Identification Number:
DI 30005 TN 39
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. 39, 07/21/2020

Audience

PSC: DE, DEC;
OCO-OEIO: CR, FDE, RECONE;
DQB: DE, PA, PL, TL;
OCO-ODO: DC, DE, DS, RECONE;
ODD-DDS: ADJ, DHU;

Originating Component

OQR

Effective Date

Upon Receipt

Background

The Office of Quality Review (OQR) is making editorial changes and completing updates throughout the quality review sections of the POMS to improve readability and organization, add clarity, and ensure conformance with Plain Language Guidelines. Currently, the bulk of the information regarding deficiencies and correcting deficiencies are in POMS subsections, DI 30005.121 to DI 30005.126, DI 30005.210 to DI 30005.228, and DI 30005.405. We are incorporating the information regarding deficiencies and correcting deficiencies into DI 30005.201 Deficiency Citation and Support, DI 30005.202 Group I Decisional Deficiencies, DI 30005.203 Group I Documentation Deficiencies and DI 30005.204 Group II Deficiencies. Additionally, the content of current DI 30005.405 Second Returns, is being moved, to new DI 30005.205 and renamed Subsequent Returns.

 

Summary of Changes

DI 30005.121 Group I Decisional Deficiencies

This subsection is being archived and information is being moved to DI 30005.202 Group I Decisional Deficiencies.

 

DI 30005.123 Group I Documentation Deficiencies

This subsection is being archived and information is being moved to DI 30005.203 Group I Documentation Deficiencies.

 

DI 30005.125 Group II Period of Disability Decisional Deficiencies

This subsection is being archived and information is being moved to DI 30005.204 Group II Deficiencies.

 

DI 30005.126 Group II Period of Disability Documentation Deficiencies

This subsection is being archived and information is being moved to DI 30005.204 Group II Deficiencies.

 

DI 30005.201 General Rules for Routing And Correcting Deficient Cases

This is a new chapter named Deficiency Citation and Support. In A, we will introduce deficiencies. In B, we explain the deficiency categories,. In C, we explain deficiency citation. In D, we explain what types of references are used to support a deficiency.

 

DI 30005.202 Group I Decisional Deficiencies

This subsection will be named Group I Decisional Deficiencies. In A, we define each group I decisional deficiency. In B, we explain how group 1 decisional deficiencies are corrected.

 

DI 30005.203 Group I Documentation Deficiencies

This subsection will be named Group I Documentation Deficiencies. In A, we define each group I documentation deficiency. In B, we explain how group 1 documentation deficiencies are corrected.

 

DI 30005.204 Group II Deficiencies

This subsection will be named Group II Deficiencies. In A, we define each group II deficiency. In B, we explain how group II deficiencies are corrected.

 

DI 30005.205 Quality Review Subsequent Returns

The content of current DI 30005.405 Second Returns will be moved to this subsection. This subsection will be named Subsequent Returns.

 

DI 30005.210 Correcting Group I Deficiencies - General

This subsection will be archived and information moved to DI 30005.202 and DI 30005.203.

 

DI 30005.215 Correcting Group I Decisional Deficiencies Involving Onset

This subsection will be archived and information moved to DI 30005.202.

 

DI 30005.216 Correcting Group I Medical Documentation Deficiencies Involving Onset

This subsection will be archived and information moved to DI 30005.203.

 

DI 30005.217 Correcting Group I SGA and Work Activity Deficiencies

This subsection will be archived and information moved to DI 30005.202 and DI 30005.203.

 

DI 30005.220 Correcting Group II Decisional Deficiencies

This subsection will be archived and information moved to DI 30005.204.

 

DI 30005.221 Correcting Group II Ending Date and Cessation Date Documentation Deficiencies

This subsection will be archived and information moved to DI 30005.204.

 

DI 30005.225 Correcting Group II Onset Date Documentation Deficiencies

This subsection will be archived and information moved to DI 30005.204.

 

DI 30005.227 Correcting Group II Onset Date Deficiencies Involving a Reopening

This subsection will be archived and information moved to DI 30005.204.

