Identification Number:
GN 04440 TN 132
Intended Audience:See Transmittal Sheet
Originating Office:OARO Office of Quality Review
Title:Federal Quality Review of Disability Determinations
Type:POMS Transmittals
Program:All Programs
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM
Part GN – General
Chapter 044 – Quality Appraisal
Subchapter 40 – Federal Quality Review of Disability Determinations
Transmittal No. 132, 01/12/2021

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. 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 will mirror it in DI 30005.205.

 

Summary of Changes

GN 04440.205 Quality Review Subsequent Returns

We added a sentence to the note in section A.

 

GN 04440.401 Resolving Deficiency Disagreements - Informal Resolution Request (IRR) and Request for Program Consultation (RPC)

We added a sentence to the last paragraph in section B.

 

GN 04440.205 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 GN 04440.205B.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.

GN 04440.401 Resolving Deficiency Disagreements - Informal Resolution Request (IRR) and Request for Program Consultation (RPC)

A. Introduction to resolving deficiency disagreements

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

  1. 1. 

    The IRR process, administered by the Office of Quality Review (OQR), 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, administered by the Office of Policy Consultation and Analysis (OPCA), 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.

B. Policy for resolving deficiency disagreements

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 are encouraged to 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.

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 codes the correct deficiency in the OQR case processing system. 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 corrects the OQR case processing system to reflect a documentation deficiency, thus there is only one chargeable deficiency for the adjudicating component.

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, if the criteria is met, 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, or submit an RPC, they must complete the request for corrective action(s) noted in the SSA-1774-U5, Request for Corrective Action.

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. (see GN 04440.205 and DI 30005.205 - Quality Review Subsequent Returns).

C. The IRR process for adjudicating components

The adjudicating component uses the IRR process to:

  • resolve disagreements in group I deficiencies, group II deficiencies, or TCAs, in a fully electronic case;

  • request a rescission of a group I deficiency or group II deficiency, in a fully electronic case; or,

  • resolve disagreements, within the appropriate time frames, regarding cases with group II deficiencies routed directly from the review component to the Field Office (FO).

When the adjudicating component prepares an IRR, the adjudicating component:

  • cannot use the federal quality review administrative procedure of probability of reversal (POR), as defined in GN 04440.110 and DI 30005.110, as the basis of an IRR for a documentation deficiency;

  • can use substitution of judgment (SOJ), as defined in GN 04440.118, as the basis of an IRR for a decisional deficiency;

  • cannot use SOJ as the basis of an IRR for a documentation deficiency; and,

  • is not required to perform any development actions requested on the SSA-1774-U5, Request for Corrective Action, or the SSA-847, SSA Request for Case Action, prior to submitting an IRR, except for those development actions not in dispute.

NOTE: The review component will not accept IRRs for the following:

  • subsequent returns (See GN 04440.205); or,

  • closed cases, with the exception of group II deficiencies routed directly to the FO.

The adjudicating component must initiate an IRR through ODP's IRR web-based tool to attempt to resolve any disagreement or to request a rescission, if applicable, of any group I deficiency, group II deficiency, or TCA. The adjudicating component must:

  • submit the IRR request in the web-based tool within 20 calendar days, beginning with the date the review component returned the deficient case, and

  • include a policy based narrative, with applicable citations, explaining the basis for the IRR.

NOTE: For any IRR submitted after the 20 calendar day time frame, the adjudicating component must provide an explanation of the unusual circumstances that caused the delay. The review component determines whether to accept the IRR due to the unusual circumstances.

If the review component disagrees with the IRR rationale for policy compliance submitted by the adjudicating component, the adjudicating component must complete the requested corrective action(s) noted in the SSA-1774, Request for Corrective Action, OR submit an RPC, if the case meets the criteria for RPC submission (see DI 30007.125 - Submitting a case for RPC).

D. When not to use the IRR process

When the adjudicating component does not request rescission of a deficiency or is not in disagreement with the deficiency citation, the adjudicating component may email or phone the review component contact found in the SSA-1774-U5, Request for Corrective Action, without submitting an IRR, to discuss the issues in the case, and/or the necessary required actions:

  • to clarify the requested corrective action(s) noted in the SSA-1774-U5;

  • to ask a specific question about the deficiency; or,

  • to ask for a policy citation(s).

E. The IRR process for review components

After receiving an IRR notification, the designated review component contact:

  • identifies the original program leader (PL) who approved the deficiency and

  • assigns the IRR in the IRR web-based tool to a designated OQR staff member who was not involved in the original return.

The review component has 10 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,

  • 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.

When the IRR response is ready for review, the OQR designated staff member will inform the branch chief (BC) or other designated OQR manager. The BC, or other designated OQR manager, will return the IRR to the OQR designated staff member if he or she declines to sign the IRR response. The OQR designated staff member will make the requested changes and resubmit the IRR to the BC, or other designated OQR manager, until achieving concurrence. The BC, or other designated OQR 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, code 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 SSA-1774, Request for Corrective 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 adjudicating component decides to complete the requested corrective action(s), the adjudicating component will return the case to the review component after completing the actions. The review component will code and clear the case according to normal business processes.

If the review component rescinds or corrects the deficiency, the IRR web-based tool will send a system-generated email notification to the OQR Reports Branch to ensure that the rescinded or corrected deficiency is appropriately recorded.

 

NOTE: When an IRR results in a rescission of a group II decisional deficiency that has been transmitted to the field office for effectuation, and the final outcome of the determination is changed, the case must be reactivated. The review component will follow policy guidance in GN 04440.111 Reopenings Certified Electronic Folders (CEF) for reactivation and reopening.


GN 04440 TN 132 - Federal Quality Review of Disability Determinations - 1/12/2021