Identification Number:
GN 04440 TN 108
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. 108, 07/15/2020

Audience

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

Originating Component

OQR

Effective Date

Upon Receipt

Background

This is a Quick Action Transmittal. These revisions do not change or introduce new policy or procedure. This POMS is being revised to make minor grammar, punctuation, and technical corrections, to improve clarity, and to update obsolete POMS references throughout the section.

Summary of Changes

GN 04440.002 Introduction to the Federal Quality Review

Section A:

Bullets. The capitalizations at the beginning of both bullets were changed to lowercase letters.

Section B:

2nd Paragraph, 2nd Sentence:

We reworded the sentence for clarity and corrected the acronym for certified electronic folders (CEF).

3rd Paragraph:

Commas were added after the first reference to "cases" and the first reference to "determinations".

5th Paragraph:

The word "legacy" was changed to "case processing" in two places, as this is the updated phrase now used by the Office of Quality Review.

We also changed the "Commissioner for SSA" to the "Commissioner of SSA", as that is the proper title.

We also added a comma after the word "components".

6th Paragraph:

The word "legacy" was replaced with "case processing", as this is the updated phrase now used by the Office of Quality Review.

7th Paragraph:

We changed "in GN 04440.002D of this section" to "below in section D.", as a hyperlink is not necessary here.

Last Paragraph:

We added the word "and" because it is possible for adjudicating components to submit an Informal Resolution Request and/or a Request for Program Consultation.

We also added the acronyms IRR and RPC.

Section C:

1st Sentence:

We removed the word "is" prior to the word "clean" as it is unnecessary.

2nd Sentence:

The word "legacy" was replaced with "case processing", as this is the updated phrase now used by the Office of Quality Review.

Section D:

2nd Paragraph:

We revised the wording to improve clarity, updated the obsolete POMS references, and combined the last two sentences into one sentence.

Section E:

1st Sentence:

We reordered and reworded this sentence to improve comprehension and clarity.

3rd Sentence:

We removed the word "subchapter", as it is unnecessary, and updated the POMS references at the end of the sentence.

 

GN 04440.002 Introduction to the Federal Quality Review

A. Introduction to the quality review process

This subchapter discusses SSA federal quality reviews and provides instructions to the Office of Quality Review (OQR) review components for conducting quality reviews of disability determinations, returning or correcting deficient cases, and for processing deficiencies rebutted by the adjudicating components. The OQR conducts federal quality reviews of disability cases in review components located nationwide.

The mandated quality reviews are:

  • quality assurance reviews and

  • preeffectuation reviews.

For a detailed explanation of quality review types and the reasons OQR performs them, see GN 04440.005.

B. Description of quality review process

The OQR reviews sample cases to ensure the evidentiary record supports the determination and that the evidence and the determination conform to SSA operating policies and procedures (see GN 04440.007 for additional information). The cases selected are representative of the universe of cases the adjudicating components review each year. The review results are extrapolated to all cases adjudicated in each case or sample type.

Federal quality reviews are virtual. Any OQR review component may review any case without regard to the adjudicating component's location. The OQR only reviews cases with certified electronic folders (CEF). (See GN 04440.010 for a definition of CEF.)

An automated selection process selects quality review sample cases, when adjudicating components input determinations, and sends cases to review components prior to effectuation of the determinations.

Quality reviewers review adjudicating components' determinations using the same policy and procedural guidelines adjudicating components use. Quality reviewers follow the steps of sequential evaluation and consider all available evidence when assessing policy compliance, sufficiency of evidence, and determination accuracy.

Quality reviewers record review results, including any medical reviews, directly to the OQR’s case processing system. The case processing system transmits review data to the OQR in Central Office, where the data are stored and used to produce national reports and to provide reports to the Commissioner of the SSA, Congress, and other agency components, as requested.

If a case contains no returnable deficiency and is otherwise correct, the review component inputs the case information into the OQR case processing system and effectuates the determination.

If a case is deficient, the quality reviewer makes the necessary correction(s) or returns the case to the adjudicating component for correction, based on the criteria listed below in section D.

If an adjudicating component disagrees with a deficiency return, they can submit an Informal Resolution Request (IRR) (see GN 04440.401) and/or file a Request for Program Consultation (RPC) (see GN 04440.405).

C. Non-deficient case review

If a quality reviewer completes a quality review and concludes a claim was completed in accordance with SSA policy, and is supported by a preponderance of the evidence in file, he or she considers the case "clean." When a case is clean, that is, it contains no deficiency that requires correction, the OQR reviewer codes the OQR case processing system and clears the CEF case to the field office, program service center, National Records Center, or PC7 for effectuation of the determination.

D. Return criteria

The OQR may return a deficient case to an adjudicating component when correcting the deficiency could affect the disability determination, the period of disability, or conformance to certain technical requirements.

Specific types of deficiencies, and how to correct them, are found in GN 04440.202 through GN 04440.204. Types of technical corrective actions (TCA), and how to correct them, are found in GN 04440.231 and GN 04440.232.

 

E. Rebuttal criteria

When a review component cites a group I or group II deficiency on a case, the adjudicating component may submit an IRR and/or RPC if the adjudicating component does not agree with the deficiency.

Rebuttal procedures are described in GN 04440.401.

RPC procedures are described in DI 30007.105 through DI 30007.155.


GN 04440 TN 108 - Federal Quality Review of Disability Determinations - 7/15/2020