Identification Number:
GN 04440 TN 116
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. 116, 07/24/2020

Audience

PSC: DE, DEC;
OCO-OEIO: FDE;
DQB: DE, PL;
OCO-ODO: DE, DEC, DS, RECONE;

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, add clarity, and ensure conformance with Plain Language Guidelines. With publication of revised GN 04440.201 through GN 04440.205, we are making necessary reference changes. In GN 04440.936, we are removing reference to the Martinez acquiescence ruling as it has expired. This is a quick action transmittal and does not change policy or procedure.

 

Summary of Changes

GN 04440.401 Resolving Deficiency Disagreements - Informal Resolution Request (IRR) and Request for Program Consultation (RPC)

Changed reference in subsection B from GN 04440.203 (Second Returns) to GN 04440.205 (Subsequent Returns).

 

GN 04440.501 Completion of the SSA-1774-U5, Request for Corrective Action

Removed reference in subsection A to Deficiency Transmittal Forms (GN 04440.201D).

Removed information in parentheses in B2a as that reference has been changed.

Changed references in subsection B2e to GN 04440.202 through .204.

 

GN 04440.510 Completing the SSA-5524-U3, Request for Assistance

Changed reference in B2, 4th bullet, to GN 04440.202 through .204.

 

GN 04440.936 State-Specific Instructions for Acquiescence Rulings (AR)

Removed Martinez AR as it has expired.

GN 04440.401 Resolving Deficiency Disagreements - Informal Resolution Request (IRR) and Request for Program Consultation (RPC)

A. Introduction to resolving deficiency disagreements

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

  1. 1. 

    The IRR process, administered by the Office of Quality Review (OQR), 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.

B. Policy for resolving deficiency disagreements

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 codes the correct deficiency in the OQR case processing system. 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 corrects the OQR case processing system to reflect a documentation deficiency, thus there is only one chargeable deficiency for the adjudicating component.

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, or submit an RPC, they must complete the request for corrective action(s) noted in the SSA-1774-U5, Request for Corrective Action.

C. The IRR process for adjudicating components

The adjudicating component uses the IRR process to:

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

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

  • 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:

  • 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;

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

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

  • is not required to perform any development actions requested on the SSA-1774-U5, Request for Corrective Action, or the SSA-847, SSA 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:

  • subsequent returns (See GN 04440.205); or,

  • 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:

  • 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

  • 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 in the SSA-1774, Request for Corrective Action, OR submit an RPC, if the case meets the criteria for RPC submission (see DI 30007.125 - Submitting a case for RPC).

D. When not to use the IRR process

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 in the SSA-1774-U5, Request for Corrective Action, without submitting an IRR, to discuss the issues in the case, and/or the necessary required actions:

  • to clarify the requested corrective action(s) noted in the SSA-1774-U5;

  • to ask a specific question about the deficiency; or,

  • to ask for a policy citation(s).

E. The IRR process for review components

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

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

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

The review component has 10 calendar days to respond to the IRR. When the review is complete, the review component will:

  • code the IRR web-based tool,

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

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

  • include policy and procedural references to support the response.

When the IRR response is ready for review, the OQR designated staff member will inform the branch chief (BC) or other designated OQR manager. The BC, or other designated OQR manager, will return the IRR to the OQR designated staff member if he or she declines to sign the IRR response. The OQR designated staff member will make the requested changes and resubmit the IRR to the BC, or other designated OQR manager, until achieving concurrence. The BC, or other designated OQR 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.

If the review component agrees that the adjudicating component’s determination was policy compliant, the review component will rescind the deficiency, code 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 SSA-1774, Request for Corrective 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, the IRR web-based tool will send a system-generated email notification to the OQR Reports Branch 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.

GN 04440.501 Completion of the SSA-1774-U5, Request for Corrective Action

A. Use of an SSA-1774-U5

The Office of Quality Review (OQR) completes an SSA-1774-U5 to return group I and group II deficiencies, as well as some technical corrective actions, that may affect the disability determination or the period of disability, to the adjudicating component.

For additional information regarding the types of transmittal forms and an exhibit of the SSA-1774-U5, see the references below:

B. Procedure for completing an SSA-1774-U5

The sections below explain how to complete the SSA-1774-U5 form.

1. How to complete the fields

Information from OQR's case processing system electronically propagates sections 1 through 6 and 8 through 11 of the SSA-1774-U5. NOTE: The “date” field in section 1 does not automatically propagate and must be entered manually. See GN 04440.501B.4.

