Quality Review (QR) performs case reviews to ensure the evidentiary records support the adjudicating component determination and the evidence and the determination conform to the Social Security Administration (SSA) operating policies and procedures. Deficiencies are cited based on adjudicating component action relative to the evidence in the case (e.g., medical evidence, statements by the claimant, information from other sources) at the time of adjudication. For an explanation of what constitutes evidence, see DI 24503.005.

The review component sometimes receives additional evidence (trailer material) while the case is undergoing review. In some instances, the trailer material changes a correct case to a deficient case or a deficient case to a correct case. The review component must determine if corrective action is necessary and whether or not to cite the adjudicating component with a deficiency.

In CEF cases, the review component can receive an UAT while a case is undergoing review. The UAT results when a field office (FO) without jurisdiction of the case initiates changes as follows.

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  The FO can update mainframe data (e.g., claimant name, address, telephone number) on SSA mainframe systems (Modernized Claims System/Modernized Supplemental Security Income Claims System) and propagates that information into the Electronic Disability Collect System (EDCS) using the UAT utility. This action produces an alert under the Alerts and Messages section and Record of Change (ROC) under the Case Data section in eView.

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  The FO can update disability report information (e.g., new medical source, new allegations, tests, medications) and add that information to the CEF by creating a Form SSA-5002 (Report of Contact) in EDCS. This action produces an alert under the Alerts and Messages section, ROC under the Case Data section, and SSA-5002 under the Case Documents section in eView.

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  The FO can add a claim to a case when another claim has been transferred to the adjudicating component. This action produces an alert under the Alerts and Messages section and ROC under the Case Data section in eView.

In some instances, the UAT changes a correct case to a deficient case or a deficient case to a correct case. The review component must determine if corrective action is necessary and whether or not to cite the adjudicating component with a deficiency.

To view UATs, the review component should access eView or SSN History in the National Case Processing System (NCPS) case processing system.

The review component may receive trailer material while a case is undergoing review. For CEF cases, the review component may also receive UATs while a case is undergoing review. However, the review component must base the QR evaluation of the adjudicating component’s determination on the evidence included in the case as a whole at the time of the adjudicating component’s case clearance.

The review component must consider any trailer material or UAT received while a case is undergoing review for purposes of case adjudication and correction, if necessary.

In some instances, the trailer material or UAT changes a correct case to a deficient case or a deficient case to a correct case. The review component must then determine if corrective action is necessary.

The review component should review the CEF to identify trailer material and UATs that may have been received while the case is undergoing review. This can be accomplished by reviewing the date the document or UAT was received into the CEF. A gap between the review sample date and the date an additional document or UAT was received into the CEF generally indicates the presence of trailer material or UAT received after adjudicating component case clearance. You can view the review sample date in the top frame of eView, or you can identify it by using the “Query” case search in the National Case Processing System (NCPS).

NOTE : NCPS allows for cases to be transferred from the review component to the adjudicating component, then re-closed by the adjudicating component back to the review component. When Trailer Mail is considered, use the most recent date the case was returned to the review component instead of the NCPS sample date.

Any component can add documents to the CEF regardless of jurisdiction of the CEF; however, only the component with jurisdiction of the CEF will be able to take adjudicative actions on that case.

NOTE: The review component should not rely solely on checking the “CEF Received?” date of documents under the Case Documents section in eView to identify trailer material. The adjudicating component may send documents to the CEF during the closure process. In addition, delays in the adjudicating component closure process (i.e., system problems) may result in a “CEF Received?” date that is later than the review sample date. When discrepancies are noted, the review component should also consider the information provided on the adjudicating component Disability Worksheet, which is under the Case Documents section, in Section F - Medical Records (Yellow Back).

The following chart explains the procedure required when trailer material and UATs are received during review.

Quality review components must use the procedures outlined below when clarification of disability program or quality review policy is necessary, at any time, during the quality review process.

If policy and procedural guidelines or Program Operations Manual System (POMS) instructions do not clarify the disability program or quality review policy issue requiring resolution, quality review components must refer the case to the Division of Disability Quality (DDQ), in Quality Review (QR), using the process described below.

NOTE : Under no circumstances should a quality review component submit policy issue referrals directly to the Office of Disability Policy (ODP) or any other central office component.

When a quality review component needs to request policy or procedure clarification, the quality review component will submit their question(s) using the Policy Clarification and Field Site Assistance Form located on the QR Field Site Home SharePoint.