 

DI 30005.228 Correcting Group II Work Activity Documentation Deficiencies

This subsection will be archived and information moved to DI 30005.204.

 

DI 30005.405 Second Returns

This subsection will be archived and information moved to new subsection DI 30005.205.

DI 30005.201 Deficiency Citation and Support

A. Deficiencies

A deficiency is a specified occurrence of noncompliance with Social Security Administration (SSA) policies and procedures in a disability determination. The Office of Quality Review (OQR) categorizes deficiencies as either group I or group II, according to their impact, or potential impact, on the disability determination.

B. Categories of group I and group II deficiencies

OQR categorizes group I and group II deficiencies as decisional or documentation.

  • Group I and group II deficiencies are categorized as decisional when a case is fully documented in accordance with SSA policy and procedures, but the adjudicating component made an incorrect determination to allow, deny, cease, continue, or establish an incorrect period of disability.

  • Group I and group II deficiencies are categorized as documentation when the case requires additional medical or vocational development of evidence to make the correct determination or to determine the correct onset, ending, or cessation date.

C. Deficiency citation

After completing a thorough review of the entire file(s), the review component will determine if the documentation is policy compliant and supports the adjudicating component’s disability determination. This includes ensuring the file contains reports of the individual’s medical history, physical and mental examinations, laboratory studies, any prescribed therapy, and any responses to therapy needed to establish one or more medically determinable impairments, assess severity of the impairment(s), and determine the duration of the impairment(s).

The review component will cite a deficiency if the evidence:

  • is programmatically insufficient, including establishing the correct onset, ending, and/or cessation date,

  • does not support the determination, including establishing the correct onset, ending, and/or cessation date, or

  • contradicts the determination, including establishing the correct onset, ending, and/or cessation date.

The review component will identify all issues in a case, but will only cite the most significant deficiency. The SSA-1774-U5, Request for Corrective Action, will identify and explain each item in the case that is deficient.

Complete descriptions of each type of deficiency can be found in:

NOTE: Even if a case does not contain a deficiency, it may still contain one or more technical corrective actions (TCAs).

More information on identification and correction of TCAs can be found in:

  • DI 30005.230 Introduction to Technical Corrective Actions (TCAs)

  • DI 30005.231 Substantive Technical Corrective Actions (TCAs)

  • DI 30005.232 Non-substantive Technical Corrective Actions (TCAs)

D. Deficiency support

When explaining the deficient element(s) in a case, the review component must support the deficiency citation with specific reference to:

  • evidence in file,

  • programmatically required evidence (DI 22505.001 Medical and Nonmedical Evidence) and,

  • relevant policy to include:

    • Program Operations Manual System (POMS)

    • Emergency Messages

    • Administrative Messages

    • Regional POMS supplements (ONLY for returns to adjudicating components in that particular region)

NOTE: The review component must not use the Office of Disability Policy memoranda, PolicyNet Questions & Answers, DDS Administrators' Letters, Request for Program Consultation resolution responses, or other similar written guidelines, to justify or explain a deficiency.

DI 30005.202 Group I Decisional Deficiencies

A. Definitions of group I decisional deficiencies

A group I decisional deficiency is a substantive deficiency that affects the determination to allow or deny, or to continue or cease, disability benefits. The review component will cite a group I decisional deficiency based on the following issues:

  1. 1. 

    Substantial gainful activity (SGA) (category 10)

    The adjudicating component allowed a disability claim despite clear evidence of ongoing SGA submitted prior to case clearance, or otherwise evident in the file, and there is no possibility of a closed period of disability. Evidence of SGA may be documented on the following:

    • SSA-820-F4-SP, Work Activity Report (Self-Employed Person)

    • SSA-821-BK, Work Activity Report (Employee)

    • SSA-823, Report of SGA Determination

  2. 2. 

    Impairment severity (category 11)

    The adjudicating component based the determination on medical considerations alone (i.e., the impairment is not severe, or the impairment meets, medically equals, or functionally equals the listings). However, the evidence does not support the adjudicating component’s determination and an opposite determination is appropriate.

