PROGRAM OPERATIONS MANUAL SYSTEMPart GN – GeneralChapter 044 – Quality AppraisalSubchapter 10 – RSI Claims Quality Appraisal SystemTransmittal No. 8, 02/07/2020
This transmittal implements a formal timeframe of 20 calendar days for OQR to review and respond to a “Completed” case.
Summary of Changes
GN 04410.030 Reported RSDI Quality Review Findings: Jurisdiction and Actions
Updated second and last paragraphs to include the phrase, "within 20 calendar days of receipt of the case."
OQR reports case findings to the field office (FO) and processing center (PC) with jurisdiction via email on the SSA-93 Quality Review Feedback Report. The SSA-93 describes the error or condition needing correction.
OQR sends the following corrective actions to FOs:
updates to the numident
beneficiary failure to cooperate
request for field contact
change of address
some representative payee issues (e.g., new payee development needed, capability determination, failure to account)
missed entitlements when an application is required
new application needed or closeout letter needs to be sent
work notices (current and past year)
FO initiated work CDR actions; and
OQR sends all other corrective action requests to the PC of jurisdiction.
If the feedback contains one of the corrective actions listed in subsection A.1. in this section and another requiring correction by the PC, then OQR sends the feedback to the PC. The PC is responsible for all corrective actions listed on the feedback.
OQR emails the SSA-93 along with any related attachments not uploaded to the electronic folder or Non-Disability Repository for Evidentiary Documents (NDRED). OQR annotates on the SSA-93 feedback the location of any uploaded documentation.
For stewardship review, OQR:
reports cases with dollar deficiencies to the appropriate Office of the Regional Commissioner (ORC) and describes the necessary corrective action;
determines the appropriate ORC based on the geographical address of the selected beneficiary. EXCEPTION: If PC 7, Office of Disability Operations (ODO) or PC 8, Office of International Operations (OIO), is the PC of jurisdiction, the controlling office is the Associate Commissioner (AC) of the Office of Central Operations (OCO); and
sends a copy of the feedback to the servicing FO or PC of jurisdiction to make the correction.
For Workers’ Compensation, Title II Post Entitlement, Transaction Accuracy Review, and Work Continuing Disability reviews, OQR:
reports cases with dollar deficiencies to the appropriate ORC or AC of OCO and describes the necessary corrective action;
determines the appropriate ORC based on the geographical address of the servicing FO. If PC 7, ODO or PC 8, OIO, is the PC of jurisdiction, the controlling office is the AC of OCO;
sends the feedback to the servicing FO to make the correction and a copy to the office that processed the sampled action, if different; or
sends the feedback to the PC of jurisdiction to make the correction and a copy to the office that processed the sampled action, if different.
When you receive a SSA-93 from the OQR field site:
evaluate the information received; and
redevelop only if the necessary documentation is insufficient, outdated, or missing.
NOTE: If you receive a SSA-93 in error or have other issues with jurisdiction and access to cases on the SSA-93 Quality Review
website, contact your ORC or AC of OCO. On the website you may view a copy of the SSA-93 via a link. Refer to the SSA-93 Quality Review Website User Guide for more information including instructions for removing or transferring a case.
If you agree with the OQR field site’s findings:
make corrective input within 90 days of the SSA-93 transmission,
upload any additional supporting documentation to the electronic folder or NDRED and reference the location in the comments area on the website, and
post the completion on the SSA-93 website.
NOTE: Do not enter the completion until all required actions are complete. This includes:
FO system exceptions pending corrective action in the PC,
additional development, etc.
If you disagree with the OQR field site’s findings:
use the SSA-93 website to send a rebuttal request, rationale, and documentation directly to the reviewing OQR field site. See Protesting Deficiency Citations GN 04410.040.
The SSA-93 website automatically notifies the ORC or AC of OCO of the rebuttal request.
NOTE: Absent evidence of timely rebuttals, OQR determines accuracy results based on current findings.
The ORC or AC of OCO uses the SSA-93 Quality Review
website to monitor cases to ensure the FOs and PCs take corrective action within the established timeframes.
The FO or PC must take corrective action within 90 days of the feedback transmission to the SSA-93 website. FO or PC management must confirm corrective actions before annotating the SSA-93 website.
There may be cases that require more than 90 days for correction. Examples are cases requiring:
cross component activities,
amended disability decisions, and
fraud or similar fault determinations.
The FO and PC can request an extension past the 90-day deadline by submitting a request via the SSA-93 website to the ORC (AC of OCO for PC 7 and 8) with an estimate of the extra time needed and a justification for the extension. The ORC or AC of OCO enters the approval or denial of the extension request in the SSA-93 website. The website notifies the requesting PC or FO once the ORC or AC of OCO enters the decision. The website retains documentation of the request for audit purposes.
If you disagree with OQR’s findings:
submit a rebuttal via the SSA-93 website within 45 calendar days as outlined in GN 04410.040F through GN 04410.040G, and
take corrective action within 90 days of OQR’s final rebuttal decision.
NOTE: The ORC or AC of OCO may request a report on the corrective action taken.
To ensure FOs and PCs take proper action on SSA-93 information, OQR also monitors the SSA-93 website. OQR reviews each case flagged with a SSA-93 indicator (referred to as High Risk cases) when the FO or PC annotates “Corrective Action Complete” on the SSA-93 website.
The OQR reviewer in central office uses the SSA-93 website to send an email to the responsible component within 20 calendar days of receipt of the case with a description of the issue if the FO or PC:
took no action,
action was incomplete, or
action was incorrect.
The ORC or AC of OCO also receives this email to ensure that the FO or PC with jurisdiction completes the necessary action as timely as possible. The SSA-93 website sends automated follow-ups every 15 days.
When the OQR reviewer determines all corrective actions are complete, they use the SSA-93 website to update the status of the case to “Correct Action Taken” within 20 calendar days of receipt of the case. The website sends an email and moves the case to the completed listing.