Identification Number:
GN 04440 TN 92
Intended Audience:See Transmittal Sheet
Originating Office:OARO Office of Quality Review
Title:Federal Quality Review of Disability Determinations
Type:POMS Transmittals
Program:
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM
Part GN – General
Chapter 044 – Quality Appraisal
Subchapter 40 – Federal Quality Review of Disability Determinations
Transmittal No. 92, 02/03/2020

Audience

PSC: DE, DEC;
OCO-OEIO: FDE;
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.

This transmittal is part of an ongoing activity by the Office of Quality Review (OQR) to update the quality review POMS.

Summary of Changes

GN 04440.123 High- and Low-Impact Grace Periods

Throughout this entire POMS, we:

Removed the phrase "or clarified" as it does not accurately reflect the general nature of grace periods.

Added subjects to sentences, as many of the existing sentences do not specifically identify who is supposed to do what.

Corrected all verb tenses that were necessitated by adding subjects to sentences.

Corrected articles "a" and "the", as appropriate. "A" is used for generic or general purposes. "The" is used to denote more specificity.

Changed personal pronouns, like "we" and "you" to "OQR" and review component, as appropriate, to more clearly define who was responsible for performing needed actions.

Add "adjudicating component", as needed, to further delineate adjudicator component information from review component information.

Changed "legacy" system to "case processing" system to avoid the need for updates if the system being used changes.

Made minor editorial changes or reordered the sequence of words or phrases in a sentence to improve clarity.

Made minor grammatical/punctuation changes, as needed.

Removed redundant words and sentences, e.g.,third sentence in subsection E.1. was removed as that information was stated in the first few paragraphs of this POMS.

Added acronyms at point of first use, as needed and required. (For example, added "POMS" in F.2.)

SECTION SPECIFIC CHANGES

In section A., we:

Removed the third sentence as it contradicts information in section C.

In section D.3., we:

Added "grace period" prior to the word "cases" in the title.

In section D.4., we:

Added "QA" prior to the word "sample" in the title.

Reworded sentence three, in its entirety, to improve clarity.

In section E.1., we:

Removed the third sentence as it is redundant.

In section F.2., we:

Revised the wording of the first paragraph to improve clarity. (For example, we added "adjudicating components" after word "for" in first sentence. We also added the phrase "use of new or revised policy or procedures" in the first sentence, for the sake of consistency in wording.

Removed the word "teletypes", as teletypes are no longer used to communicate or disseminate information.

In section G.1., we:

Expanded the first phrase set off by commas to read, "including obtaining medical or psychological contractor review", to reflect updated terminology and improve clarity.

In section G.2., we:

Removed the "i.e." portion of the third paragraph as it contained the phrase, "misapplication of the new, revised, or clarified policy or procedure". This sentence was problematic as it contains the word "clarified" that we wanted to delete from this entire POMS and it also contained the word "misapplication". "Misapplication" is problematic as oftentimes, the issue is not that the new or revised policy or procedure is misapplied, but rather the old policy or procedure continues to be used, even after expiration of the grace period.

GN 04440.123 High- and Low-Impact Grace Periods

A. Definition of a grace period

A grace period is the time between the date new or revised policy, procedure, or a type of quality review becomes effective and the date when quality reviewers can begin to cite group I deficiencies on cases involving the new policy or procedure. Grace periods ONLY apply to initial quality assurance (QA) sample cases.

B. Purpose of a grace period

The purpose of a grace period is to allow adjudicating components time to become familiar with, and proficient in using, the new or revised policies and/or procedures.

C. Types of grace periods

There are two types of grace periods:

  • high-impact grace periods and

  • low-impact grace periods.

The Office of Quality Review (OQR) determines which type of grace period to establish.

  • In a high-impact grace period, OQR removes all grace period cases from adjudicating component's performance accuracy calculations.

  • In a low-impact grace period, OQR includes all grace period cases, with a group I deficiency, in calculating adjudicating component's performance accuracy, but OQR counts these cases as deficiency-free cases.

D. High-impact grace period

1. Introduction to a high-impact grace period

When OQR expects a new or revised policy or procedure to affect a large workload, e.g., when there has been a major revision to a widely applied listing(s), OQR excludes all grace period cases from adjudicating component's performance accuracy statistics and does not report them in the normal QA process. Instead, OQR tracks grace period cases separately and maintains separate data for these cases. OQR augments the initial QA sample, to replace the grace period cases, to maintain statistical precision in the reported accuracy rates of adjudicating components.