    NOTE: The review component should not use this code if the adjudicating component’s determination is based on a residual functional capacity (RFC) assessment.

  3. 3. 

    Duration (category 12)

    The adjudicating component based the determination on the severity of the disabling impairment that did not meet policy requirements for 12-month duration.

  4. 4. 

    Medical improvement (MI) and whether MI affects the ability to work (category 13)

    The adjudicating component incorrectly determined, or should have determined, MI related to the ability to work, in a Continuing Disability Review (CDR).

  5. 5. 

    MI exception regarding whether the individual has benefited from advances in medical or vocational therapy or technology (category 14)

    The adjudicating component applied, or should have applied, the MI exception in a CDR regarding significant MI due to medical or vocational therapy or technology.

  6. 6. 

    MI exception regarding successful vocational therapy (category 15)

    The adjudicating component applied, or should have applied, the MI exception in a CDR regarding the individual’s successful completion of vocational therapy.

  7. 7. 

    MI exception regarding new or improved diagnostic techniques or evaluation shows the individual's impairment(s) is not as disabling as it was at the time of the most recent prior favorable medical determination (category 16)

    The adjudicating component applied, or should have applied, the MI exception in a CDR regarding new or improved diagnostic techniques that demonstrate an individual’s impairment(s) is not as disabling, as it was at the time of the most recent prior favorable medical determination.

  8. 8. 

    MI exception regarding a prior determination made in error (category 17)

    The adjudicating component applied, or should have applied, the MI exception in a CDR regarding a prior determination made in error, due to:

    • error on the face of the record,

    • missing, required and material evidence, or

    • new evidence related to the prior determination or decision.

  9. 9. 

    MI exception regarding a prior determination based on fraudulent circumstances (category 18)

    The adjudicating component applied, or should have applied, the MI exception in a CDR regarding a prior determination made in error based on documentation of fraud and similar fault.

  10. 10. 

    Residual functional capacity (RFC) (category 19)

    The adjudicating component based the determination on an RFC assessment. However, the evidence does not support the adjudicating component’s RFC and an opposite determination is appropriate.

    NOTE: The review component should not use this code if the adjudicating component’s determination is based on medical considerations alone (i.e., the impairment is not severe or the impairment meets, medically equals, or functionally equals the listings).

  11. 11. 

    Evaluation of vocational factors (category 20)

    The adjudicating component determined, or should have determined, disability based on one or more of the following vocational factors:

    • Age

    • Education (including illiteracy),

    • Transferability of skills

    • Ability to perform past relevant work (PRW)

    • Ability to perform other work

      NOTE: Use this code only when the RFC assessment is correct, but the vocational determination is incorrect.

  12. 12. 

    Failure to follow prescribed treatment (category 21)

    The adjudicating component:

    • allowed or continued disability for a claimant who should have been denied or ceased because the individual failed, without good cause, to follow prescribed treatment, or

    • denied or ceased disability for a claimant who should have been allowed or continued because the individual had good cause for FTFPT.

  13. 13. 

    Drug addiction and alcoholism (DAA) materiality (category 22)

    The adjudicating component:

    • allowed or continued disability despite evidence that DAA is material to the determination, or

    • denied or ceased disability on the basis that DAA is material, despite evidence that DAA is not material to the determination.

  14. 14. 

    Onset of disability (category 23)

    The adjudicating component allowed a title II disability claim despite:

    • an established onset date (EOD) after the date last insured (DLI) for a Title II disabled worker, after the end of the prescribed period for a disabled widow(er), or after the attainment of age 22 for a childhood disability claim,

    • the field office (FO) documenting the certified electronic folder (CEF) with the correct DLI, prescribed period, or childhood disability claimant's date of birth, and

    • evidence indicating an earlier onset date is not supported.

      NOTE: The review component will only cite this deficiency when the Title II claimant had a disabling impairment at the time of adjudication, but the impairment did not exist, or was not disabling, on or before the date the claimant last met the insured status requirements.

