Identification Number:
GN 04440 TN 93
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. 93, 02/03/2020

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 Office of Quality Review (OQR) is making editorial changes and completing updates throughout the quality review sections of the POMS to improve consistency, add clarity, and remove obsolete or archived references. This POMS was previously updated in 3/19, but was in need of further revisions.

Summary of Changes

GN 04440.003 Explanation of Quality Review Terms

In subsection A, we:

Changed information in parentheses to "federal disability processing branches or units".

In subsection B, we:

Changed "case" to "claim" in first sentence.

Added word "needed" prior to "field" in first sentence of second paragraph.

Added word "only" after "pertains" in second sentence of second paragraph to add emphasis.

Added "federal" prior to "quality reviewer" throughout the "NOTE".

Reworded "NOTE" for clarity.

Changed the word "subsequent" in last line of "NOTE" to "second", as that is the correct term.

In subsection C, we:

Added word "federal" prior to "quality reviewer" throughout subsection, as needed.

Used "federal quality reviewer" rather than "we" throughout subsection.

Changed the word "identify" to "classify" in third sentence.

Added "adjudicating component" after word "require" in last sentence to clearly delineate who is responsible for corrections.

Made minor editorial changes to last sentence to improve clarity.

Removed the second use of the word "when" in the second bullet in C.1., as it was unnecessary.

Made minor editorial and punctuation changes to the bullets in C.2. and C.3.

Changed the POMS reference in the last line of C.3. to reflect the recent changes to the technical corrective action (TCA) POMS.

Added the full POMS titles to the last line of C.3.

In subsection D., we:

Added quotation marks around the phrase "de novo" throughout the subsection, including in the title.

Expanded and reworded the definition of "de novo" to improve clarity.

Bolded the words "do not" in the first line of the second paragraph to add emphasis.

In subsection E., we:

Cleaned up the lead in sentence for the POMS reference at the end of the subsection.

In subsection F., we:

Revised sentence to improve flow and clarity.

In subsection G., we:

Revised second sentence of the first paragraph to improve clarity.

Removed CFR reference as it added no real value or additional clarifying information.

Reworded last sentence in subsection regarding POMS reference as it contained an unnecessary word.

In subsection H., we:

Added the phrase "length of the" prior to the word "period" in the second sentence to make verbiage more closely mirror how that phrase is generally written in POMS.

Reworded and shortened the POMS reference in the last line.

In subsection I., we:

Added the word "federal" prior to "quality reviewer" throughout the subsection.

Made the words "reviewer" and "PL" plural.

Changed the reference to "federal review physician/psychologist" to "regional office medical and/or psychological contractors" to more accurately describe the position of these personnel.

In subsection J., we:

Fixed a spacing issue in first bullet.

Changed the first letter of each bullet to a lower case letter.

In subsection K., we:

Added the word "federal" prior to "quality review" and " quality reviewer" throughout subsection, as needed.

Changed the references to "federal MCs and PCs" to "regional office medical and/or psychological contractors".

Added quotation marks around "de novo" in both places where that phrase appears in the first paragraph.

Corrected the explanation of the POMS reference in the second paragraph.

In subsection L., we:

Added the word "disability" prior to the word "determination" in the title of the subsection and throughout the subsection, as needed.

Revised entire paragraph to improve clarity.

GN 04440.003 Explanation of Quality Review Terms

A. Adjudicating component

An adjudicating component is a state or federal component that adjudicates disability claims (e.g., disability determination services or federal disability processing branches or units).

B. Another returnable deficiency

A claim is considered to have "another returnable deficiency" if, in addition to a group I or group II work activity documentation deficiency, there is a technical corrective action (TCA) that requires adjudicating component development or action. This is a rare occurrence.

The development or action required by the adjudicating component is in addition to the needed field office (FO) development or action and is unrelated to the work activity documentation deficiency. The FO development or action pertains only to a cited group I or group II work activity documentation deficiency.

NOTE: A federal quality reviewer should never cite more than one group I or group II deficiency on a claim. However, it is possible that when development for a cited group I or group II deficiency is completed by an adjudicating component, the need for additional medical or vocational development or documentation may become apparent. In this instance, federal quality reviewers should return the claim to the adjudicating component, requesting additional development and/or correction, as a second return, not as “another returnable deficiency.”

C. Deficiency

A deficiency is a specific instance of noncompliance with SSA policies and procedures classified according to its impact, or potential impact, on the disability determination. Federal quality reviewers categorize deficiencies as group I or group II. Federal quality reviewers further classify group I and group II deficiencies as decisional or documentation. There are also TCAs that require adjudicating component correction, but federal quality reviewers do not categorize TCAs as deficiencies.

1. Group I deficiencies

Group I deficiencies are substantive deficiencies that affect, or have the potential to affect, the basic decision to allow or deny or to continue or cease disability benefits. There are two categories of group I deficiencies:

  • Group I decisional deficiencies exist when the evidence in file supports an opposite disability determination and the file is documented in accordance with SSA disability policy.