Manually enter onset information in section 7 for deficient initial and recon disability determinations. Complete the alleged onset (AOD) field. Enter the adjudicating component’s established onset date (EOD) for all allowance determinations. Complete the reviewer onset date (ROD) field when a group I decisional deficiency results in a favorable disability determination or a group II decisional deficiency warrants a different onset date.

For complete and accurate data propagation, quality reviewers must complete all OQR case processing system coding prior to creating the SSA-1774-U5. Following completion of the appropriate review screens, quality reviewers must:

  • Review the propagated fields for accuracy and make any necessary changes in OQR’s case processing systems, as applicable.

  • Incorporate policy references into the case discussion. Do not list policy references in section 10 ("REFERENCES").

  • Select the “YES” or “NO” block for the "FOLDER ATTACHED" section of the SSA-1774-U5, as applicable.

  • Select the "YES" or "NO" blocks for “MEDICAL REVIEW” and “MED NOTE IN FILE", as applicable.

2. How to format and organize the narrative discussion

The following sections explain how to complete the narrative fields on the SSA-1774-U5.

a. Narrative fields

The narrative fields on the SSA-1774-U5 include:

  • Item 11 ("ACTION REQUESTED AND RATIONALE") on the first page and

  • Continuation pages (up to 10 total) provided when you select the ["More"] button.

In item 11, summarize the relevant facts of the case and clearly state:

  • the policy issue,

  • reasons why the case is deficient, and

  • necessary corrective action(s).

To explain or justify the deficiency, do not use:

  • Office of Disability Policy’s policy memorandums,

  • PolicyNet Questions and Answers (Q & As) or

  • other similar written guidelines that are not part of National policy.

NOTE: Quality reviewers cannot cite a Q & A as the sole basis for a deficiency, but may refer to a Q & A on the SSA-1774-U5, for clarification purposes only, as long as the Q & A is not expired or archived.

Acceptable references include:

  • The Program Operations Manual System (POMS)

  • The Social Security Act

  • Regulations

  • Social Security and Acquiescence Rulings

  • Administrative and Emergency Messages

Follow the appropriate format when completing each section of the narrative discussion on the SSA-1774-U5, as explained below.

b. The header section of the SSA-1774-U5

The OQR case processing system propagates the header section onto the SSA-1774-U5 form. The heading will differ based on the type of review and deficiency code.

  • For cases with "TYPE OF REVIEW" noted as “OTHER” in block 4, OQR’s case processing system propagates a heading of “Informational Only”.

  • For cases with a deficiency code between 10 and 85, OQR’s case processing system propagates a heading that includes the deficiency group, deficiency type, OQR’s case processing system assigned deficiency code, and a narrative description of the deficiency code. The information will be correct if the reviewer completes OQR’s case processing system coding prior to creating the SSA-1774-U5. For example, Group I Decisional – 11 – Incorrect Impairment Severity Decision.

c. How to complete the “ISSUE” section

Provide a brief summary to describe the basis of the deficiency. Two to three sentences is generally sufficient.

d. How to complete the "CASE DISCUSSION & POLICY ANALYSIS" section, including relevant policy citations

Follow the Federal Plain Language Guidelines, as enacted by the Plain Language Act of 2010, when writing the narrative discussion of the SSA-1774-U5. Compose the body of the SSA-1774-U5 in typeface Courier New, Arial Regular, or Times New Roman with font size 10 to 14 points.

If applicable to the return, the section should include:

  • A brief statement of the claimant's allegations and the alleged onset date.

  • Discussion of the vocational issues, including incorporation of specific policy references to support any deficiency findings.

  • Discussion of the medical issues, with respect to sufficiency of documentation or medical severity, as it relates to listing requirements or impact on the claimant's residual functional capacity (RFC). Include incorporation of specific policy references.

  • Discussion of symptom evaluation, medical source statements, all opinion evidence, and any related policy.

DO NOT:

  • Cut and paste POMS sections into the return without providing a discussion of the policy interpretation and how it specifically applies to the cited deficiency.

  • Provide a list of references or cite a range of POMS chapters.

  • Cite a POMS table of contents or introductory section, unless the introductory section contains specific instructions related to the deficiency (e.g., introductory text in specific Listing of Impairments).

NOTE: Be very specific. Adjudicating components, the Office of Disability Policy's Request for Program Consultation staff, and subsequent reviewers must be able to identify the incorrectly applied policy to determine the proper course of corrective action(s).

e. How to complete the “REQUEST FOR CORRECTIVE” section

Explicitly state the action(s) necessary to correct the deficiency.