  15. 15. 

    Adoption of a prior administrative law judge (ALJ) or Appeals Council (AC) finding under an acquiescence ruling (AR) (category 25)

    The adjudicating component erroneously adopted, or should have adopted, a prior ALJ or AC disability decision or specific finding (e.g., impairment severity, RFC, demands of PRW) based on an AR.

  16. 16. 

    Collateral estoppel (category 26)

    The adjudicating component:

  • incorrectly adopted a prior final determination and disability cannot be established based on the current evidence in file, or

  • incorrectly denied a claim when adoption of a prior favorable determination or decision was warranted.

NOTE: If disability can be established based on the current evidence in file, no group I decisional deficiency exists.

B. Correcting group I decisional deficiencies

The review component returns all cases with group I decisional deficiencies to the adjudicating component for correction, with the exception of SGA deficiencies, which are returned to the FO to process an SGA denial.

1. Case returned to the adjudicating component for corrective action

For group I decisional deficiencies returned to the adjudicating component for corrective action, the review component will:

  1. a. 

    annotate all of the adjudicating component’s original determination and medical assessment forms, as well as notices, in the CEF, as “Do Not Process” or “Do Not Release”, as applicable,

  2. b. 

    code the deficiency in the case processing system,

  3. c. 

    notify the adjudicating component, via an SSA-1774-U5, Request For Corrective Action, to explain why the determination is not policy compliant and request the adjudicating component to change the determination,

  4. d. 

    route the case to the adjudicating component for correction, as a controlled return, and

  5. e. 

    follow-up with the adjudicating component in 30 days if the corrected determination has not been returned to the review component.

NOTE: All of the adjudicating component’s original determination and medical assessment forms, as well as notices, must remain in the CEF as part of the audit trail.

2. Case returned to the FO for corrective action

For a group I decisional deficiency involving clear evidence the claimant is engaging in SGA, the review component will:

  1. a. 

    annotate all of the adjudicating component’s original determination and medical assessment forms, as well as notices, in the CEF, as “Do Not Process” or “Do Not Release”, as applicable,

  2. b. 

    code the deficiency in the case processing system,

  3. c. 

    notify the FO, via an SSA-5524-U3, Request for Assistance, to explain there is clear evidence of SGA and an SGA denial is appropriate,

  4. d. 

    notify the adjudicating component, via an SSA-1774-U5, Request For Corrective Action, to explain why the determination is not policy compliant and that the case will be routed to the FO for an SGA denial, and

  5. e. 

    route the case to the FO.

NOTE: All of the adjudicating component’s original determination and medical assessment forms, as well as notices, must remain in the CEF as part of the audit trail.

DI 30005.203 Group I Documentation Deficiencies

A. Definitions of group I documentation deficiencies

A group I documentation deficiency is a substantive deficiency in which the medical, vocational, functional, or other relevant evidence, is insufficient to make a determination about the claimant’s disability, such that there is potential for reversing the determination to allow or deny, or to continue or cease, disability benefits. The review component will cite a group I documentation deficiency based on the following issues:

1. Substantial gainful activity (SGA) (category 30)

The adjudicating component allowed a disability claim despite insufficient evidence as to whether the claimant is performing ongoing SGA.

2. Medical evaluation involving vocational documentation (category 31)

The adjudicating component made an incorrect assessment of impairment severity or residual functional capacity (RFC), which makes additional vocational documentation necessary to determine disability.

3. Collateral estoppel (CE) (category 36)

The adjudicating component had insufficient documentation to determine whether adoption applied, or incorrectly adopted a prior favorable disability determination, which makes additional medical or vocational documentation necessary to determine disability on the current claim.

4. Insufficient medical documentation to determine impairment severity (category 41)

The adjudicating component based the determination on medical considerations alone (i.e., the impairment is not severe or the impairment meets, medically equals, or functionally equals the listings) without sufficient evidence to support the determination.

NOTE: The review component should not use this code if the adjudicating component’s determination is based on an RFC assessment.

