Identification Number:
GN 04440 TN 112
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. 112, 07/21/2020

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 procedures. This POMS is being revised to make minor grammar, punctuation, or technical corrections, to improve clarity, and to update obsolete POMS references.

Summary of Changes

GN 04440.025 Processing Concurrent Claims or Split Samples in Certified Electronic Folder (CEF) Cases

In Section A., we:

Removed the acronym "QR", as this acronym is not approved for use by the Office of Quality Review (OQR).

Changed the capital "F" in the word "Federal" in the NOTE to a lower case "f", as "federal" is only capitalized when part of a proper noun.

In Section C., we:

Removed the acronym "QR" in the first sentence and replaced it with "quality review", as this acronym is not approved for use by OQR.

Replaced the numeric POMS references in the NOTE with "sections D through F below", as hyperlinks are not necessary here.

In Section D., we:

Replaced the numeric POMS reference in the first sentence with "section A above", as a hyperlink is not necessary here.

Removed the semi-colon after the last use of the word "component" in the second paragraph and made two independent sentences instead, to improve clarity.

Removed the semi-colon at the end of the first bullet, as it is not necessary.

Bolded the word "or" at the end of the first bullet to add emphasis.

In Section E., we:

Replaced the word "legacy" with "case processing" throughout this section, as "case processing" is the term approved for use by OQR.

Removed the quotation marks from the tab and page types to improve readability of the instructions. We retained the quotation marks used to identify items within a tab or page or items needing further action by the user.

In Section E.3., we:

Added a comma after the word "pending" at the end of the last sentence.

In the NOTE in Section E., we:

Added a comma after "eView".

Added a comma after "queries".

In Section F.1., we:

Added the word "review" after (QA) in the first bullet.

In Section F.2., we:

Added a comma after the acronym "PER" in the second bullet.

In Section G., we:

Added a comma after the word "possible" in the second sentence.

 

 

 

GN 04440.025 Processing Concurrent Claims or Split Samples in Certified Electronic Folder (CEF) Cases

A. How are concurrent cases received?

  • The claims in a concurrent case (e.g., the claimant filed claims for both Title II and Title XVI benefits) may arrive at the review component for quality review at the same time, or

  • One or more of the non-sample claims in a concurrent case may arrive at the review component subsequent to the other claim(s).

NOTE: For federal sampling purposes, treat concurrent cases as one case (i.e., count a concurrent claim as one case in the sample selection process).

B. What is a split sample in a concurrent case?

The National Disability Determination Services System (NDDSS) or the Electronic Folder Interface (EFI) splits the routing of one or more of the claims within a concurrent case (e.g., in a concurrent case, the Title II claim is routed to review component 1 and the Title XVI claim is routed to review component 2).

C. Policy for reviewing concurrent cases

In a concurrent case situation, the quality reviewer is responsible for reviewing (and initiating corrective action, when appropriate) each of the disability determinations, even though quality review data are only recorded for the sample case determination.

NOTE: It is the responsibility of the program leader or administrative assistant to resolve split samples, as described in sections D through F below.

D. Background on how concurrent cases become split samples

NDDSS or EFI splits the routing of one or more of the claims in a concurrent case, see section A above.

“Split samples” occur when all claims filed in a concurrent case do not arrive in the same download. Specifically, a “split sample” situation occurs when one or more of the claims in a concurrent case are sampled (i.e., the claim(s) that the field office (FO) and the adjudicating component processed correctly), but the other non-sample claim(s) is still pending in the FO, adjudicating component, or another review component. Thus, the claims become split.

EXAMPLES:

  • The FO does not process the mainframe (i.e., Modernized Claims System (MCS), Modernized Supplemental Security Income Claims System (MSSICS)) or Electronic Disability Collect System (EDCS) case transfers for one or more of the concurrent claims in the case or

  • The adjudicating component does not properly process and transfer one or more of the concurrent claims in a case (e.g., the adjudicating component does not clear both claims in a concurrent Title II/Title XVI case at the same time). The review component encounters this situation most often.

E. Identifying split samples

  1. 1. 

    In eView, determine the status of a claim by reviewing the information displayed after selecting the Status/History tab on the eView Case Selection page (if accessing the claim through the Office of Quality Review (OQR’s) case processing system or on the Search window in eView).

    NOTE: The Search screen is usually bypassed when using OQR’s case processing system to open eView.

  2. 2. 

    On the Search screen, after entering the SSN or claimant's name and selecting the Search button, several items appear (e.g., the claimant's name, claim type, status and office code). This is the same information that displays after selecting the Status/History tab. If the review component has jurisdiction, “Pending” shows under Case Status and the Office Code shows “R##” (i.e., the numeric review component’s office code displays).

  3. 3. 

    If there is a split sample situation in a concurrent case, and one or more claims have been sampled, the remaining non-sampled claim(s) still shows as pending in the FO or the adjudicating component (the component that last had jurisdiction). There may be instances where the remaining non-sampled claims do not always show as “pending”, but may be “closed”.

  4. 4. 

    If one or more non-sampled claims exist, verify the status of the non-sampled claim(s) by using email or a phone call to contact the component shown as having the claim(s). Document the CEF with an SSA-5002 (Report of Contact).

NOTE: If EDCS exclusions apply and you cannot access the claim in eView, it is the review component’s responsibility to use MCS, MSSICS, or other queries, to determine if a concurrent claim situation exists

F. Procedure on split samples involving multiple review components

1. Situation 1 – multiple auxiliary Title II claims

  • Title II sampled for preeffectuation review (PER) or quality assurance (QA) review and routed to review component 1.

  • Title II or Title XVI sampled for PER or QA and routed to review component 2.

In this situation, central office will consolidate the claims in one review component.

2. Situation 2 – involving SSI PER claim

  • Title II sampled for PER or QA.

  • Title XVI is sampled for SSI PER, but not routed to the review component.

Take manual action to add the Title XVI to the Title II workload unit (WU).

G. Procedure for split samples involving non-sampled claims

Actions taken on one claim often affect the other claim(s) in a concurrent claim situation. Therefore, as early in the review process as possible, and before the review component clears the sampled claim(s), determine if a concurrent case situation exists by using eView. Verify the status of the non-sampled claim(s) to ensure that it has not been inadvertently overlooked.

If the non-sampled claim(s) is a denial due to technical reasons or a no determination, complete case review actions and clear the sampled claim(s).

If the non-sampled claim(s) is not a denial due to technical reasons, ask the FO or adjudicating component to expedite processing and transfer the claim(s) to the review component for review. Do not clear the sampled claim(s) in the interim.


GN 04440 TN 112 - Federal Quality Review of Disability Determinations - 7/21/2020