The information needed to submit a question includes:

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  the subject or topic of the question,

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  the primary requestor's contact information,

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  the type and level of the case associated with the question,

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  the social security number associated with the case,

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  the specific policy issue or question,

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  the proposed resolution, and

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  any applicable policy or procedure references.

Once a quality review component submits a question using the designated submission form, a notification e-mail will automatically be sent to the ^DCARO OQR Policy Questions mailbox.

The mailbox leads in DDQ will assign the question to a DDQ staff member(s) and change the status on the submission form to "Assigned".

NOTE : The individual designated as the "Primary Requestor", and all other individuals listed in the "Notify Other Users" field on the submission form, will receive automatic e-mail notifications upon initial submission of a question, when a question is referred to another component, and when the response to the question is completed by DDQ staff members.

For pending cases, the assigned DDQ staff member(s) will respond to the submitted question in:

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  two business days, if the question can be answered with DDQ input alone, or

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  seven business days, if the question requires multi-component collaboration and input.

For closed cases, the assigned DDQ staff member(s) will respond to the submitted question in:

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  five business days, if the question can be answered with DDQ input alone, or

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  fourteen business days, if the question requires multi-component collaboration and input.

If the assigned DDQ staff member(s) is unable to provide a response within the allotted time, that staff member will provide a status update, via e-mail, to all of the quality review component staff designated on the original submission form and send a copy of the e-mail to the ^DCARO OQR Policy Questions mailbox.

When a quality review component disagrees with a response provided by a DDQ staff member(s), and the policy at issue is owned by QR, the quality review component will send an e-mail to the ^DCARO OQR Policy Questions mailbox with a detailed explanation of the disagreement.

To ensure proper routing and expedite the resolution process, the subject line of the e-mail should include:

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  the word "disagreement",

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  the Request ID # associated with the initial question, and

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  any other pertinent information that may assist in the resolution process (e.g., case status, additional relevant POMS, new developments, etc.).

Upon receipt of the quality review component's disagreement e-mail, the question will be assigned to a different DDQ staff member(s), who did not participate in the initial response, for resolution and to help ensure that additional input is impartial. The newly assigned DDQ staff member will send a "Reply All" response to the submitting quality review component's disagreement e-mail, within one business day, to acknowledge receipt.

The DDQ time frames for resolving disagreements are as follows:

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  two business days for pending cases and

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  five business days for closed cases.

If the assigned DDQ staff member(s) is unable to provide a response within the allotted time, that staff member will provide a status update, via e-mail, to all of the quality review component staff designated on the original submission form and send a copy of the e-mail to the ^DCARO OQR Policy Questions mailbox.

Once the disagreement is resolved, the assigned DDQ staff member(s) will forward a draft response, via e-mail, to the Quality Review Policy and Procedures Branch Chief for review, approval, and final release to the involved quality review component.

When a quality review component disagrees with a response provided by a component outside of QR, and the policy at issue is owned by the outside component, the quality review component will send an e-mail to the ^DCARO OQR Policy Questions mailbox with a detailed explanation of the disagreement.

To ensure proper routing and expedite the resolution process, the subject line of the e-mail should include:

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  the word "disagreement",

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  the Request ID # associated with the initial question, and

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  any other pertinent information that may assist in the resolution process (e.g., case status, additional relevant POMS, new developments, etc.).

Upon receipt of the quality review component's disagreement e-mail, the question will be assigned to the same DDQ staff member(s), who participated in the initial response, for resolution. The DDQ staff member(s) will send a "Reply All" response to the submitting quality review component's disagreement e-mail, within one business day, to acknowledge receipt.

The DDQ time frames for resolving disagreements are as follows:

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  seven business days for pending cases and

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  fourteen business days for closed cases.

If the assigned DDQ staff member(s) is unable to provide a response within the allotted time, that staff member will provide a status, via e-mail, to all of the quality review component staff designated on the original submission form and send a copy of the e-mail to the ^DCARO OQR Policy Questions mailbox.

Once policy clarification is received from the outside component, the assigned DDQ staff member(s) will prepare a response to the involved quality review component and update the resolution in the Policy and Procedure Clarification and Field Site Assistance Request Form.

There are two methods of resolving deficiency disagreements between adjudicating and review components:

1. 1. 

   The IRR process, administered by Quality Review (QR), attempts to resolve deficiency disagreements informally between the adjudicating and review components. The adjudicating component directs the IRR submission to the review component that cited the deficiency for another impartial review of the case facts and applicable policies in contention. The review component will prepare a policy-based IRR resolution to address the adjudicating component's deficiency disagreement.

2. 2. 