5. Insufficient medical documentation to determine duration (category 42)

The adjudicating component had insufficient medical evidence to document the severity of the disabling impairment to meet policy requirements for 12-month duration.

6. Medical improvement (MI) and whether MI affects the ability to work (category 43)

The adjudicating component had insufficient medical documentation to determine whether there is MI, or whether MI is related to the ability to work, in a continuing disability review (CDR).

7. RFC (category 44)

The adjudicating component based the determination on an RFC assessment without sufficient evidence to support the assessment.

NOTE: The review component should not use this code if the adjudicating component’s determination is based on medical considerations alone (i.e., the impairment is not severe, or the impairment meets, medically equals, or functionally equals the listings).

8. Failure to follow prescribed treatment (FTFPT) (category 45)

The adjudicating component had insufficient evidence to determine whether consideration of FTFPT policy was necessary prior to assessing impairment severity.

9. Drug addiction and alcoholism (DAA) materiality (category 46)

The adjudicating component had insufficient evidence to:

  • determine whether DAA is material in the case, or

  • determine the severity of the non-DAA impairments when DAA is material.

10. Onset of disability relative to a title II eligibility period (category 47)

The adjudicating component had insufficient evidence to determine whether onset can, or cannot, be correctly established, in a Title II disability claim, relative to the date first insured, date last insured, end of the prescribed period, or before the attainment of age 22.

11. MI exception regarding new or improved diagnostic or evaluative techniques (category 48)

The adjudicating component had insufficient evidence to determine whether new or improved diagnostic or evaluative techniques showed the individual’s impairment(s) is, or is not, as severe as previously determined in the most recent favorable medical determination, in a CDR.

12. MI exception regarding whether the individual has benefited from advances in medical or vocational therapy or technology (category 49)

The adjudicating component had insufficient evidence to determine whether the MI exception, regarding significant MI in a CDR due to medical or vocational therapy, or technology, applies.

13. Age (category 51)

The adjudicating component had insufficient evidence to determine the claimant’s age, when it is material to the determination.

14. Education or illiteracy (category 52)

The adjudicating component had insufficient evidence to determine the claimant’s education or illiteracy, when it is material to the determination.

15. Work history (category 53)

The adjudicating component had insufficient work history evidence to determine:

  • relevance of past work,

  • the demands of past relevant work, including physical, mental, and environmental demands, or

  • transferable skills.

16. MI exception regarding advances in medical or vocational therapy or technology (category 54)

The adjudicating component obtains new medical evidence that results in a new RFC, but no MI. However, the vocational evidence is insufficient to determine whether the MI exception in a CDR regarding significant MI due to medical or vocational therapy, or technology applies.

17. MI exception regarding successful vocational therapy (category 55)

The adjudicating component had insufficient evidence to determine whether vocational therapy (related to the individual’s ability to work) improved the individual’s ability to meet the vocational requirements of more occupations, since the time of the most recent prior favorable medical determination, in a CDR.

18. Failure to obtain a prior folder or copy of the ALJ/AC ruling under an acquiescence ruling (category 60)

The adjudicating component did not obtain the prior folder or a copy of the ALJ or AC decision as required by the AR. Therefore, the evidence is insufficient to make a determination.

19. The prior determination was in error (category 61)

The prior determination was potentially incorrect, indicating a group I or II exception, but the adjudicating component did not follow policy regarding application of the exception, in a CDR.

20. Failure to follow prescribed treatment (FTFPT) (category 62)

The adjudicating component had insufficient documentation to allow or deny the claim, or continue or cease benefits, when evidence implied FTFPT was central to the assessment of impairment severity.

21. Whereabouts unknown (WU) (category 65)

The adjudicating component had insufficient documentation to deny the claim or cease benefits based on WU.

22. Failure to cooperate (FTC) (category 66)

The adjudicating component had insufficient documentation to deny the claim or cease benefits based on FTC.

B. Correcting group I documentation deficiencies

The review component returns all cases with group I documentation deficiencies to the adjudicating component for correction except for SGA category 30 deficiencies, which may require return to the field office (FO) or the adjudicating component.

