Identification Number:
DI 30005 TN 37
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. 37, 07/16/2020

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

07/17/2020

Background

This is a Quick Action Transmittal. There are no changes to policy we updated references

Summary of Changes

DI 30005.005 Types of Federal Quality Reviews

Subsection A3, first bullet, we removed reference to GN 04440.202 as this chapter no longer contains information about controlled returns.

DI 30005.005 Types of Federal Quality Reviews

A. Types and purpose of quality reviews

1. Quality assurance (QA) review

SSA's Office of Quality Review (OQR) conducts ongoing QA reviews of adjudicating components' disability determinations to ensure effective and uniform administration of the disability program and to conform to the statutory requirements set forth in section 221(a) of the Social Security Act (Act).

QA reviews measure the accuracy of adjudicating components’ disability determinations to determine performance accuracy, as required by SSA regulations. SSA uses data from QA reviews to determine whether states perform at acceptable levels in terms of decisional accuracy and documentation requirements, as explained in DI 30005.001B.6.

2. Pre-effectuation review (PER)

SSA conducts the PER to meet statutory requirements of the Act. Section 221(c) of the Act requires SSA to review at least 50 percent of favorable Title II and concurrent Title II and Title XVI initial and reconsideration determinations made by adjudicating components on a pre-effectuation basis. A predictive model selects a sample of claims from those determinations considered most likely to be incorrect.

Section 1633(e)(1) of the Act requires SSA to review at least 50 percent of favorable Title XVI adult initial and reconsideration determinations made by adjudicating components on a pre-effectuation basis.

Favorable Title XVIII Medicare for Qualified Government Employee disability claims (disabled worker, disabled widow (er), and childhood disability) are also subject to PER review.

3. Other quality reviews

OQR performs other disability process quality reviews and studies to evaluate disability program performance in areas of concern and to alert adjudicating components and SSA management to current and potential problems.

Other quality reviews include:

  • Targeted denial review (TDR) - The TDR is a discretionary review of denial determinations. The review uses a predictive model, similar to the one used in the PER case selection, to identify and select cases based on deficiency-prone case characteristics. The sample size for each adjudicating component varies. Deficiencies cited under the TDR are informational and do not count against an adjudicating component's performance accuracy. However, OQR controls all returns and the adjudicating component must correct all deficiencies cited.

  • Disability hearing officer (DHO) review - OQR reviews continuing disability review decisions made by DHOs prior to effectuation. The DHO review is discretionary and the percentage of cases reviewed may vary.

OQR may also conduct ad hoc studies, including early information studies and systems reviews, to validate new policies or procedures.


DI 30005 TN 37 - Adjudicating Component Actions on Deficient Cases - 7/17/2020