Identification Number:
GN 04440 TN 70
Intended Audience:See Transmittal Sheet
Originating Office:OARO Office of Quality Review
Title:Federal Quality Review of Disability Determinations
Type:POMS Transmittals
Program:Disability
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM
Part GN – General
Chapter 044 – Quality Appraisal
Subchapter 40 – Federal Quality Review of Disability Determinations
Transmittal No. 70, 07/03/2019

Audience

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

Originating Component

OQR

Effective Date

Upon Receipt

Background

We applied minor revisions, without substantive change, in the policies for SSA-392 and SSA-392-SUP use and form completion.

This is a Quick Action Transmittal. These revisions do not change or introduce new policy or procedure.

Summary of Changes

GN 04440.524 Completing the SSA-392, Medical Consultant's Review of Physical Residual Functional Capacity Assessment

We revised the content in each subsection to eliminate repetitive language, reduce passive voice, and enhance readability.

We also replaced 'consultant' with 'contractor' in subsection A, and eliminated use of 'AC' for 'adjudicating component'.

We corrected the format and order number errors in subsection C.

GN 04440.525 Completing the SSA-392-SUP, Medical Consultant's Review of Mental Residual Functional Capacity Assessment

We revised the content in each subsection to eliminate repetitive language, reduce passive voice, and enhance readability.

We also replaced 'consultant' with 'contractor' in subsection A, and eliminated use of 'AC' for 'adjudicating component'.

GN 04440.524 Completing the SSA-392, Medical Consultant's Review of Physical Residual Functional Capacity Assessment

A. Background on using the SSA-392

Federal review medical contractors (MC) use the SSA-392 to record their agreement or disagreement with the adjudicating component SSA-4734-BK, Physical Residual Functional Capacity Assessment (RFC).

Use the SSA-392 to:

  • Identify findings of physical capacity and restrictions that are the same as, or different from, those of the adjudicating component,

  • Cite and discuss the evidence supporting the different finding(s),

  • Discuss specific problems with the adjudicating component's completion of the SSA-4734-BK, and

  • Record conclusions as to whether the adjudicating component’s findings on physical RFC are reasonable, consistent with program policy, and supported by the evidence.

For an exhibit of the SSA-392, see GN 04440.929.

B. Policy for completing the SSA-392

Reviewing MCs complete the SSA-392 to record agreement or disagreement with the physical RFC assessment established by the adjudicating MC on an SSA-4734-BK. The MC completes the SSA-392 only when there is an SSA-4734-BK in file.

1. When to complete an SSA-392

The MC completes an SSA-392 when:

  • An SSA-4734-BK is in file, and

  • A physical impairment of less than listing. level severity requiring an RFC assessment is present.

For further explanation of when to use the SSA-392, see GN 04440.135.

NOTE: When an RFC is not in the file, but one is required, the reviewing MC will prepare the assessment on an SSA-4734-BK. The reviewing MC should not use the SSA-392 to prepare an RFC assessment..

2. When not to complete an SSA-392

The MC does not complete an SSA-392 when:

  • The adjudicating component prepared an SSA-4734-BK, but MC review establishes that the adjudicating component should have made the disability determination on a medical basis only (i.e., the impairment is a “not severe”physical impairment, or the impairment is of listing-level severity), or

  • The disability determination is not supported by sufficient evidence and additional medical evidence is needed (i.e., a medical documentation deficiency), regardless of whether the adjudicating component decided the case on a medical-vocational basis.

NOTE: For situations in GN 04440.524B2, the MC records case analysis and disagreement(s) with the RFC determination on an SSA-416, Case Analysis.

C. Procedure for completing the SSA-392

1. Heading

The items in the heading are self-explanatory. In the field, “Date(s) SSA-4734-BK Applicable”, enter the RFC date(s) or date range, as documented by the adjudicating component.

2. Part A – Evaluation

After review of all the evidence, complete Part A.

  • Indicate whether you agree or disagree with the adjudicating component's RFC conclusion, considering reasonableness and evidence support.

  • If you disagree with any of the adjudicating component's findings, proceed to Part B; or

  • If you agree with all the adjudicating component's findings, proceed directly to Part C.

3. Part B – Discussion and/or Comments

Cite the section and number of each item in dispute.

For each disputed item:

  • Explain why particular findings are inconsistent with policy.

  • Show how the adjudicating component drew erroneous conclusions from the facts.

