An automated sample selection process selects quality review sample cases when adjudicating components input determinations, and sends cases to review components , prior to effectuating the determinations.
Quality reviewers conduct reviews of adjudicating components' determinations using the same policy and procedural guidelines adjudicating components use. Quality reviewers follow the steps of sequential evaluation and consider all available evidence before assessing the acuracy of determinations, citing deficiencies and returning cases to adjudicating components.
Quality reviewers record review results, including any medical reviews, directly to OQR’s legacy system. The legacy system transmits review data to OQR in Central Office, where the data are stored and used to produce national reports.
When a case contains no returnable deficiency and is otherwise correct, the review component inputs the case information into the OQR legacy system and effectuates the determination.
If a case is deficient, the quality reviewer returns the case to the adjudicating component for correction, based on the criteria listed in GN 04440.002D. of this section.
If an adjudicating component disagrees with a deficiency return, they can submit an informal resolution request (see GN 04440.401) or file a Request for Program Consultation (RPC) (see GN 04440.405)
NOTE: If the quality reviewer identifies a potential disability fraud issue during review, the review component will send a fraud referral via an e8551 following local procedures. If the review component is returning the case to the adjudicating component for correction of a returnable deficiency, they will instruct the adjudicating component to make the fraud referral.
DI 23025.000 for an explanation of fraud or similar fault.
GN 04111.065 for instructions on preparing the e8551.