Identification Number:
GN 04440 TN 91
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. 91, 01/23/2020

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.

The SSA-e8551, the electronic form used by SSA and DDS employees to report allegations of programmatic fraud for referral to the Office of the Inspector (OIG), will be replaced by the Allegation Referral Intake System (ARIS) as of 1/18/2020. The Office of Quality Review (OQR) is revising the POMS below to remove references to the obsolete form due to the release of ARIS.

Summary of Changes

GN 04440.009 Fraud or Similar Fault (FSF) Procedures for Quality Reviewers

Removed all references to the e-8551 as it is being replaced by ARIS as of 1/18/2020.

Added the link to ARIS in the last line of the first paragraph in section E.

GN 04440.009 Fraud or Similar Fault (FSF) Procedures for Quality Reviewers

A. Background

In most cases, field offices and adjudicating components identify FSF issues during the adjudication process. However, agency personnel are responsible for identifying FSF at every level of the adjudication process. Preserving the public’s trust in the Social Security Administration’s (SSA) disability program and reducing improper payments are critical elements in what all employees, including quality reviewers, do.

B. Identifying Fraud during the Quality Review Process

For a definition of fraud, please see GN 04105.005B.

C. Identifying Similar Fault during the Quality Review Process

For a definition of similar fault, please see GN 04105.005B.

D. Performing Quality Reviews on Cases involving FSF

If an adjudicating component identifies FSF in a case, the adjudicator is required to evaluate and disregard evidence as necessary, per DI 23025.025, when making the determination.

  1. 1. 

    If an investigation unit (IU) (i.e., the Office of the Inspector General (OIG) or a Cooperative Disability Investigations Unit (CDIU)) completed an investigation, consider the report of investigation (ROI), or any additional documentation received, in your review. Evidence in the case file may be discarded based on findings outlined in the ROI. If there is an ROI, or any other investigative information, in file when you receive the case for quality review, ensure that the adjudicating component weighed the evidence carefully and followed directions per DI 23025.025B.

  2. 2. 

    The adjudicating component is required, in most cases, to hold the case until the investigation for FSF is complete. If you receive a claim with an open FSF investigation, return it to the adjudicating component. There are two exceptions per DI 23025.020B.1.2.

    1. a. 

      If there is sufficient evidence in file to make a denial determination, the adjudicating component can make the determination. The investigator stops his or her investigation and provides any existing documentation. The adjudicator adds the available evidence to the case file.

    2. b. 

      If the evidence in file supports an allowance determination based on impairments other than those suspected for FSF, the adjudicating component can make the determination.

IMPORTANT NOTE: If an ROI or any other investigatory information is received during the quality review, quality reviewers will treat that information as trailer mail (see DI 22520.000).

E. Referring cases for FSF in the review component

The process of referring a FSF case in the quality review component differs from that of the adjudicative process. If you identify a potential FSF issue during review, refer the issue using the following link : Allegation Referral Intake System (ARIS)

  1. 1. 

    If you have prepared a return form and are returning the case to the adjudicating component for correction of a deficiency, instruct the adjudicating component to refer the case for a FSF investigation per guidelines in DI 23025.015.

  2. 2. 

    If you are sending the case to the field office for additional work development or information (i.e., category 30 or 85 deficiencies), prepare a fraud referral as described below in GN 04440.009E.3.

  3. 3. 

    If there is no returnable deficiency present, follow these steps:

    1. a. 

      Consult with a member of management to ensure the referral is appropriate and complete.

    2. b. 

      Effectuate the claim and send the appropriate personalized notices (if applicable) to the claimant and any representatives. NOTE: If the IU decides to accept the case for investigation, clearing the case from the case processing system will not cease the process.

    3. c. 

      Forward the case to the appropriate office (field office or payment center) with an alert in the file explaining that there is a pending referral.

NOTE: Do not hold the case in the quality review component after making a fraud referral.

References :

See DI 23025.005 for additional information regarding identifying fraud and similar fault.


GN 04440 TN 91 - Federal Quality Review of Disability Determinations - 1/23/2020