2. What is a high-impact grace period case?

A high-impact grace period case is any initial QA case in which a new or revised policy or procedure is a factor in the adjudication of the case, regardless of whether the case contains a deficiency.

3. Excluding grace period cases from performance accuracy

To preclude distortion of performance accuracy data and prevent artificial inflation of adjudicating component's accuracy rates, OQR central office (CO) systems staff exclude all initial QA sample cases, that fall under a high-impact grace period, from adjudicating component's performance accuracy calculations. This exclusion applies to both deficient and non-deficient cases.

4. QA sample augmentation

Since OQR excludes all high-impact grace period cases, regardless of whether they contain a deficiency, from adjudicating component's performance accuracy calculations, additional "non-grace period" sample cases are selected for quality review while a grace period is in effect. This means that a larger number of randomly chosen cases for the initial QA sample are selected from each adjudicating component. This number is approximately equal to the number of cases in each adjudicating component that involve a grace period issue. OQR does this to maintain the required statistical precision and validity of the initial QA sample, i.e., to ensure review of a sufficient number of cases.

E. Low-impact grace period

1. Introduction to a low-impact grace period

When OQR does not expect a new or revised policy or procedure to affect a large workload, OQR does not exclude grace period cases from adjudicating component's performance accuracy statistics. However, OQR treats initial QA cases that fall under a grace period, and contain a group I deficiency, as deficiency-free cases with regard to performance accuracy calculations.

2. What is a low-impact grace period case?

A low-impact grace period case is any initial QA case in which a new or revised policy or procedure is a factor in the adjudication of the case, regardless of whether the case contains a deficiency.

F. Policy on grace periods

1. Authority

OQR establishes grace periods in consultation with the Office of Disability Programs.

2. Length of grace period

The grace period for adjudicating components to implement use of new or revised policy or procedures, as provided in Program Operations Manual System (POMS) transmittals (TN) and emergency messages (EM), is two full calendar months after the effective date of the issuance. For example, if the POMS transmittal is effective 6/28, the grace period would continue through 8/31.

The date an adjudicating component disability examiner signs the SSA-831-C3/U3 (Disability Determination and Transmittal) determines when and whether the grace period applies.

G. Review component procedure for coding and reviewing cases involving a grace period

1. General

Quality reviewers will review grace period cases in the usual manner, including obtaining medical or psychological contractor review, if applicable, and return deficient cases to the adjudicating component for corrective action.

2. Grace period coding

High-impact grace period cases

If the grace period in effect is a high-impact grace period, the quality reviewer will enter the assigned grace period code in the "Grace Period" field on the QA Initial Allowance tab in OQR’s case processing system for any case that falls under the grace period, regardless of whether the case contains a deficiency, i.e., all initial QA sample cases in which the new or revised policy or procedure is a factor in the adjudication of the case. Quality reviewers will code group I or group II deficiencies, if applicable, in the usual manner in the "Med/Voc Deficiency" field under the QA Initial Allowance tab in OQR’s case processing system.

OQR CO systems staff remove all initial QA sample cases that are coded as grace period cases from the adjudicating component's accuracy computations, i.e., OQR CO systems staff remove all cases coded as grace period cases from the QA database.

Low-impact grace period cases

If the grace period in effect is a low-impact grace period, the quality reviewer will enter the assigned grace period code in the “Grace Period” field on the QA Initial Allowance tab in OQR’s case processing system only if there is a group I deficiency in the grace period case that is directly related to the new or revised policy or procedure.

Quality reviewers will code group I deficiencies in the usual manner in the “Med/Voc Deficiency” field under the QA Initial Allowance tab in OQR’s case processing system.

3. Citing deficiencies and correcting cases

When a quality reviewer identifies a deficiency in a case, that is related to a new or revised policy or procedure covered by a grace period, the quality reviewer will cite the deficiency and return the deficient case to the adjudicating component for correction. The quality reviewer will annotate the SSA-1774-U5 (Request for Corrective Action) with either of the following remarks, depending on the type of grace period in effect:

  • High- Impact - Case Excluded From Performance Accuracy Calculations - Informational Only or

  • Low- Impact - Informational Only. Group I Deficiency Not Counted in Performance Accuracy Calculations.

NOTE: When a quality reviewer identifies a deficiency in a case, that is NOT related to a new or revised policy or procedure covered by a grace period, the quality reviewer will cite and record the deficiency following the standard quality review process.


GN 04440 TN 92 - Federal Quality Review of Disability Determinations - 2/03/2020