Identification Number:
DI 30005 TN 35
Intended Audience:See Transmittal Sheet
Originating Office:OARO Office of Quality Review
Title:Adjudicating Component Actions on Deficient Cases
Type:POMS Transmittals
Program:All Programs
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM
Part DI – Disability Insurance
Chapter 300 – Quality Assurance
Subchapter 05 – Adjudicating Component Actions on Deficient Cases
Transmittal No. 35, 06/18/2020

Audience

PSC: DE, DEC;
OCO-OEIO: CR, FDE, RECONE;
DQB: DE, PL;
OCO-ODO: DC, DE, DS, RECONE;
ODD-DDS: ADJ, DHU;

Originating Component

OQR

Effective Date

Upon Receipt

Background

This is a QAT. This is NOT a change in current 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 readability, add clarity, and ensure conformance with Plain Language Guidelines. We realized a current procedure on how to handle the rescission of group II decisional deficiencies was omitted from this POMS when the IRR process was added. It was always intended that the procedure for the rescission of a group II decisional deficiency upon completion of the IRR process is be handled in the same manner as when it is rescinded based on the RPC process. This is NOT a change in current policy or procedure.

 

Summary of Changes

DI 30005.501 Resolving Deficiency Disagreements --- Informal Resolution Request (IRR) and Request for Program Consultation (RPC)

At the end of subsection E, we have added the following 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.

DI 30005.501 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.

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 a 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:

  • 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-U5, 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 of the case, and/or the necessary required actions:

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

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

  • to ask about a policy citation(s).

E. The IRR process for review components

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.

After the review component completes and closes the IRR in the IRR web-based tool, the tool will upload the adjudicating component IRR submission and review component IRR response to the certified electronic folder and will notify 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.


DI 30005 TN 35 - Adjudicating Component Actions on Deficient Cases - 6/18/2020