Identification Number:
DI 30005 TN 41
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. 41, 07/28/2020

Audience

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

Originating Component

OQR

Effective Date

Upon Receipt

Background

This is a Quick Action Transmittal. These revisions do not change or introduce new policy or procedures. This POMS is being revised to make minor grammar, punctuation, and technical corrections, to improve clarity, and to update obsolete POMS references.

 

Summary of Changes

DI 30005.110 Probability of Reversal (POR) in the Quality Review Process

In Section A., we:

Updated the POMS references in both sets of parentheses in the third sentence.

In Section C.2., we:

We updated the POMS reference in the last paragraph after the bullets.

In Section D.5.c., we:

Added the closing parentheses after the eCAT acronym.

 

DI 30005.110 Probability of Reversal (POR) in the Quality Review Process

A. POR definition

POR is an administrative tool used by federal quality reviewers. When a case does not contain complete medical or vocational documentation, as required by the Social Security Administration (SSA) disability program policy, federal quality reviewers must decide whether obtaining additional documentation is likely to reverse the disability determination or change the length of the period of disability. Federal quality reviewers cannot consider or apply POR to decisional deficiencies (See GN 04440.202 and GN 04440.204 for additional information on decisional deficiencies.) or documentation deficiencies (See GN 04440.203 and GN 04440.204 for additional information on documentation deficiencies).

The federal quality reviewer uses the POR process, as described in section D below, to determine whether a non-substantive deficiency (Technical Corrective Action (TCA)) or a substantive deficiency (Group I or Group II documentation deficiency) exists in a case.

The purpose of POR is to avoid the unnecessary use of resources.

B. Who makes POR determinations

Only federal quality reviewers can make POR determinations. An adjudicating component cannot use POR in deciding whether to request required medical or vocational documentation or as the basis for a rebuttal of a cited deficiency. (See DI 22505.001 for additional information regarding evidence requirements.)

The consideration or application of POR is solely at the discretion of the federal quality reviewer.

Under the POR policy, if a disability determination is not documented per SSA disability program policy, but the evidence is sufficient for the federal quality reviewer to determine that the missing documentation is unlikely to reverse the disability determination or change the length of the period of disability, the federal quality reviewer may classify the missing documentation as a medical or vocational documentation TCA, as defined in GN 04440.232A.3., and not return the case to the adjudicating component for further development and correction.

When a case does not contain complete medical documentation per SSA disability program policy, the federal quality reviewer must send the case to the regional office medical contractor (MC) and/or psychological contractor (PC) for review prior to making a POR determination. The regional office MC or PC will generally either indicate the evidence is insufficient to determine the severity of any alleged impairment(s) or prepare a conditional severity rating (CSR) (usually a residual functional capacity (RFC)) based on the existing evidence in file. A regional office MC and/or PC may prepare a CSR when the medical evidence in file is insufficient to rate the overall severity of all of the claimant's allegations, but is sufficient to prepare an assessment of the severity of one or more medically determinable impairments (MDI). Regional office MCs or PCs may also offer opinions on the potential effect of missing documentation on impairment severity or RFC. However, these opinions are not binding on the federal quality reviewer. Federal quality reviewers should exercise caution when using a CSR to support a POR determination when the disability determination is unfavorable or less than fully favorable.

NOTE: In unfavorable or less than fully favorable determinations, there is a statutory requirement that adjudicators must "consider all evidence available in such individual's case record, and shall develop a complete medical history of at least the preceding twelve months for any case in which a determination is made that the individual is not under a disability." See Section 223(d)(5)(B) of the Social Security Act. Federal quality reviewers must return 12-month medical evidence of record (MER) TCAs, which are limited to unfavorable or less than fully favorable determinations, to the adjudicating component for additional development and correction. See GN 04440.232A.1. (Non-substantive Technical Corrective Action (TCA)) for additional information. Adjudicators and federal quality reviewers are reminded that in some cases, such as those involving traumatic or acute illnesses or injuries, 12 months of evidence may not be available.

If the federal quality reviewer determines that the missing documentation is likely to reverse the disability determination or change the length of the period of disability, or if the federal quality reviewer is unable to determine whether the missing documentation may reverse the disability determination or change the length of the period of disability, the federal quality reviewer will cite a group I or group II documentation deficiency and return the case to the adjudicating component for further development and correction.

C. When to consider and/or apply POR

1. Level of adjudication

Federal quality reviewers may consider and/or apply POR to all types of determinations (i.e., fully favorable, less than fully favorable, or unfavorable). For fully favorable determinations, the federal quality reviewer may consider and/or apply POR at the initial and reconsideration level. For less than fully favorable and unfavorable determinations, the federal quality reviewer may consider and/or apply POR, but only at the initial filing level.

When the next level of appeal is a hearing, the federal quality reviewer cannot apply POR because an administrative law judge is required to fully document the case record. If the only reason for returning a case to the adjudicating component is to complete the record in the event of a hearing, the case contains a TCA, not a group I or group II documentation deficiency, and the federal quality reviewer will return the case to the adjudicating component for additional development.