  • Describe your findings, and include additional limitations or restrictions, if applicable.

  • Cite the facts and discuss how and why the evidence supports your conclusions.

  • As appropriate, evaluate and discuss limitations imposed by symptoms, such as pain or fatigue.

  • Resolve all inconsistencies in the evidence when the adjudicating component failed to do so.

4. Part C – Conclusion

  • If you agree with all the adjudicating component's findings in Part A, check 1, “AGREE”; or

  • If you disagree with any of the adjudicating component's findings in Part A, and provide a discussion in Part B, check 2, “DISAGREE”.

NOTE: See GN 04440.524B2 for disagreement involving insufficient evidence or support for medical assessment other than RFC.

5. MC signature

Sign, date, and enter the MC code.

GN 04440.525 Completing the SSA-392-SUP, Medical Consultant's Review of Mental Residual Functional Capacity Assessment

A. Background on using the SSA-392-SUP

Federal review medical contractors (MC) and psychological contractors (PC) use the SSA-392-SUP to record agreement or disagreement with the adjudicating component SSA-4734-F4-SUP, Mental Residual Functional Capacity Assessment (MRFC). The MC or PC completes the SSA-392-SUP only when there is an SSA-4734-F4-SUP in file.

For an exhibit of an SSA-392-SUP, see GN 04440.930.

1. When to complete an SSA-392-SUP

The MC or PC completes an SSA-392-SUP when:

  • An SSA-4734-F4-SUP is in file, and

  • A mental impairment of less than listing level severity requiring an RFC assessment is present.

For a further explanation of when to use the SSA-392-SUP, see GN 04440.135.

NOTE: When an MRFC is not in the file, but one is required, the reviewing MC or PC will prepare the assessment on an SSA-4734-F4-SUP. The reviewing MC or PC should not use the SSA-392-SUP to prepare an MRFC assessment.

2. When not to complete an SSA-392-SUP

The MC or PC does not complete an SSA-392-SUP when:

  • The adjudicating component prepared an SSA-4734-F4-SUP, but MC or PC review establishes that the adjudicating component should have made the disability determination on a medical basis only, (i.e., the impairment is a “not severe” mental impairment, or the impairment is of listing-level severity.), or

  • The disability determination is not supported by sufficient medical evidence and additional medical evidence is needed (i.e., a medical documentation deficiency), regardless of whether the adjudicating component decided the case on a medical-vocational basis.

NOTE: For situations in GN 04440.525A2, the MC or PC records case analysis and disagreement(s) with the MRFC determination on an SSA-416, Case Analysis.

B. Procedure for completing the SSA-392-SUP

1. Heading (SSN through Level of Claim)

The items in the heading are self-explanatory. In the field, “DATE OF SSA-4734-F4-SUP BEING REVIEWED”, enter the MRFC date(s) or date range, as documented by the adjudicating component.

2. Section I - Summary of Agreement/Disagreement

After you review all the evidence, complete Section I.

  • If you agree with the narrative statement regarding all four mental areas, (Understanding and Memory; Sustained Concentration and Persistence; Social Interaction; and Adaptation), and evidence is supportive, check the appropriate "agree" block, and do not complete Section II; and

  • Sign, date, and enter the MC code; or

  • If you disagree with any of the four mental areas, check the "disagree" block and complete Section II of the SSA-392-SUP; or

  • If the adjudicating component’s narrative is inadequate or insufficient to address any particular mental area (A,B,C, or D), check the block appropriate to the mental area; and

  • Indicate if documentation is sufficient to support the assessment provided by checking the block for "YES" or "NO".

3. Section II. - Narrative Discussion

Complete Section II only for substantive disagreement with the SSA-4734-F4-SUP narrative statement of the four areas of mental impairment(s) or for incomplete documentation in support of that narrative statement.

  • If Section I indicates substantive disagreement or need for documentation, provide a complete, detailed narrative discussion of the reason(s), as applicable to each mental area;

  • In your discussion, cite specific evidence that supports mental capacity conclusions that are substantively different from those presented in the adjudicating component's SSA-4734-F4-SUP narrative statement;

  • If the deficiency is for missing or incomplete evidence, explain what evidence is needed; and

  • Sign, date, and enter the MC code on page 2.


GN 04440 TN 70 - Federal Quality Review of Disability Determinations - 7/03/2019