There are two methods of resolving deficiency disagreements between adjudicating and review components:

1. 1. 

   The IRR process attempts to resolve deficiency disagreements informally between the adjudicating and review components. The adjudicating component directs the IRR submission to the review component that cited the deficiency for another impartial review of the case facts and applicable policies in contention. The review component will prepare a policy-based IRR resolution to address the adjudicating component's deficiency disagreement.

2. 2. 

   The RPC process resolves deficiency disagreements between the adjudicating and review components through an RPC Panel Discussion. For an explanation of the RPC process, see DI 30007.000.

When the adjudicating component disagrees with any cited group I deficiency, group II deficiency, or technical corrective action (TCA), in a fully electronic case, they may attempt to resolve the disagreement on an informal basis by submitting an IRR via the Office of Disability Policy’s (ODP) IRR web-based tool, within twenty (20) calendar days, beginning with the date the review component returned the deficient case. For any IRR submitted after the twenty (20) calendar-day time limit, the adjudicating component must provide an explanation of the unusual circumstances that caused the delay. The review component will determine whether to accept the IRR due to the unusual circumstances.

NOTE: RPC will not accept submissions when the disagreement involves a change in deficiency type only, otherwise known as a "wrong deficiency cited", unless the case has first been through the IRR process. A wrong deficiency citation 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 review component updates the QR case processing system database with the correct deficiency. This still only results in one chargeable deficiency against the adjudicating component.

EXAMPLE: The review 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 review 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 review component updates the QR case processing system database with the correct deficiency, thus there is only one chargeable deficiency for the adjudicating component.

NOTE: The QR case processing system allows recording more than one deficiency code when applicable to the Federal quality review results. However, only the deficiency marked as "Primary" is counted against the adjudicating component. Deficiencies marked as "Other" do not count against the adjudicating component unless they subsequently become "Primary" as a result of the IRR or RPC.

If the adjudicating component chooses not to attempt 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 RPC). The adjudicating component may not simultaneously submit an IRR and RPC.

If the adjudicating component does not resolve the deficiency through the IRR process, they must complete the request for corrective action(s) noted on the Request for Corrective Action, or Request for Case Action, or submit an RPC, if the case meets the criteria for RPC submission (see DI 30007.125 - Submitting a Case for RPC).

For subsequent returns and corrective action inquiries, which are precluded from the IRR/RPC process, the adjudicating component may choose to contact reviewing component directly to discuss concerns informally prior to completion of the action(s) noted on the Request for Corrective Action or Request for Case Action. (see QR 04440.205 - Quality Review Subsequent Returns).

After receiving an IRR notification, the review component’s designated manager will:

• •

  identify the original program leader (PL) who approved the deficiency, and

• •

  assign the IRR in the IRR web-based tool to a QR staff member who was not involved in the original return.

The review component has 14 calendar days to respond to the IRR. When the review is complete, the review component will:

• •

  code the IRR web-based tool.

• •

  prepare a narrative response to the IRR in the IRR web-based tool,

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  ensure that the IRR response addresses all relevant policy concerns or questions raised by the adjudicating component, and

• •

  include policy and procedural references to support the response, unless the review component agrees with the adjudicating component’s IRR, rescinds the deficiency, and no further action is needed.

When the IRR response is ready for review, the QR staff member will inform the branch chief (BC) or other designated QR manager (both referenced as “manager” going forward). The manager will return the IRR to the QR staff member if the IRR response requires revision prior to release. The QR staff member will make the requested changes and resubmit the IRR to the manager for approval. The manager will close the IRR in the IRR web-based tool. This action uploads the adjudicating component's IRR submission and review component's IRR response to the certified electronic folder and the tool notifies the adjudicating component by email that the response is available to view.

If the review component agrees that the adjudicating component’s determination was policy compliant, the review component will rescind the deficiency in the IRR web-based tool. Once the case is returned by the adjudicating component, the review component will update the QR case processing system database and clear the case according to normal business processes.

If the review component disagrees with the adjudicating component’s IRR rationale for policy compliance and affirms the deficiency, the adjudicating component must take the requested corrective action(s) noted on the Request for Corrective Action, or Request for Case Action, or submit an RPC, if the case meets the criteria for RPC submission (see DI 30007.125 - Submitting a case for RPC).

If the review component rescinds or corrects the deficiency within the IRR web-based tool, the QR case processing system database will be automatically updated with the applied revisions to ensure that the rescinded or corrected deficiency is appropriately recorded.