Identification Number:
GN 04440 TN 35
Intended Audience:See Transmittal Sheet
Originating Office:OARO Office of Quality Review
Title:Federal Quality Review of Disability Determinations
Type:POMS Transmittals
Program:Disability
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM
Part GN – General
Chapter 044 – Quality Appraisal
Subchapter 40 – Federal Quality Review of Disability Determinations
Transmittal No. 35, 01/04/2019

Audience

PSC: DE, DEC;
OCO-OEIO: FDE;
DQB: DE, PL;
OCO-ODO: DE, DEC, DS, RECONE;

Originating Component

OQR

Effective Date

Upon Receipt

Background

This is a quick action transmittal request and does not contain policy or procedure changes.

OQR is updating all quality review POMS to reflect that OQR no longer reviews paper files.

This subchapter discusses SSA federal quality reviews and provides instructions to Office of Quality Review (OQR) review components for reviewing and assessing sampled cases; and for handling deficiencies rebutted by adjudicating components.

 

 

Summary of Changes

GN 04440.002 The Quality Review (QR) Process

We made minor editorial changes throughout to update the language to comply with federal plain language guidelines and for clarity. We also removed all references to paper folders.

GN 04440.002 The Quality Review Quality Review Process

A. Introduction to the quality review process

This subchapter discusses SSA federal quality reviews and provides instructions to the Office of Quality Review (OQR) review components for returning or correcting deficient quality review cases, and for processing deficiencies rebutted by the adjudicating components. OQR conducts federal quality reviews of disability cases in the OQR review components located in the 10 regions .

The main quality reviews are:

  • Quality assurance reviews, and

  • Preeffectuation reviews.

For a detailed explanation of the quality review types and the reason we perform them, see GN 04440.005.

B. Description of QR process

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.

See Also:

DI 23025.000 for an explanation of fraud or similar fault.

GN 04111.065 for instructions on preparing the e8551.

C. Sample case review

OQR reviews sample cases to ensure the evidence of record supports the determination and that the evidence and the determination conform to SSA operating policies and procedures, as defined in GN 04440.007A.

D. Return criteria

OQR may return a deficient case to an adjudicating component when correcting the deficiency could affect the disability determination, the period of disability, or conformance to certain technical requirements.

Specific types of deficiencies and other technical corrective actions (TCA) are defined in DI 30005.121 - DI 30005.127.

Procedures for correcting deficiencies and TCAs are described in GN 04440.201 - GN 04440.243.

E. Rebuttal criteria

The adjudicating component may file an RPC for any group I or group II deficiency with which the adjudicating component does not agree with the review component.

Rebuttal procedures are described in GN 04440.401.

RPC procedures are described in subchapter DI 30007.000.


GN 04440 TN 35 - Federal Quality Review of Disability Determinations - 1/04/2019