  • Group I documentation deficiencies exist when the evidence in file is insufficient to make a policy compliant determination and the file is not documented in accordance with SSA disability policy.

For more information on the categories of group I decisional and documentation deficiencies, see DI 30005.121 and DI 30005.123.

2. Group II deficiencies

Group II deficiencies are substantive deficiencies that affect only the onset date, ending date, or cessation date. There are two categories of group II deficiencies:

  • Group II decisional deficiencies exist when the evidence supports a different period of disability and the file is documented in accordance with SSA disability policy.

  • Group II documentation deficiencies exist when the evidence in file is insufficient to establish the correct period of disability and the file is not documented in accordance with SSA disability policy.

For more information on the categories of group II decisional and documentation deficiencies, see DI 30005.125 and DI 30005.126.

3. Technical Corrective Actions (TCAs)

TCAs are instances of noncompliance with SSA's procedural requirements or programmatic documentation requirement deficiencies that do not have the potential to affect the determination or the length of the period of disability.

TCAs are cited when they are:

  • identified during the review process, but not covered by the formal group I or group II definitions or

  • identified in a non-sample case, regardless of whether the group I or group II definitions cover the incorrect action.

TCAs may be substantive or non-substantive.

For more information on TCAs, see GN 04440.230 (Introduction to Technical Corrective Actions (TCAs)), GN 04440.231 (Substantive Technical Corrective Actions (TCAs)), and GN 04440.232 (Non-substantive Technical Corrective Actions (TCAs)).

D. "De novo" review

A "de novo" review is one in which the evidence of record in a claim is objectively read and scrutinized, without considering the determination previously made by an adjudicating component. In effect, a "de novo" review is a re-adjudication of a disability claim.

Quality reviewers and regional office medical and psychological contractors do not perform "de novo" reviews. They review claims to ensure adjudicating component determinations comply with SSA disability program policy and procedures.

E. Documentation

The term “documentation” refers to the record SSA establishes and maintains of its determination of a claimant’s benefit rights and the evidence supporting that determination.

For additional information, see GN 00301.285 (Statements and Other Documentation).

F. Federal quality reviewer

A federal quality reviewer is a reviewer or program leader (PL), in a federal review component, who evaluates specific quality review sample claims to determine if an adjudicating component's evidentiary record and determination conform to SSA operating policies and procedures.

G. Preponderance of the evidence

Preponderance of the evidence means such relevant evidence that, as a whole, shows the existence of the fact to be proven is more likely than not. SSA bases the adjudication of all disability claims on the preponderance of the evidence standard.

Preponderance of the evidence is the greater weight of evidence that, when weighed against other evidence, is more convincing of the truth. It does not represent any specific quantity or volume of evidence, only that which is more probable of its truth and accuracy.

For additional information on preponderance of the evidence, see DI 23025.001B.5.

H. Probability of reversal (POR)

POR is an administrative tool used by federal quality reviewers to distinguish returnable group I or group II documentation deficiencies from TCAs. The determining factor is whether obtaining missing documentation is likely to reverse the disability determination or change the length of the period of disability.

For a complete explanation of POR, see GN 04440.110.

I. Quality review team

The federal quality review team is made up of federal quality reviewers and PLs, in federal quality review components, and the regional office medical and/or psychological contractors who perform the medical and/or psychological review portion of the quality reviews.

J. Substantive change

Per DI 40115.005, a substantive change is a change that alters the conclusions as to:

  • whether an individual is disabled,

  • when disability begins or ends, or

  • the basis for a determination, even when there is no change that affects benefits.

K. Substitution of judgment (SOJ)

One of the principles of the federal quality review is that federal quality reviewers and regional office medical and/or psychological contractors must not substitute their judgment for that of the adjudicating component’s medical and/or psychological consultants and adjudicators. Regional office medical and psychological contractors must be aware of SOJ as a review principle to ensure they do not perform a "de novo" case review. (See GN 04440.003D. for a definition of "de novo" review.)

For a description of the regional office medical and psychological contractor's review process, see GN 04440.130B.

Federal quality reviewers must be aware of SOJ as a review principle in decisional deficiency deliberations.

If an adjudicating component documents and assesses a claim in accordance with SSA's disability policy and the preponderance of the evidence in file supports the determination, the federal quality reviewer must not cite a deficiency, even if the federal quality reviewer arrived at a different, but equally supportable, conclusion.

For a complete explanation of SOJ, see GN 04440.118.

L. Supported or supportable disability determination

A disability determination is supported, or supportable, if it complies with SSA policy and procedural requirements, does not contain internal inconsistencies, and is supported by a preponderance of the evidence in file. A federal quality reviewer may find a disability determination is not supported if it does not comply with specific SSA policy or documentation requirements.


GN 04440 TN 93 - Federal Quality Review of Disability Determinations - 2/03/2020