PROGRAM OPERATIONS MANUAL SYSTEMPart GN – GeneralChapter 044 – Quality AppraisalSubchapter 40 – Federal Quality Review of Disability DeterminationsTransmittal No. 107, 07/10/2020
This is a Quick Action Transmittal. These revisions do not change or introduce new policy or procedure.
Summary of Changes
GN 04440.950 Exhibit of Group I and Group II Deficiency Codes in the Office of Quality Review (OQR) Legacy System
We updated the title and chart title to reflect "Case Processing" System rather than "Legacy" System.
We updated the affected POMS sections to reflect the changes in the regulation and the guidance provided in SSR 20-01p by removing reference to the "inability to communicate in English" in subsection C.
The deficiencies are listed in the same sequence as in DI 30005.121 through DI 30005.126; the numbers on the left correspond to the defined deficiencies in those sections.
OQR Case Processing System Code
An incorrect decision regarding:
1. Substantial gainful activity (SGA) – clear evidence the claimant is engaging in SGA
2. Impairment Severity
4. Medical improvement (MI) and whether MI affects the ability to work
5. MI exceptions, including :
Whether an individual is a beneficiary of advances in medical or vocational therapy or technology,
Whether an individual has successfully undergone vocational therapy,
Whether new or improved methods of diagnostics or evaluative techniques show that the individual’s impairment(s) is not as severe as it was previously determined in the most recent favorable determination,
Whether a prior determination was made in error, or
Whether the prior determination was based upon fraudulent circumstances.
6. Residual Functional Capacity (RFC)
7. Evaluation of vocational factors including age, education, transferable skills, ability to do past relevant work, or ability to do other work
8. Failure to follow prescribed treatment
9. Drug addiction and alcoholism (DAA) materiality
10. Onset of disability, relative to a Title II eligibility period
11. Incorrectly adopting, or not adopting a prior administrative law judge (ALJ) or appeals council (AC) finding when adjudicating a subsequent disability claim.
12. Collateral estoppel
The medical documentation is insufficient to determine:
1a. Impairment severity
1c. MI, including whether MI affects the ability to work
1d. MI exceptions including:
Whether an individual is a beneficiary of advances in medical or vocational therapy or technology, or
Whether new or improved methods of diagnostics or evaluative techniques show that the individual’s impairment(s) is not as severe as it was previously determined in the most recent favorable determination
1f. Failure to follow prescribed treatment
1g. DAA materiality
1h. Onset of disability relative to a Title II eligibility period
The vocational documentation is insufficient to determine the effect of the following on an individual's ability to engage in SGA:
2b. Education or illiteracy
2c. Work history, including transferable skills, physical, mental, and environmental demands of past work and the relevance of past work
2d. Advances in medical or vocational therapy or technology when there is new medical evidence and a new RFC but no MI
2e. Vocational therapy
Group I medical evaluation deficiency involving vocational documentation
3. An incorrect assessment of impairment severity or RFC makes additional vocational documentation necessary to determine disability
The documentation is insufficient to show conformance to prescribed procedures for a determination based on the following:
4a. Work activity
4b. Failure to obtain a prior folder or copy of the ALJ/AC ruling under an acquiescence ruling
4c. The prior determination was in error
4d. Failure to follow prescribed treatment
4e. Whereabouts unknown
4f. Failure to cooperate
5. There is insufficient documentation to determine if collateral estoppel applies, or an incorrect collateral estoppel adoption makes medical or vocational documentation necessary to determine disability on the current claim.
The case contains sufficient documentation to support a different:
1. Onset date
2. Ending date
3. Cessation date
The case contains insufficient documentation to support the:
4. Unresolved work activity that has potential to affect the period of disability