Identification Number:
GN 04440 TN 145
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. 145, 06/21/2022

Audience

PSC: DE, DEC;
OCO-OEIO: FDE;
DQB: DE, PL;
OCO-ODO: DE, DEC, DS, RECONE;

Originating Component

OQR

Effective Date

Upon Receipt

Background

The Office of Quality Review (OQR) is making editorial changes and completing updates throughout the quality review sections of the POMS to improve readability, update terminology, add clarity, consolidate instructions. OQR has identified another potential substantive technical corrective action (TCA) which we are naming the verification of Field Office's (FO) technical information TCA. This TCA is not new, as it exists in OQR POMS.

Summary of Changes

GN 04440.231 Substantive Technical Corrective Actions (TCAs)

Subsection A3, we defined the verification of FO's technical information TCA. It occurs when the field office provides potentially incorrect information regarding the date last insured, the prescribed period in Disabled Widow(er) benefit cases, or the attainment of age 22 in Childhood Disability Benefit cases, and this potential inaccuracy provided by the FO may impact the allowance, denial or onset date (i.e., the allowance should be a denial, or the denial should be an allowance, or a different period of eligibility is supported).

Subsection B4, we identified the corrective actions required when a potential problem with the technical information is identified and, after clarification by the field office, what corrective action the review component and/or the adjudicating component must take based on the resolution provided by the FO.

GN 04440.231 Substantive Technical Corrective Actions (TCAs)

A. Substantive TCA definitions

A substantive TCA changes some element of the determination, or has the potential to change some element of the determination, and is not classified as a group I or group II deficiency. The three types of substantive TCAs are discussed below.

1. Regulation basis code TCAs

A regulation basis code TCA, also known as a decision basis code TCA, occurs when the adjudicating component completes the regulation basis code incorrectly on either the:

  • SSA-831-C3/U3 (Disability Determination and Transmittal---Item 22, Regulation Basis Code),

  • SSA-832-C3/U3 (Cessation or Continuance of Disability or Blindness Determination and Transmittal-Title XVI---Item 11 or 12, “Reason For Continuance” or “Reason For Cessation"), or

  • SSA-833-C3/U3 (Cessation or Continuance of Disability or Blindness Determination and Transmittal-Title II---Item 11 or 12, “Reason For Continuance” or “Reason For Cessation").

2. Group I or group II deficiencies in a non-sample case

A group I or group II deficiency in a non-sample case (e.g., the non-sample claim in a concurrent Title II/Title XVI claim selected for the quality assurance sample), are considered TCAs regardless of whether the group I or group II definitions covers the incorrect action.

See GN 04440.202, GN 04440.203, and GN 04440.204 for definitions of group I and group II deficiencies.

3. Verification of technical information in the Field Office's (FO) jurisdiction

The FO has the primary responsibility for documenting required technical information including dates relevant to potential disability (and/or blindness) entitlement (e.g., protective filing date (PFD), disability date first insured (DFI), disability date last insured (DLI), or Potential Onset Date (POD)). If the FO does not provide the technical information, or a documentation issue exists, and a group I or group II deficiency does not apply, this TCA applies.

B. Correcting Substantive TCAs

Substantive TCAs are either corrected by the review component or returned to the adjudicating component for correction. The sections below explain the procedures for correcting substantive TCAs.

1. Regulation basis code TCA occurs in adverse reopenings, cessations or reconsiderations of adverse reopenings or cessations

The review component will:

  • notify the adjudicating component of the needed correction, via SSA Request for Case Action (SSA-847-U3), or Request for Corrective Action (SSA-1774-U5), and

  • return the case to the adjudicating component for correction.

2. Regulation basis code TCA occurs in all other types of cases

The review component will:

  • assume jurisdiction and prepare an amended determination,

  • prepare a new notice and rationale (if necessary),

  • enter the statement “SSA jurisdiction exercised. This amends the unapproved adjudicating component determination of MM/DD/YY”, in item 34 of the SSA-831 for initial or reconsideration claims,

  • enter the statement “SSA jurisdiction exercised. This amends the unapproved adjudicating component determination of MM/DD/YY", on the SSA-832 or SSA-833 for CDR claims, and

  • prepare an SSA-847-U3 or SSA-1774-U5, explaining the reason for the regulation basis code change.

EXCEPTION: If the incorrect regulation basis code is due to an obvious typographical or data entry error, the review component may correct the regulation basis code entry on the determination form without assuming jurisdiction.

3. Group I and II deficiencies identified in a non-sample case

If the incorrect action occurs in a non-sample claim and the group I or group II deficiency or TCA definitions cover the incorrect action, the review component follows the corrective action procedures indicated for that deficiency or TCA.

NOTE: Create an SSA-847-U3 when citing TCAs per GN 04440.505, or an SSA-1774-U5 per GN 04440.501.

For information regarding group I and group II deficiencies, see GN 04440.202, GN 04440.203 and GN 04440.204 . For additional information regarding TCAs, see GN 04440.230 .

4. Verification of FO technical information TCA

a. To prepare the TCA, the review component will:

  • code the review screens prior to creating the return form so the information propagates accordingly,

  • prepare a Request for Assistance (SSA-5524–U3) and ask the FO to verify the technical information and document the Certified Electronic Folder (CEF),

  • prepare an SSA-847–U3, or an SSA-1774-U5, and notify the adjudicating component of the TCA,

  • control the return,

  • clear the case to the FO, and

  • send the SSA-5524-U3 and SSA-847–U3, or SSA-1774-U5 to the CEF during the clearance process.

b. When the FO documents the CEF with their completed development of the technical information necessary and there is no substantive impact on the outcome of the claim, the review component will:

  • complete the applicable screens,

  • make changes to the determination form(s) and notice(s) as appropriate, and

  • clear the case using standard procedures for completed cases or subsequent returns (as appropriate).

NOTE: In the rare occurrence where there is a substantive change which impacts the period of disability, please follow the instruction in GN 04440.204B3e regarding group II decisional onset date changes made by the reviewing component.

c. If an unexpected substantive corrective action by the adjudicating component is needed, the review component will:

  • code the review screens prior to creating a new SSA-847-U3 or SSA-1774-U5, so the information propagates accordingly,

  • prepare a new SSA-847–U3 or SSA-1774-U5,

  • indicate the necessary corrective action,

  • inform the adjudicating component which review component they should transfer jurisdiction to upon completion of their actions,

  • send the SSA-847–U3 or SSA-1774-U5 to the CEF during the clearance process, and

  • clear the case to the adjudicating component (this action transfers jurisdiction to the adjudicating component).

NOTE: For controlled returns, the review component will input the results data when the adjudicating component returns the corrected case.


GN 04440 TN 145 - Federal Quality Review of Disability Determinations - 6/21/2022