   The RPC process, administered by the Office of Policy Consultation and Analysis (OPCA), resolves deficiency disagreements between the adjudicating and review components through an RPC Panel Discussion. For an explanation of the RPC process, see DI 30007.000.

When the adjudicating component disagrees with any cited group I deficiency, group II deficiency, or technical corrective action (TCA), in a fully electronic case, they are encouraged to attempt to resolve the disagreement on an informal basis by submitting an IRR via the Office of Disability Policy’s (ODP) IRR web-based tool.

NOTE: RPC will not accept submissions when the disagreement involves a change in deficiency type only, otherwise known as a "wrong deficiency cited", unless the case has first been through the IRR process. A wrong deficiency citation occurs when one type of deficiency is cited, but program instructions support a different type; e.g., documentation vs. decisional, or group I vs. group II. In these situations, there is no rescission of the deficiency, but the review component updates the QR case processing system database with the correct deficiency. This still only results in one chargeable deficiency against the adjudicating component.

EXAMPLE: The review component cites a decisional deficiency, changing an allowance determination to a denial determination, but fails to recognize in doing so, that the adjudicating component must first develop all allegations or medical sources prior to denying the claim. The adjudicating component requests the review component change, or replace, the decisional deficiency to a documentation deficiency, agreeing that the evidence does not currently support an allowance, but acknowledging the adjudicating component must develop all allegations or medical sources before making a denial determination. The review component updates the QR case processing system database with the correct deficiency, thus there is only one chargeable deficiency for the adjudicating component.

NOTE: The QR case processing system allows displaying of more than one deficiency code if applicable as a result of the Federal quality review. However, only the deficiency marked as "Primary" is counted against the adjudicating component. Deficiencies marked as "Other" do not count against the adjudicating component unless they subsequently become "Primary" as a result of the IRR or RPC.

If the adjudicating component chooses not to attempt to resolve the disagreement through the IRR process, or if they cannot resolve the deficiency after the IRR process, the adjudicating component may submit an RPC, if the criteria is met, to OPCA for a fully electronic case (see DI 30007.125 - Submitting a Case for RPC). The adjudicating component may not simultaneously submit an IRR and RPC.

If the adjudicating component does not resolve the deficiency through the IRR process, they must complete the request for corrective action(s) noted on the Request for Corrective Action, or Request for Case Action, or submit an RPC, if the case meets the criteria for RPC submission (see DI 30007.125 - Submitting a Case for RPC).

For subsequent returns, which are precluded from the IRR/RPC process, the adjudicating component may choose to contact reviewing component directly to discuss concerns informally prior to completion of the action(s) noted on the Request for Corrective Action or Request for Case Action. (see GN 04440.205 and DI 30005.205 - Quality Review Subsequent Returns).

The adjudicating component uses the IRR process to:

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  resolve disagreements in group I deficiencies, group II deficiencies, or TCAs, in a fully electronic case;

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  request a rescission of a group I deficiency or group II deficiency, in a fully electronic case; or

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  resolve disagreements, within the appropriate time frames, regarding cases with group II deficiencies routed directly from the review component to the Field Office (FO).

When the adjudicating component prepares an IRR, the adjudicating component:

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  cannot use the federal quality review administrative procedure of probability of reversal (POR), as defined in GN 04440.110 and DI 30005.110, as the basis of an IRR for a documentation deficiency;

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  can use substitution of judgment (SOJ), as defined in GN 04440.118, as the basis of an IRR for a decisional deficiency;

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  cannot use SOJ as the basis of an IRR for a documentation deficiency; and

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  is not required to perform any development actions requested on the Request for Corrective Action or the Request for Case Action, prior to submitting an IRR, except for those development actions not in dispute.

NOTE: The review component will not accept IRRs for the following:

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  subsequent returns (See GN 04440.205); or

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  closed cases, with the exception of group II deficiencies routed directly to the FO.

The adjudicating component must initiate an IRR through ODP's IRR web-based tool to attempt to resolve any disagreement or to request a rescission, if applicable, of any group I deficiency, group II deficiency, or TCA. The adjudicating component must:

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  submit the IRR request in the web-based tool within 20 calendar days, beginning with the date the review component returned the deficient case, and

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  include a policy-based narrative, with applicable citations, explaining the basis for the IRR.

NOTE: For any IRR submitted after the 20-calendar-day time frame, the adjudicating component must provide an explanation of the unusual circumstances that caused the delay. The review component determines whether to accept the IRR due to the unusual circumstances.

If the review component disagrees with the IRR rationale for policy compliance submitted by the adjudicating component, the adjudicating component must complete the requested corrective action(s) noted on the Request for Corrective Action, or Request for Case Action, or submit an RPC, if the case meets the criteria for RPC submission (see DI 30007.125 - Submitting a Case for RPC).

