForms so the information propagates into the eForm.

  • Prepare an eForm SSA-5524 and ask the FO to develop work activity and document the CEF.

  • Prepare an SSA-1774-U5 using eForms and notify the DDS of the deficiency.

  • Control the return.

  • Clear the case to the FO.

  • Send the SSA-5524 and SSA-1774-U5 to the CEF during the clearance process.

    NOTE: DQB retains jurisdiction of the CEF in pending status. DQB clearance stops processing time from accruing on the case while the FO completes the requested development.

2. Group I/II Documentation Deficiency and No Other Returnable Deficiency - Work Activity Not Documented on Modernized Claims System (MCS) or Modernized Supplemental Security Income Claims System (MSSICS)

When there is a group I work activity procedural documentation deficiency or a group II work activity documentation deficiency, and no other returnable deficiency, and the work activity is not documented on MCS/MSSICS per GN 04440.211C.2.b. and GN 04440.228C.2.b.:

  • Code the review screens prior to creating the eForms so the information propagates into the eForm.

  • Prepare an eForm SSA-5524 and ask the FO to develop work activity and document the CEF.

  • Prepare an SSA-1774-U5 or SSA-847–U3, as appropriate, using eForms and notify the DDS of the deficiency. See DI 04440.201D to determine whether to use form SSA-1774–U5 or SSA-847–U3.

  • Control the return.

  • Clear the case to the FO.

  • Send the SSA-5524 and SSA-1774-U5 or SSA-847–U3 to the CEF during the clearance process.

    NOTE: DQB retains jurisdiction of the CEF in pending status. DQB clearance stops processing time from accruing on the case while the FO completes the requested development.

3. Non-Recorded Substantive Deficiency

When the case contains a non-recorded substantive deficiency and the FO must take corrective action because the date last insured (DLI), prescribed period (PP) or attainment of age 22 is at issue, develop per GN 04440.235C.1.b., Correcting Non-Recorded Deficiencies, and take the following additional action:

  • Code the review screens prior to creating the eForms so the information propagates into the eForm.

  • Prepare an eForm SSA-5524 and ask the FO to verify the DLI, PP or attainment of age 22 (whichever is at issue) and document the CEF.

  • Prepare an informational SSA-1774-U5 or SSA-847–U3 using eForms and notify the DDS of the non-chargeable deficiency. See DI 04440.210D to determine whether to use form SSA-1774–U5 or SSA-847–U3.

  • Control the return.

  • Clear the case to the FO.

  • Send the SSA-5524 and SSA-1774-U5 or SSA-847–U3 to the CEF during the clearance process.

    NOTE: DQB retains jurisdiction of the CEF in pending status. DQB clearance stops processing time from accruing on the case while the FO completes the requested development.

E. Procedure - DQB Action after FO Corrective Action

1. FO Determines that SGA Denial is Applicable

If the FO agrees that there is clear evidence of SGA (per DI 81030.021D.1.), or if after the group I work activity procedural documentation deficiency issue is resolved (per DI 81030.021C or DI 81030.021D.2.), the FO determines that an SGA denial determination is appropriate, the FO documents the CEF with their completed development.

When the FO responds to DQB's assistance request with completed development, the DQB:

  • Creates a Return Workload Unit (WU).

  • Completes the applicable review screens, including entering “Y” in the FO determination required (FO Detn Reqd? Y/N) field.

  • Clears the case to the FO.

    NOTE: Once the case is cleared, OQR’s legacy system automatically transfers jurisdiction of the CEF to the FO in pending status.

The FO takes the appropriate actions to complete the SGA denial.

2. FO Determines SGA Denial is Inappropriate

If the FO does not agree that the claimant is engaging in SGA (per DI 81030.021D.1.), or if after the group I work activity procedural documentation deficiency issue is resolved (per DI 81030.021C or DI 81030.021D.2.), the FO documents the CEF with their completed development.

When the FO responds to DQB's assistance request with completed development:

  1. If no DDS corrective action is needed, the DQB:

    • Creates a Return WU.

    • Completes the applicable screens. Makes changes to the SSA-831 (Disability Determination and Transmittal) and notice, as appropriate.

    • Clears the case as you normally would for completed cases or second returns, as appropriate.

      NOTE: Once the case is cleared, OQR’s legacy system automatically transfers jurisdiction of the CEF to the FO in closed status, or

  2. If DDS corrective action is needed, the DQB:

    • Creates a Return WU.

    • Codes the review screens prior to creating the eForms so the information propagates into the eForm.

    • Prepares a new SSA-1774-U5 using eForms, and:

      • Indicates the necessary corrective action;

      • Informs the DDS which component they should transfer jurisdiction to upon completion of their actions.

    • Controls the return, if appropriate.

    • Clears the case to the DDS. This action transfers jurisdiction to the DDS.

    • Sends the SSA-1774-U5 to the CEF during the clearance process.

    • For controlled returns, inputs the results data when the corrected case is returned.

      NOTE: Follow guidelines in GN 04440.201 GN 04440.243 for instructions regarding whether or not to control the return.

3. Onset/Ending Date

If, after the work activity (per DI 81030.021C or DI 81030.021D.2.) Date Last Insured (DLI), Prescribed Period (PP) or attainment of age 22 (per DI 81030.021D.3.) issues are resolved, the onset/ending date remains the same, or onset/ending date changes, the FO documents the CEF with their completed development.

When the FO responds to DQB's assistance request with completed development:

  1. If no DDS corrective action is needed, the DQB:

    • Creates a Return WU.

    • Completes the applicable screens. Makes changes to the SSA-831 and notice, as appropriate.

    • Clears the case as you normally would for completed cases or second returns, as appropriate.

      NOTE: Once the case is cleared, OQR’s legacy system automatically transfers jurisdiction of the CEF to the FO in closed status, or

  2. If DDS corrective action is needed, the DQB:

    • Creates a Return WU.

    • Codes the review screens prior to creating the