Identification Number:
GN 04440 TN 119
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. 119, 07/28/2020

Audience

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

Originating Component

OQR

Effective Date

Upon Receipt

Background

We are changing the language on how medical forms are completed based on updates to policy and terminology.

 

Summary of Changes

GN 04440.520 Completing the SSA-3023-F3, Medical Consultant's Review of Psychiatric Review Technique Form

We removed the word "required" or reworded the language when noting that an SSA-3023 needs to be created, especially when a PRTF is in file.

GN 04440.520 Completing the SSA-3023-F3, Medical Consultant's Review of Psychiatric Review Technique Form

A. Background on using the SSA-3023-F3

1. Purpose of the SSA-3023-F3

Use the SSA-3023-F3 to:

  • facilitate the medical contractor's (MC) or psychological contractor's (PC) review of the SSA-2506-BK, Psychiatric Review Technique Form (PRTF), prepared by the adjudicating component and

  • record MC or PC agreement or disagreement with the PRTF in file.

See GN 04440.925 for an exhibit of the SSA-3023-F3.

2. When to complete an SSA-3023-F3

The MC or PC may complete an SSA-3023-F3 when an adjudicating component's PRTF is in the file.

NOTE: Creation of multiple PRTFs may be necessary for separate periods of disability or for different titles within the same claim.

NOTE: Use the SSA-3023-F3 to establish agreement or disagreement with the adjudicating component prepared PRTF. If the review component assumes jurisdiction, the reviewing MC or PC completes an SSA-2506-BK, as described in GN 04440.135B.1.

3. When not to complete an SSA-3023-F3

The MC or PC does not complete an SSA-3023-F3 when:

  • the adjudicating component should have prepared a PRTF, but did not, or

  • the PRTF in file is unsigned.

NOTE: The MC or PC use an SSA-416 (Case Analysis) to address the issue(s), as described in GN 04440.520A.3.

B. Procedure for completing the SSA-3023-F3

1. Heading (SSN through Level of Claim)

The items in the heading are self-explanatory. It is important to check this information for accuracy.

2. Part I - Summary of Agreement/Disagreement

  • Complete Part I after reviewing the case and the completed PRTF in file.

  • Record only substantive disagreements. A substantive disagreement exists when the adjudicating MC or PC's conclusion is not supported by the evidence.

  • Check the N/A block if any item, I.A. through I.D., does not apply to the case.

NOTE: A substantive disagreement does not exist when the evidence supports the adjudicating MC or PC's conclusions, but the reviewing MC or PC disagrees with the interpretation of that evidence. This is a difference of medical opinion.

3. Part I.A. - Categories of Disorders

  • This item refers to section II.A.-I., "Documentation of Factors That Evidence the Disorder", in the PRTF.

  • A substantive disagreement exists when the reviewing MC or PC disagrees with the category(ies) of disorders that was used to evaluate the case, not with the individual signs, symptoms, and findings that follow the category(ies) of disorders and capsule definition(s), except listing 12.05.

    NOTE: You can only conclude the existence of a particular category of disorder when the capsule definition that follows the category of disorder is satisfied.

  • For impairment category 12.05, the signs, symptoms, and findings contained in items 1. through 4. of section II.D. of the PRTF serve both to substantiate the existence of the disorder and establish its severity. Therefore, a substantive disagreement exists when the reviewing MC or PC disagrees with the adjudicating MC or PC's assessment of these items.

4. Part I.B. - Rating of Functional Limitations

  • This item refers to section III.A.1.-4., "Rating of Functional Limitations", of the PRTF.

  • The "degrees of limitation" found in section III.A of the PRTF can be selected to differentiate the major levels of functional limitation.

  • If the reviewing MC or PC disagrees with the rating of these functional limitations, a substantive disagreement may exist.

5. Part I.C. - Listing 12.02C, 12.03C, or 12.04C in Remission

  • This item refers to section III.B.1. of the PRTF.

  • A substantive disagreement exists when the MC or PC's evaluation establishes that this criterion is present, or absent, or that the evidence in file is insufficient, and the PRTF evaluation is contrary to the reviewing MC or PC's evaluation.

6. Part I.D. - Listing 12.06C

  • This item refers to section III.B.2. of the PRTF.

  • If the reviewing MC or PC's evaluation differs from that found on the PRTF, a substantive disagreement exists.

7. Part I.E. - Medical Disposition

  • This item refers to the final outcome of the case, which is found in section I.B.1.through 8. of the PRTF.

  • A substantive disagreement is present when the reviewing MC or PC's final evaluation differs from that shown on the PRTF.

8. Part II - Narrative Discussion

Complete Part II for substantive disagreements, as indicated in Part I.

Prepare a detailed, narrative discussion citing specific evidence (history, signs and symptoms, daily activities, etc.) that supports the reviewing MC or PC's differing conclusions. If the disagreement is due to missing or incomplete evidence, identify the needed evidence and explain why the evidence is necessary.

NOTE: The reviewing MC or PC may discuss in Part II any other issue believed to be pertinent in review of the PRTF (e.g., onset, duration).

9. Medical Consultant Signature

Sign and enter the MC code and date.

C. Process for Central Office (CO) MC or PC for the SSA-3023-F3

If the CO MC or PC directly reviews an adjudicating component’s case that contains a PRTF, the MC or PC completes an SSA-3023-F3.


GN 04440 TN 119 - Federal Quality Review of Disability Determinations - 7/28/2020