When the adjudicating component does not request rescission of a deficiency or is not in disagreement with the deficiency citation, the adjudicating component may email or phone the review component contact found on the Request for Corrective Action or Request for Case Action, without submitting an IRR, to discuss the issues in the case, and/or the necessary required actions:

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  to clarify the requested corrective action(s) noted on the Request for Corrective Action or Request for Case Action;

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  to ask a specific question about the deficiency; or

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  to ask for a policy citation(s).

NOTE: The Request for Corrective Action and Request for Case Action are displayed on the first page of the QR Disability Determination Explanation.

After receiving an IRR notification, the designated review component contact:

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  identifies the original program leader (PL) who approved the deficiency and

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  assigns the IRR in the IRR web-based tool to a designated QR staff member who was not involved in the original return.

The review component has 14 calendar days to respond to the IRR. When the review is complete, the review component will:

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  code the IRR web-based tool,

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  prepare a narrative response to the IRR in the IRR web-based tool,

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  ensure that the IRR response addresses all relevant policy concerns or questions raised by the adjudicating component, and

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  include policy and procedural references to support the response, unless the review component agrees with the adjudicating component’s IRR, rescinds the deficiency, and no further action is needed.

When the IRR response is ready for review, the QR designated staff member will inform the branch chief (BC) or other designated QR manager. The BC, or other designated QR manager, will return the IRR to the QR designated staff member if they decline to sign the IRR response. The QR designated staff member will make the requested changes and resubmit the IRR to the BC, or other designated QR manager, until achieving concurrence. The BC, or other designated QR manager, will close the IRR in the IRR web-based tool. This action uploads the adjudicating component's IRR submission and review component's IRR response to the certified electronic folder and the tool notifies the adjudicating component by email that the response is available to view.

NOTE: The review component should not obtain medical contractor (MC) or psychological contractor (PC) review(s) during the informal resolution request (IRR) process. MC/PC review results must be coded in the case processing system per GN 04440.130D . The review component’s case processing system does not support coding results of MC/PC reviews during the IRR process.

If the review component agrees that the adjudicating component’s determination was policy compliant, the review component will rescind the deficiency in the IRR web-based tool. Once the case is returned by the adjudicating component, the review component will update the QR case processing system database and clear the case according to normal business processes.

If the review component disagrees with the adjudicating component’s IRR rationale for policy compliance and affirms the deficiency, the adjudicating component must take the requested corrective action(s) noted on the Request for Corrective Action, or Request for Case Action, or submit an RPC, if the case meets the criteria for RPC submission (see DI 30007.125 - Submitting a case for RPC).

If the adjudicating component decides to complete the requested corrective action(s), the adjudicating component will return the case to the review component after completing the actions. The review component will code and clear the case according to normal business processes.

If the review component rescinds or corrects the deficiency within the IRR web-based tool, the QR case processing system database will be automatically updated with the applied revisions to ensure that the rescinded or corrected deficiency is appropriately recorded.

NOTE: When an IRR results in a rescission of a group II decisional deficiency that has been transmitted to the field office for effectuation, and the final outcome of the determination is changed, the case must be reactivated. The review component will follow policy guidance in GN 04440.111 Reopenings Certified Electronic Folders (CEF) for reactivation and reopening.

The decision to rescind or correct a deficiency after rebuttal is based on whether the adjudicating component’s disability determination conformed to the Social Security Act, regulations, rulings, and the POMS as of the date of the determination. When the review component agrees to rescind the deficiency following the adjudicating component’s successful rebuttal action, the review component removes the deficiency from the record.

The adjudicating component prepares the rebuttal submission, and takes the following actions:

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  submits an Informal Resolution Request (IRR) if the IRR criteria is met in GN 04440.401; or

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  submits a Request for Program Consultation (RPC) if the RPC criteria is met in GN 04440.405.

The review component rescinds:

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  a group I deficiency, if the resolution is that no group I deficiency applies;

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  a group II deficiency, if the resolution is that no group II deficiency applies;

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  deficiencies in rebuttals requiring referral for resolution of policy issues only when the Office of Disability Policy (ODP), QR, or other SSA component determines that the policy clarification was indeed necessary before the case could be adjudicated accurately.

The review component corrects, but does not rescind, the cited deficiency for:

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  group I deficiency, if the correct deficiency citation is determined to be a group II deficiency or other technical corrective action; or

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  group I or II deficiency, if the incorrect type was cited (decisional to documentation).