1. Case returned to the adjudicating component for corrective action

For group I documentation deficiencies returned to the adjudicating component for correction, the review component will:

  1. a. 

    annotate all of the adjudicating component’s original determination and medical assessment forms, as well as notices, in the CEF as “Do Not Process” or “Do Not Release”, as applicable,

  2. b. 

    code the deficiency in the case processing system,

  3. c. 

    notify the adjudicating component, via an SSA-1774-U5, Request For Corrective Action, to explain why the determination is not policy compliant and request the adjudicating component to obtain additional documentation,

  4. d. 

    route the case to the adjudicating component for correction as a controlled return, and

  5. e. 

    follow-up with the adjudicating component in 60 days if the case has not been returned to the review component.

NOTE: All of the adjudicating component’s original determination and medical assessment forms, as well as notices, must remain in the CEF as part of the audit trail.

2. Case returned for a group I SGA documentation deficiency (category 30)

For group I documentation deficiencies based on SGA, the review component will:

  1. a. 

    annotate all of the adjudicating component’s original determination and medical assessment forms, as well as notices, in the CEF as “Do Not Process” or “Do Not Release”, as applicable,

  2. b. 

    code the deficiency in the case processing system,

  3. c. 

    notify the FO, via an SSA-5524-U3, Request for Assistance, to explain that SGA development is needed,

  4. d. 

    notify the adjudicating component, via an SSA-1774-U5, Request For Corrective Action, explaining why the determination is not policy compliant and that the case will be routed to the FO for SGA development, and

  5. e. 

    route the case to the FO.

NOTE: All of the adjudicating component’s original determination and medical assessment forms, as well as notices, must remain in the case record as part of the audit trail.

After resolving the work activity issue, if the FO determines an SGA denial or cessation is appropriate, the FO will:

  • effectuate the denial or cessation and

  • notify the review component of the outcome.

After resolving the work activity issue, if the FO determines an SGA denial is not appropriate, and the established onset date (EOD) remains the same, the FO will:

  • effectuate the allowance,

  • prepare and release any necessary personalized notices, and

  • notify the review component of the outcome.

After resolving the work activity issue, if the FO determines an SGA denial is not appropriate, but the EOD changes as a result of the work activity, the review component will:

  • annotate all of the adjudicating component’s original determination and medical assessment forms, as well as notices, in the CEF as “Do Not Process” or “Do Not Release”, as applicable,

  • code the deficiency in the case processing system,

  • correct the onset or ending date on the SSA-831-C3/U3, prepare and release any necessary personalized notices, and

  • route the case to the FO for effectuation.

NOTE: All of the adjudicating component’s original determination and medical assessment forms, as well as notices, must remain in the CEF as part of the audit trail.

If the FO determines an earlier onset date may be possible, and further medical development is necessary to establish the onset date, the review component will:

  • prepare an informational SSA-1774-U5, Request For Corrective Action, for the adjudicating component, to explain why the determination is not policy compliant and to request the adjudicating component to obtain additional documentation,

  • route the case to the adjudicating component for correction as a controlled return, and

  • follow-up with the adjudicating component in 60 days if the case has not been returned to the review component.

DI 30005.204 Group II Deficiencies

A. Definitions of group II decisional deficiencies

There are two types of group II deficiencies, decisional and documentation. A group II decisional deficiency is a substantive deficiency in which the evidence supports a different onset, ending, or cessation date for a disability determination. A group II documentation deficiency is a substantive deficiency in which the evidence is insufficient and obtaining additional evidence has the potential to change the onset, ending, or cessation date for a disability determination.