REMINDER: Federal quality reviewers cannot consider or apply POR to disability determinations originating from the remaining prototype states.

2. Deficiency type

Federal quality reviewers may consider and/or apply POR for:

  • Group I medical documentation deficiencies

  • Group I vocational documentation deficiencies

  • Group I medical evaluation deficiencies involving vocational documentation

  • Group II onset date documentation deficiencies

  • Group II ending date documentation deficiencies

  • Group II cessation date documentation deficiencies

  • Group II work activity documentation deficiencies

See GN 04440.950, Exhibit of Group I and Group II Deficiency Codes in the Office of Quality Review (OQR) Case Processing System, for additional information regarding deficiency types.

D. Guidelines for making the POR determination

Federal quality reviewers should use the following guidelines to make a POR determination. Federal quality reviewers will seek input from regional office MCs and/or PCs if the specific facts of a case require MC and/or PC review or the federal quality reviewer deems such input beneficial.

1. Step 1

The federal quality reviewer will thoroughly review the sample case per normal procedures.

If the existing medical and vocational documentation is sufficient to support the adjudicating component’s determination and is policy compliant, the federal quality reviewer will clear the case as clean and route it to the Field Office (FO).

2. Step 2

If the federal quality review of the sample case reveals the existing medical and vocational documentation reasonably appears to support the adjudicating component’s determination, but the efforts made to obtain documentation are not fully policy compliant, the federal quality reviewer may consider POR.

3. Step 3

The federal quality reviewer will specifically identify what medical or vocational documentation is missing and what policies the adjudicating component failed to follow when developing the documentation.

4. Step 4

The federal quality reviewer will determine what level of impairment severity, RFC, and/or vocational factors would reverse the disability determination or change the length of the period of disability.

EXAMPLE: If an unfavorable determination is not documented per policy, and the claimant is 25 years old with a high school education and has the capacity to perform a full range of sedentary work, the claimant's impairment(s) will generally have to meet or medically equal the listings for the missing documentation to reverse the disability determination. Thus, a TCA would generally be prudent in this case.

EXAMPLE: If an unfavorable determination is not documented per policy, and the claimant is 56 years old with a fifth grade education and does not retain the capacity for past relevant work (PRW), a moderately severe impairment and certain functional limitations, potentially found in the missing documentation, are much more likely to reverse the disability determination. Thus, citing a group I documentation deficiency would generally be prudent in this case.

5. Step 5

If the federal quality reviewer, based on disability policy knowledge and quality review case experience:

  1. a. 

    surmises that the missing medical or vocational documentation is likely to reverse the determination or change the length of the period of disability, the federal quality reviewer will cease consideration of POR, cite the appropriate documentation deficiency on a SSA-1774-U5 (Request for Corrective Action), document consideration of POR on the SSA-1774-U5 (See section E below for POR documentation requirements.), and return the case to the adjudicating component for additional development and correction.

  2. b. 

    cannot reasonably ascertain whether the missing documentation is likely to reverse the determination or change the length of the period of disability, the federal quality reviewer will cease consideration of POR, cite the appropriate documentation deficiency on a SSA-1774-U5, document consideration of POR on the SSA-1774-U5 (See section E below for POR documentation requirements.), and return the case to the adjudicating component for additional development and correction.

  3. c. 

    surmises that the missing medical or vocational documentation is unlikely to reverse the determination or change the length of the period of disability, the federal quality reviewer must document application of POR using a claims communication (for cases completed in the Electronic Claims Analysis Tool (eCAT)) or an SSA-5002 (Report of Contact). See section E below for POR documentation requirements.

NOTE: The POR process is inherently subjective and difficult to define precisely. POR is most likely to be considered or applied with unfavorable determinations, but can also be used with favorable determinations.

E. Documenting application and consideration of POR

1. POR applied

When an adjudicating component does not fully document a case according to SSA disability program policy, and the federal quality reviewer applies POR instead of returning the case to the adjudicating component for correction, the federal quality reviewer must document the file with a rationale explaining the application of POR. The federal quality reviewer's rationale must provide subsequent adjudicators and reviewers with an understanding of why the federal quality reviewer did not return the case to the adjudicating component for additional development and correction.

When POR is applied, the federal quality reviewer must document the file with a claims communication (if using the Electronic Claims Analysis Tool (eCAT)) or an SSA-5002 (Report of Contact), stating, verbatim, the following:

The Office of Quality Review used probability of reversal, as explained in GN 04440.110 and DI 30005.110, to determine that obtaining additional evidence is unlikely to reverse the disability determination or change the length of the period of disability. This case contains a medical or vocational documentation technical corrective action. No adjudicating component action is required.

The federal quality reviewer's POR rationale must also contain a brief summary of the case facts, what specific documentation is missing, and why obtaining the missing documentation is unlikely to reverse the disability determination or change the length of the period of disability.