If documentation is necessary, specify the type of documentation. Do not direct the adjudicating component to purchase a consultative examination or otherwise tell them how to obtain the evidence. For additional information on routing and correcting deficient cases, see GN 04440.202,GN 04440.203, and GN 04440.204.

If the return does not require corrective action by the adjudicating component, include the statement, “No corrective action required”.

NOTE: Select the ["More"] button at the bottom of page one of the SSA-1774-U5 if you need additional pages to explain the reason for the return. If you need more than the allotted ten continuation pages, use an SSA-1774A-U5 Continuation sheet.

3. How to access the continuation pages of the SSA-1774-U5

Item 11 on the first page of the SSA-1774-U5, and each continuation page, is recognized as a separate narrative field. At times, you must “work around” the space limitation (displayed in the “current field” attributes in each of the narrative fields) by selecting and moving some of the text to a continuation page. The pages are separate fields and text will not "wrap" like it would in a Word document.

  • To access continuation page 2, scroll down, and select the ["More"] button located at the bottom right of page 1.

  • To access additional continuation pages, scroll down, move the cursor to the far right margin, and select the ["More"] button.

4. How to sign the SSA-1774-U5

The name of the person who creates the SSA-1774-U5 form will propagate in the "REVIEWER" field at the bottom left of the SSA-1774-U5.

If the primary basis of the deficiency involves a medical, psychological, or psychiatric issue, you must manually enter at least one name in the "MEDICAL REVIEWER" field located under the "REVIEWER" field on the SSA-1774-U5.

If the primary basis of the deficiency does not involve a medical, psychological, or psychiatric issue, the "MEDICAL REVIEWER" field may be left blank.

The approving official must manually enter information in the "OFFICE", "APPROVED", and "DATE" fields. The “DATE” fields include those located at the top and bottom right of the SSA-1774-U5 and must coincide with the date the case returns to the adjudicating component.

5. How to upload the SSA-1774-U5 to the certified electronic folder (CEF)

To upload the final version of the SSA-1774-U5 to the CEF, select the form for upload at OQR’s case processing system clearance screen. Authorized SSA personnel may view the SSA-1774-U5 in the CEF.

GN 04440.510 Completing the SSA-5524-U3, Request for Assistance

A. Policy – SSA-5524-U3, Request for Assistance

Electronic assistance requests (AR) allow one processing component to contact another for assistance, while retaining full jurisdiction of the Certified Electronic Folder (CEF). Any component processing a CEF can initiate or receive an AR (e.g., Disability Determination Services (DDS), Office of Hearings Operations (OHO), and the Office of Quality Review (OQR)).

NOTE: Field offices (FO) receive, but cannot initiate, ARs.

Only the component with jurisdiction of the CEF can initiate an AR. The receiving component can update the CEF in response to the AR.

When a case contains work or earnings issues you must resolve prior to the final determination, contact the Field Office by creating and completing an SSA-5524-U3. In addition, create and complete an SSA-1774-U5 (Request for Corrective Action) to notify the adjudicating component of the deficiency. For an exhibit of the SSA-5524-U3 see GN 04440.915. For an exhibit of the SSA-1774-U5, see GN 04440.901.

B. Procedure – Completing the SSA-5524-U3

1. Completing the fields on the SSA-5524-U3

Complete all appropriate information throughout the SSA-5524-U3. All information must be accurate and complete for the FO to address the deficiency properly.

2. Completing the SSA-5524-U3 narrative

Select the “Assistance Needed” box and complete the narrative section as follows:

  • Explain what information is missing from the file and the actions you need the FO to take

  • Cite the evidence that supports your deficiency (document name, date, page number, etc.)

  • Exclude any information not relevant to the issue the FO must resolve (e.g., age, education, medical summaries, etc.)

  • Note the appropriate deficiency return diary date per GN 04440.202B, GN 04440.203B, and GN 04440.204B in the Diary Due Date box

  • Create a continuation page(s), SSA-5524A-U3, if needed, to continue your narrative

3. Completing the SSA-1774-U5 for use with the SSA-5524-U3

Complete or verify the demographic information in items 1 through 9. Verify or complete the header section in item 11 (Action Requested and Rationale) per GN 04440.501B.2.b.

Complete the Issue section with a one to two sentence statement of fact that quickly lets the reader know the reason for the return. You may also use one of these statements, as appropriate,:

  • There is insufficient work/earnings information to determine the correct onset date of disability.