1. Group II decisional deficiencies

The review component will cite a group II decisional deficiency based on the following issues:

a. Onset date (category 71)

The adjudicating component allows a disability claim, but evidence supports a different onset date. In potential reopening situations, cite this deficiency when the adjudicating component:

  • should have reopened, but did not (even when the established onset date (EOD) is correct),

  • should not have reopened, but did (even when EOD is correct), or

  • correctly reopened, but established an incorrect onset date that is material.

b. Ending date (category 72)

The adjudicating component allows a disability claim:

  • for a closed period, but evidence supports a different ending date,

  • for a closed period, but evidence is sufficient to show disability did not end, or

  • for an open period, but evidence is sufficient to show disability ended.

c. Cessation date (category 73)

The adjudicating component ceases an individual’s disability benefits, but evidence supports a different cessation date.

2. Group II documentation deficiencies

The review component will cite a group II documentation deficiency based on the following issues:

a. Onset date (category 81)

The adjudicating component allows a disability claim, but evidence is insufficient to support the onset date. This includes situations where the adjudicating component’s EOD falls within a previously adjudicated period, and there is insufficient evidence to determine whether the prior denial determination can be reopened.

The review component should not cite a Group II onset date documentation deficiency when the field office (FO) did not inform the adjudicating component of a prior determination, and there was no indication of a prior determination in the certified electronic folder (CEF).

b. Ending date (category 82)

The adjudicating component allows a disability claim for a closed period, but evidence is insufficient to support the ending date.

c. Cessation date (category 83)

The adjudicating component allows a disability claim, but evidence is insufficient to determine the correct cessation date.

d. Unresolved work activity that has potential to affect the period of disability (category 85)

The adjudicating component allows a disability claim, but evidence is insufficient to determine either the correct onset or ending date because of unresolved work activity.

B. Correcting group II deficiencies

The review component handles group II deficiencies differently depending on the specific deficiency involved and the circumstances of the case. The review component either returns the case to the adjudicating component for correction, contacts the FO for resolution, or corrects the case.

1. Case returned to the adjudicating component for corrective action

Group II onset and ending date documentation deficiencies, and all cessation date deficiencies, are returned to the adjudicating component for correction. In these cases, the review component will:

a. code the deficiency in the case processing system,

b. notify the adjudicating component, via an SSA-1774-U5, Request For Corrective Action, to explain why the determination is not policy compliant and to request the adjudicating component to undertake appropriate development,

c. route the case to the adjudicating component for correction as a controlled return, and

d. follow-up with the adjudicating component in 60 days if the corrected determination has not been returned to the review component.

2. Case corrected in the review component

Group II onset and ending date decisional deficiencies are corrected by the review component. In these cases, the review component will:

a. annotate all of the adjudicating component’s original determination and medical assessment forms, as well as notices, in the CEF as “Do Not Process” or “Do Not Release”, as applicable,

b. code the deficiency in the case processing system,

c. notify the adjudicating component, via an SSA-1774-U5, Request For Corrective Action, to explain why the determination is not policy compliant,

d. correct the onset or ending date,

e. prepare and release any necessary personalized notices, and

f. route the case to the FO for effectuation

EXCEPTION: If the case has another deficiency or technical corrective action requiring correction by the adjudicating component, or changing the ending date results in an adverse reopening of either an initial or a reconsideration case, the review component will follow the instructions in GN 04440.204B.1 above, to return the case to the adjudicating component for correction.

NOTE: All of the adjudicating component’s original determination and medical assessment forms, as well as notices, must remain in the CEF as part of the audit trail.

3. Correcting group II SGA documentation deficiencies

For group II documentation deficiencies based on SGA, the review component will:

  1. a. 

    annotate all of the adjudicating component’s original determination and medical assessment forms, as well as notices, in the CEF as “Do Not Process” or “Do Not Release”, as applicable,

  2. b. 

    code the deficiency in the case processing system,

  3. c. 

    notify the FO, via an SSA-5524-U3, Request for Assistance, to explain that SGA development is needed,

  4. d. 

    notify the adjudicating component, via an SSA-1774-U5, Request For Corrective Action, to explain why the determination is not policy compliant and that the case will be routed to the FO for SGA development, and

  5. e. 

    route the case to the FO.

NOTE: All of the adjudicating component’s original determination and medical assessment forms, as well as notices, must remain in the CEF as part of the audit trail.

