An adjudicating component is a state or federal component that adjudicates disability claims (e.g., disability determination services or federal disability processing branches or units).

A claim is considered to have "another returnable deficiency" if, in addition to a group I or group II work activity documentation deficiency, there is a technical corrective action (TCA) that requires adjudicating component development or action. This is a rare occurrence.

The development or action required by the adjudicating component is in addition to the needed field office (FO) development or action and is unrelated to the work activity documentation deficiency. The FO development or action pertains only to a cited group I or group II work activity documentation deficiency.

NOTE: A federal quality reviewer should never cite more than one group I or group II deficiency on a claim. However, it is possible that when development for a cited group I or group II deficiency is completed by an adjudicating component, the need for additional medical or vocational development or documentation may become apparent. In this instance, federal quality reviewers should return the claim to the adjudicating component, requesting additional development and/or correction, as a subsequent return, not as “another returnable deficiency.”

A deficiency is a specific instance of noncompliance with SSA policies and procedures, classified according to its impact, or potential impact, on the disability determination. Federal quality reviewers categorize deficiencies as group I or group II. Federal quality reviewers further classify group I and group II deficiencies as decisional or documentation. There are also TCAs that require adjudicating component correction, but federal quality reviewers do not categorize TCAs as deficiencies.

A "de novo" review is one in which the evidence of record in a claim is objectively read and scrutinized, without considering the determination previously made by an adjudicating component. In effect, a "de novo" review is a re-adjudication of a disability claim.

Quality reviewers and regional office medical and psychological contractors do not perform "de novo" reviews. They review claims to ensure adjudicating component determinations comply with SSA disability program policy and procedures.

The term “documentation” refers to the record SSA establishes and maintains of its determination of a claimant’s benefit rights and the evidence supporting that determination.

For additional information, see QR 00301.285 (Statements and Other Documentation).

A federal quality reviewer is a reviewer or program leader (PL), in a federal review component, who evaluates specific quality review sample claims to determine if an adjudicating component's evidentiary record and determination conform to SSA operating policies and procedures.

Preponderance of the evidence means such relevant evidence that, as a whole, shows the existence of the fact to be proven is more likely than not. SSA bases the adjudication of all disability claims on the preponderance of the evidence standard.

Preponderance of the evidence is the greater weight of evidence that, when weighed against other evidence, is more convincing of the truth. It does not represent any specific quantity or volume of evidence, only that which is more probable of its truth and accuracy.

For additional information on preponderance of the evidence, see DI 23025.001B.5.

POR is an administrative tool used by federal quality reviewers to distinguish returnable group I or group II documentation deficiencies from TCAs. The determining factor is whether obtaining missing documentation is likely to reverse the disability determination or change the length of the period of disability.

For a complete explanation of POR, see QR 04440.110.

The federal quality review team is made up of quality reviewers and PLs, in federal quality review components, and the regional office medical and/or psychological contractors who perform the medical and/or psychological review portion of the quality reviews.

Per DI 40115.005, a substantive change is a change that alters the conclusions as to:

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  whether an individual is disabled,

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  when disability begins or ends, or

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  the basis for a determination, even when there is no change that affects benefits.

One of the principles of the federal quality review is that federal quality reviewers and regional office medical and/or psychological contractors must not substitute their judgment for that of the adjudicating component’s medical and/or psychological consultants and adjudicators. Regional office medical and psychological contractors must be aware of SOJ as a review principle, to ensure they do not perform a "de novo" case review. (See subsection D for a definition of "de novo" review.)

For a description of the regional office medical and psychological contractor's review process, see QR 04440.130B.

Federal quality reviewers must be aware of SOJ as a review principle in decisional deficiency deliberations.

If an adjudicating component documents and assesses a claim in accordance with SSA's disability policy and the preponderance of the evidence in file supports the determination, the federal quality reviewer must not cite a deficiency, even if the federal quality reviewer arrived at a different, but equally supportable, conclusion.

For a complete explanation of SOJ, see QR 04440.118.

A disability determination is supported, or supportable, if it complies with SSA policy and procedural requirements, does not contain internal inconsistencies, and is supported by a preponderance of the evidence in file. A federal quality reviewer may find a disability determination is not supported if it does not comply with specific SSA policy or documentation requirements.

Fraud exists when a person, with the intent to defraud, either makes or causes to be made, a false statement or a misrepresentation of a material fact for use in determining rights under the Social Security Act (Act); or conceals or fails to disclose a material fact for use in determining rights under the Act.

Similar fault is involved with respect to a determination if an incorrect or incomplete statement that is material to the determination is knowingly made or information that is material to the determination is knowingly concealed.