A medical review includes assessing impairment severity, the RFC, and related medical issues. The MC or PC reviews the adjudicating component's medical assessment and may independently arrive at a different assessment of impairment severity or RFC than the adjudicating component. It is NOT a “de novo” review. If the adjudicating component’s assessment complies with SSA disability program policy, and the evidence in file fully supports and documents the assessment, the MC or PC must not substitute his or her judgment.
As part of their medical and response, the MC or PC should:
respond to the medical referral completed by the quality reviewer requesting MC or PC review, medical advice, or clarification of a medical issue and offer an explanation or guidance as to the course of action recommended. The advice or recommendation should be more detailed when it is not consistent with the reviewer’s guidance or possible expectations,
provide an opinion on probability of reversal (POR) determinations, as needed. MCs and PCs must limit their opinions to the potential effect of missing documentation on impairment severity or RFC only,
complete appropriate forms to respond to the medical referral,
code results of a medical review in the case processing system.
The documentation in the file must fully explain the discrepancy or disagreement with the adjudicating component. MCs and PCs may prepare a SSA-3023-F3 (Medical Consultant's Review of Psychiatric Review Technique Form), SSA-392 (Medical Consultant's Review of Physical Residual Functional Capacity Assessment), or SSA-392-SUP (Medical Consultant's Review of Mental Residual Functional Capacity Assessment), to express findings of agreement or disagreement with an adjudicating component’s proposed PRT, RFC, or MRFC assessment(s).
MCs and PCs generally prepare a SSA-416 to provide medical comments if a determination should have been made on a medical-only basis (i.e., non-severe impairment(s) or impairment(s) meets/equals a listing) or the case is insufficient to establish a severe medically determinable impairment.
NOTE: For a discussion of “de novo” review and substitution of judgment, see GN 04440.003 - Explanation of Quality Review Terms and GN 04440.118 - Substitution of Judgment (SOJ) in the Quality Review Process.