After the FO resolves the work activity issue, if the onset date remains the same, the FO will:

  • effectuate the allowance,

  • prepare and release any necessary personalized notices, and

  • notify the review component of the outcome.

After the FO resolves the work activity issue, if the onset date changes, the review component will:

  • annotate all of the adjudicating component’s original determination and medical assessment forms, as well as notices, in the CEF as “Do Not Process” or “Do Not Release”, as applicable,

  • code the deficiency in the case processing system,

  • correct the onset or ending date on the SSA-831,

  • prepare and release any necessary personalized notices, and

  • route the case to the FO for effectuation.

NOTE: All of the adjudicating component’s original determination and medical assessment forms, as well as notices, must remain in the CEF as part of the audit trail.

If the FO determines an earlier onset date may be possible, and further medical development is necessary to establish the onset date, the review component will:

  • prepare an informational SSA-1774-U5, Request For Corrective Action, to explain why the case is not policy compliant and to request the adjudicating component to undertake appropriate development,

  • route the case to the adjudicating component for correction as a controlled return, and

  • follow-up with the adjudicating component in 60 days if the case has not been returned to the review component.

DI 30005.205 Quality Review Subsequent Returns

A. Introduction to subsequent returns

A subsequent return occurs when a review component returns a claim to an adjudicating component for additional development and/or correction, and the adjudicating component either:

  • does not complete all of the requested actions before routing the claim back to the review component, or

  • new, potentially material, issues arise because of the actions taken by the adjudicating component.

NOTE: The review component must not cite additional deficiencies on subsequent returns.

B. Correcting subsequent returns

When an adjudicating component does not complete all of the corrective actions delineated on the SSA-1774-U5 (Request for Corrective Action), or when subsequent case development raises material issues, the review component will either correct the case, or return the case to the adjudicating component for correction.

1. Case corrected in the review component

When the adjudicating component fully documents a case in response to a return, but the final determination, onset date, or ending date is incorrect, the review component will:

a. annotate all of the adjudicating component’s original determination and medical assessment forms, as well as notices, in the certified electronic folder (CEF) as “Do Not Process” or “Do Not Release”, as applicable,

b. code the subsequent return in the case processing system,

c. notify the adjudicating component, via an SSA-847-U3 (Request for Case Action), to explain the additional actions taken on the case, and why further corrections were needed,

d. either correct the onset or ending date or assume jurisdiction to correct the final determination,

e. prepare and release any necessary personalized notices, and

f. route the case to the field office.

NOTE: Do not assume jurisdiction for cases when the next level of appeal is a disability hearing at reconsideration. This includes:

  • continuing disability review medical cessations,

  • adverse reopenings of favorable initial determinations based on medical factors,

  • adverse reopenings of reconsideration reversals based on medical factors, and

  • adverse reopenings of cessations that change only the basis for the cessation.

These cases must always be returned to the adjudicating component for correction.

NOTE: All of the adjudicating component’s original determination and medical assessment forms, as well as notices, must remain in the CEF as part of the audit trail.

EXCEPTION: If the case has another deficiency or technical corrective action requiring corrective action by the adjudicating component, or changing the ending date results in an adverse reopening of either an initial or a reconsideration case, the review component will follow the instructions in GN 04440.204B.1.

2. Case returned to the adjudicating component for corrective action

When the adjudicating component’s documentation is still insufficient to make the final determination or to determine the correct onset or ending date, the review component will:

a. code the subsequent return in the case processing system,

b. notify the adjudicating component, via a new SSA-1774-U5, Request For Corrective Action, to acknowledge the corrective actions already completed, explain why the case is still not policy compliant, and specify what additional actions are needed,

c. annotate the heading of the new SSA-1774-U5, “Second Return – No Additional Deficiency Cited”,

d. route the case to the adjudicating component for correction as a controlled return, and

e. follow-up with the adjudicating component in 60 days if the corrected determination has not been returned to the review component.


DI 30005 TN 39 - Adjudicating Component Actions on Deficient Cases - 7/21/2020