  • There is insufficient work/earnings information to determine whether we can establish a period of disability.

  • There is insufficient information to determine when/whether the claimant ceased substantial gainful activity (SGA).

a. No DDS corrective action required

Under the Case Discussion and Policy Analysis header, you may complete a succinct explanation of the deficiency and why it was the DDS’ responsibility to resolve the issue (including any POMS reference(s)), or state, “Work/ Earnings issue referred to field office. See SSA-5524-U3 for details.”

Under the Request for Corrective Action header, enter the statement, “No corrective action required.”

Complete the signature blocks appropriately and date the form with the date you release the form to the adjudicating component.

NOTE: The review component’s management determines who signs the SSA-1774-U5.

b. DDS corrective action required

Complete the Case Discussion and Policy Analysis section describing the issues the DDS must address in accordance with GN 04440.501B.2.c. and GN 04440.501B.2.d.

For the issues addressed on the SSA-5524-U3, you may complete a succinct explanation of the deficiency and why it was the DDS’ is responsible for resolving the issue (including any POMS reference(s)). It is also sufficient to state, “Work (or Earnings) issue referred to field office. See SSA-5524-U3 for details.”

Complete the Request for Corrective Action section per GN 04440.501B.2.e.

Complete the signature blocks appropriately and date the form with the date you release the SSA-1774-U5 to the adjudicating component.

NOTE: The review component’s management determines who signs the SSA-1774-U5.

C. Disposition of the SSA-5524-U3 and the SSA-1774-U5

Upload the SSA-5524-U3 and the SSA-1774-U5 to the CEF prior to clearing the case from OQR's case processing system.

The FO receives an assistance request on the Electronic Disability Collect System Actions page and is able to view the SSA-5524-U3 in the CEF. The DDS receives notification via OQR’s weekly deficiency report and can view the SSA-1774-U5 in the CEF.

GN 04440.936 State-Specific Instructions for Acquiescence Rulings (AR)

State

Acquiescence Rulings

Alabama

Alaska

Chavez AR DI 52755.000ff

Arizona

Chavez AR DI 52755.000ff

Arkansas

Brock AR 14-1(8) DI 25003.001D

California

Chavez AR DI 52755.000ff

Colorado

Connecticut

Delaware

Sykes AR DI 52735.000ff

District of Columbia

FDDS

Florida

Georgia

Guam

Chavez AR DI 52755.000ff

Hawaii

Chavez AR DI 52755.000ff

Idaho

Chavez AR DI 52755.000ff

Illinois

Indiana

Iowa

Brock AR 14–1(8) DI 25003.001D

Kansas

Kentucky

Drummond AR DI 52705.001

Dennard AR DI 52706.001

Louisiana

 

Maine

Maryland

Albright AR DI 52715.001

Radford AR 15–1(4)

Massachusetts

Michigan

Drummond AR DI 52705.001

Dennard AR DI 52706.001

Minnesota

Brock AR 14–1(8) DI 25003.001D

Mississippi

Missouri

Brock AR 14–1(8) DI 25003.001D

Montana

Chavez AR DI 52755.000ff

Nebraska

Brock AR 14–1(8) DI 25003.001D

Nevada

Chavez AR DI 52755.000ff

New Hampshire

New Jersey

Sykes AR DI 52735.001

New Mexico

New York

Stieberger CC DI 32586.001

 

North Carolina

Albright AR DI 52715.001

Hyatt CC DI 32548.001

Radford AR 15–1(4)

North Dakota

Brock AR 14–1(8) DI 25003.001D

Ohio

Dennard AR DI 52706.001 Drummond AR DI 52705.001

Oklahoma

Oregon

Chavez AR DI 52755.000ff

Pennsylvania

Sykes AR DI 52735.001

Puerto Rico

Rhode Island

South Carolina

Albright AR DI 52715.001

Radford AR 15–1(4)

South Dakota

Brock AR 14–1(8) DI 25003.001D

Tennessee

Drummond AR DI 52705.001

Dennard AR DI 52706.001

Texas

Utah

Vermont

 

Virginia

Albright AR DI 52715.001

Radford AR 15–1(4)

Virgin Islands

Washington

Chavez AR DI 52755.000ff

West Virginia

Albright AR DI 52715.001

Radford AR 15–1(4)

Wisconsin

Wyoming


GN 04440 TN 116 - Federal Quality Review of Disability Determinations - 7/24/2020