Identification Number:
DI 30005 TN 47
Intended Audience:See Transmittal Sheet
Originating Office:OARO Office of Quality Review
Title:Adjudicating Component Actions on Deficient Cases
Type:POMS Transmittals
Program:Disability
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM
Part DI – Disability Insurance
Chapter 300 – Quality Assurance
Subchapter 05 – Adjudicating Component Actions on Deficient Cases
Transmittal No. 47, 01/05/2021

Audience

PSC: DE, DEC;
OCO-OEIO: CR, FDE, RECONE;
DQB: DE, PA, PL, TL;
OCO-ODO: DC, DE, DS, RECONE;
ODD-DDS: ADJ, DHU;

Originating Component

OQR

Effective Date

Upon Receipt

Background

This is a Quick Action Transmittal. These revisions do not change or introduce new policy or procedure. DI 30007.125 Submitting a Case for RPC, subsection E bullet 6 explains that subsequent returns are precluded from IRR/RPC, but that the DDS may contact the DQB to discuss informally. The narrative then points the reader to GN 04440.401 Resolving Deficiency Disagreements - IRR/RPC subsection B Policy for resolving deficiency disagreements. The GN does not include anything about informal discussions on subsequent returns. To remedy this we added a sentence in GN 04440.401B and mirror it here in DI 30005.205.

Summary of Changes

DI 30005.205 Quality Review Subsequent Returns

Added clarifying sentence to DI 30005.205A Note

 

DI 30005.205 Quality Review Subsequent Returns

A. Introduction to subsequent returns

A subsequent return occurs when a review component returns a claim to an adjudicating component for additional development and/or correction, and the adjudicating component either:

  • does not complete all of the requested actions before routing the claim back to the review component, or

  • new, potentially material, issues arise because of the actions taken by the adjudicating component.

NOTE: The review component must not cite additional deficiencies on subsequent returns. For subsequent returns, which are precluded from the IRR/RPC process, DDS may choose to contact DQB directly to discuss concerns informally prior to completion of the action(s) noted in the SSA-1774-U5, Request for Corrective Action DI 30005.205B.2.

B. Correcting subsequent returns

When an adjudicating component does not complete all of the corrective actions delineated on the SSA-1774-U5 (Request for Corrective Action), or when subsequent case development raises material issues, the review component will either correct the case, or return the case to the adjudicating component for correction.

1. Case corrected in the review component

When the adjudicating component fully documents a case in response to a return, but the final determination, onset date, or ending date is incorrect, the review component will:

a. annotate all of the adjudicating component’s original determination and medical assessment forms, as well as notices, in the certified electronic folder (CEF) as “Do Not Process” or “Do Not Release”, as applicable,

b. code the subsequent return in the case processing system,

c. notify the adjudicating component, via an SSA-847-U3 (Request for Case Action), to explain the additional actions taken on the case, and why further corrections were needed,

d. either correct the onset or ending date or assume jurisdiction to correct the final determination,

e. prepare and release any necessary personalized notices, and

f. route the case to the field office.

NOTE: Do not assume jurisdiction for cases when the next level of appeal is a disability hearing at reconsideration. This includes:

  • continuing disability review medical cessations,

  • adverse reopenings of favorable initial determinations based on medical factors,

  • adverse reopenings of reconsideration reversals based on medical factors, and

  • adverse reopenings of cessations that change only the basis for the cessation.

These cases must always be returned to the adjudicating component for correction.

NOTE: All of the adjudicating component’s original determination and medical assessment forms, as well as notices, must remain in the CEF as part of the audit trail.

EXCEPTION: If the case has another deficiency or technical corrective action requiring corrective action by the adjudicating component, or changing the ending date results in an adverse reopening of either an initial or a reconsideration case, the review component will follow the instructions in GN 04440.204B.1.

2. Case returned to the adjudicating component for corrective action

When the adjudicating component’s documentation is still insufficient to make the final determination or to determine the correct onset or ending date, the review component will:

a. code the subsequent return in the case processing system,

b. notify the adjudicating component, via a new SSA-1774-U5, Request For Corrective Action, to acknowledge the corrective actions already completed, explain why the case is still not policy compliant, and specify what additional actions are needed,

c. annotate the heading of the new SSA-1774-U5, “Second Return – No Additional Deficiency Cited”,

d. route the case to the adjudicating component for correction as a controlled return, and

e. follow-up with the adjudicating component in 60 days if the corrected determination has not been returned to the review component.


DI 30005 TN 47 - Adjudicating Component Actions on Deficient Cases - 1/05/2021