2. POR considered, not applied

When the adjudicating component does not fully document a case according to SSA disability program policy, and the federal quality reviewer determines the missing documentation has the potential to reverse the disability determination or change the length of the period of disability, or the likelihood of such cannot be determined, the federal quality reviewer will document consideration of POR on the SSA-1774-U5, stating, verbatim, the following:

The Office of Quality Review considered probability of reversal for this case, as explained in GN 04440.110 and DI 30005.110, to determine that the missing documentation has the potential to reverse the disability determination or change the length of the period of disability, or the likelihood of such could not be determined. Adjudicating component action is required.

If a federal quality reviewer considers POR, but ultimately decides to return the case to the adjudicating component for further development and correction, the paragraph above should appear on the SSA-1774-U5. There is no need for the federal quality reviewer to provide further information regarding POR consideration, as the content of the SSA-1774-U5 must delineate the reason(s) the federal quality reviewer cited a documentation deficiency.

F. When not to consider or apply POR

When the medical evidence in the file is insufficient to establish impairment severity and/or to determine the length of the period of disability, federal quality reviewers should not apply POR. Federal quality reviewers should classify the missing documentation as a group I or group II medical documentation deficiency, as the facts of each case warrant. What constitutes "insufficient medical evidence" depends on the specific facts of the case under review and the nature of the medical evidence, if any, in the file.

1. Insufficient medical evidence in initial and reconsideration cases

If the medical evidence in the file is insufficient, federal quality reviewers should classify the missing documentation as a group I medical documentation deficiency, without making a POR determination, in the following situations:

  • The only medical evidence in the file consists of a diagnosis without any acceptable clinical or laboratory findings to establish a MDI. See DI 24501.020 for additional information regarding MDIs.

  • The only medical evidence in the file is unrelated to the alleged disabling impairment(s) (e.g., the medical evidence is about colds, flu, or other generally short-lived minor ailments when only a mental health impairment is alleged).

  • The only medical evidence in the file is irrelevant (e.g., evidence pertains to someone other than the claimant).

  • There is no medical evidence in the file.

  • The only medical evidence in the file is not from, or signed by, an acceptable medical source (AMS), as defined in DI 22505.003A.

NOTE: In rare situations, an adjudicator can make a disability determination, without evidence from an AMS, when the claimant has an obvious impairment (e.g., amputations as described in listing 1.05A. or 101.05A. or total blindness due to the loss of both eyes). Federal quality reviewers should not cite a medical documentation deficiency if the claimant's impairment(s) meets the requirements in DI 22505.012B.2. (Development Issue --- No Evidence Furnished from an Acceptable Medical Source).

2. Insufficient medical evidence in continuing disability reviews (CDR)

If a MDI was previously established, the adjudicating component needs medical evidence from a medical source (which need not be an AMS) to determine whether there is medical improvement (MI). For the definition of a "medical source", see DI 22505.001A.4. (Medical and Nonmedical Evidence).

For an exception to the medical source requirement in "medical improvement not expected" (MINE) CDR cases, see DI 28040.115 (Verification of Continued Impairment Severity --- General) and DI 28040.125 (Determining the Need for a Medical Source or Third Party Contact in Medical Improvement Not Expected (MINE) or MINE-Equivalent Cases).

If it is necessary to establish a new MDI, SSA disability program policy requires medical evidence from an AMS. For examples of an AMS, see DI 22505.003A. (Evidence from an Acceptable Medical Source (AMS)).

If the medical evidence in the file is insufficient, the federal quality reviewer will classify the missing documentation as a group I medical documentation deficiency, without making a POR determination, when a CDR determination has been made in a "medical improvement expected" (MIE) or "medical improvement possible" (MIP) diary case, and one (or more) of the following is true:

  • The file does not contain sufficient evidence from a medical source to determine current severity or functioning.

  • The only evidence from a medical source is an opinion that is not supported by acceptable clinical or laboratory findings (e.g., the medical evidence contains only a statement regarding whether there has been any MI).

  • The evidence from a medical source is unrelated to the alleged disabling impairment (e.g., the medical evidence is about colds, flu, or other generally short-lived minor ailments when only a mental health impairment is alleged).

  • The evidence from the medical source is irrelevant (e.g., the evidence pertains to someone other than the claimant).

3. Insufficient vocational evidence

If the vocational evidence in the file is insufficient to rule out the performance of PRW, federal quality reviewers should not apply POR. Federal quality reviewers should classify the missing documentation as a group I vocational documentation deficiency, as the facts of each case warrant. What constitutes "insufficient vocational evidence" depends on the specific facts of the case under review.

If the vocational evidence in the file is insufficient to rule out the performance of PRW, federal quality reviewers should classify the missing documentation as a group I vocational documentation deficiency, without making a POR determination, regardless of how limited the proposed RFC or mental residual functional capacity (MRFC) may be.

EXCEPTION: The federal quality reviewer should not cite a group I vocational documentation deficiency if the vocational expedite described in DI 25005.005 (Expedited Vocational Assessment at Steps 4 and 5 of Sequential Evaluation) applies to the case under review.


DI 30005 TN 41 - Adjudicating Component Actions on Deficient Cases - 7/28/2020