Identification Number:
GN 04440 TN 75
Intended Audience:See Transmittal Sheet
Originating Office:OARO Office of Quality Review
Title:Federal Quality Review of Disability Determinations
Type:POMS Transmittals
Program:Disability
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM
Part GN – General
Chapter 044 – Quality Appraisal
Subchapter 40 – Federal Quality Review of Disability Determinations
Transmittal No. 75, 08/08/2019

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. Currently, the bulk of the information regarding technical corrective actions are in POMS sections, GN 04440.230 through GN 04440.243, GN 04440.947 and GN 04440.951. We are incorporating the information from all of these sections into GN 04440.230 Introduction to Technical Corrective Actions (TCAs), GN 04440.231 Substantive Technical Corrective Actions (TCAs) and GN 04440.232 Non-substantive Technical Corrective Actions (TCAs).

 

Summary of Changes

GN 04440.230 Technical Corrective Actions (TCAs) in General

The title of this POMS section was revised to Introduction to Technical Corrective Actions (TCAs).

In Subsection A: This section contains the basic definition of TCAs. It further explains that all TCAs fall into two basic categories, substantive and non-substantive.

In Subsection B: We define substantive TCAs and which TCAs are included in these categories. We refer the reader to revised section GN 04440.231 for a detailed definition of substantive TCAs and how they are to be corrected.

In Subsection C: We define non-substantive TCAs and which TCAs are included these categories. For non-substantive TCAs, we modernized some of the categories to reflect technical corrective actions that occur in the electronic environment. We refer the reader to revised section GN 04440.232 for a detailed definition of non-substantive TCAs and how they are to be corrected.

 

GN 04440.231 12-Month Medical Evidence of Record (MER) Technical Corrective Action (TCA)

The title of this POMS section was revised to Substantive Technical Corrective Actions (TCAs).

In Subsection A: We define substantive TCAs in more detail. In subsection A1, we define the regulation basis code TCA. We have renamed to “regulation basis code” from “decision basis code” to more accurately define the TCA.

In subsection A2, we define the “group I or group II deficiencies in a non-sample case and give an example. We included references to GN 04440.945 for definitions of group I deficiencies and GN 04440.946 for definitions of group II deficiencies.

In Subsection B: Subsection B is titled Correcting Substantive TCAs. We explain that substantive TCAs are corrected by the review component or returned to the adjudicating component based on case type.

In subsection B.1, we explain the steps for correcting a regulation basis code TCA when it occurs in an adverse reopening, a cessation or a reconsideration of an adverse reopening or cessation. In subsection B.2, we explain the steps for correcting a regulation basis code TCA when it occurs in all other case types. At the end of subsection B.2, we added the exception that if the regulation basis code is due to an obvious typographical error, we can correct without assuming jurisdiction of the case.

In subsection B.3, we explain how to correct incorrect actions in a non-sample case. We explain these are handled the same as a deficiency or TCA in a sample case but no deficiency is coded and the SSS-1774, if required, is labeled “informational”. We refer readers to GN 04440.204 through GN 04440.220 for how to correct group I and group II deficiencies and this section and GN 04440.232 for correcting TCAs.

 

GN 04440.232 Decision Basis Code Technical Corrective Action (TCA)

The title of this section was revised to Non-substantive Technical Corrective Actions (TCAs).

In Subsection A:

We define non-substantive TCAs in more detail.

In subsection A.1, we define the 12-month medical evidence of record (MER) TCA.

In subsection A.2, we define the diary entry TCA.

In subsection A.3, we define a medical or vocational documentation TCA.

In subsection A.4, we define a Notice TCA.

In subsection A.5, we define a determination form TCA.

In subsection A.6, we define a medical assessment form TCA. We expanded the definition to include all medical assessment forms that are either incorrect, missing, incomplete or not applied to the case to reflect the electronic process.

In subsection A.7, we define an un-imaged disability determination explanation (DDE) TCA. This is a new TCA occurring in the new electronic environment.

In subsection A.8, we define a mental impairment case TCA.

In subsection A.9, we define an unsigned consultative exam (CE) TCA.

In subsection A.10, we define an illegible or missing essential evidence TCA and update the definition to reflect the electronic environment.

In subsection A.11, we define the capability development TCA.

In Subsection B:

In subsection B, we title it Correcting Non-substantive TCAs. We explain that non-substantive TCAs are handled in several ways depending on the case type, the type of TCA or both.

In subsection B.1, we explain the steps for correcting a un-imaged DDE, illegible or missing medical evidence or unsigned CE report TCA. We further explain we will contact the designated adjudicating component contact for correction BEFORE completion of the review. We also added a note to explain the review component may still cite a group I or group II deficiency or another TCA after the information is secured.

In subsection B.2, we explain the steps for handling a medical or vocational documentation TCA. We explain that we do not notify the adjudicating component if these occur but we do apply probability of reversal and provide a rationale when this occurs. We further explain in the note if the quality reviewer is unable to determine whether missing medical or vocational documentation will change the determination or period of disability, a group I or II documentation deficiency exists.

In subsection B.3, we explain the steps for handling a diary entry, notice, capability development or determination form TCA. We will no longer notify the adjudicating component when these TCAs occur and the review component will make the corrections.

In subsection B.4, we explain the steps for handling a 12-month MER TCA. We will return the case to the adjudicating component, along with an SSA-847-U3, SSA Request For Case Action, for correction.

In subsection B.5, we explain the steps for handling a medical assessment form or mental impairment form TCA. We will assume jurisdiction, correct and notify the adjudicating component without returning the case. We provide a link to GN 04440.244 for instructions on assuming jurisdiction. We include a note at the end of this subsection to remind the reader of the cases where we are unable to assume jurisdiction.

 

GN 04440.233 Diary Entry Technical Corrective Action (TCA)

This section is being archived because the information in this section has been incorporated into sections GN 04440.230, GN 04440.231 and GN 04440.232.

 

GN 04440.234 Medical and Vocational Documentation Technical Corrective Actions (TCAs)

This section is being archived because the information in this section has been incorporated into sections GN 04440.230, GN 04440.231 and GN 04440.232.

 

GN 04440.235 Correcting Other Technical Corrective Actions (TCAs)

This section is being archived because the information in this section has been incorporated into sections GN 04440.230, GN 04440.231 and GN 04440.232.

 

GN 04440.236 Notices Requiring a Technical Corrective Action (TCA)

This section is being archived because the information in this section has been incorporated into sections GN 04440.230, GN 04440.231 and GN 04440.232.

 

GN 04440.237 Determination Forms Technical Corrective Action (TCA)

This section is being archived because the information in this section has been incorporated into sections GN 04440.230, GN 04440.231 and GN 04440.232.

 

GN 04440.238 Correcting Incorrect or Missing Residual Functional Capacity (RFC) Assessment and Psychiatric Review Technique Forms (PRTF)

This section is being archived because the information in this section has been incorporated into sections GN 04440.230, GN 04440.231 and GN 04440.232.

 

GN 04440.239 Correcting Cases with Other Missing or Incorrect Forms

This section is being archived because the information in this section has been incorporated into sections GN 04440.230, GN 04440.231 and GN 04440.232.

 

GN 04440.240 Mental Impairment Case Technical Corrective Action (TCA)

This section is being archived because the information in this section has been incorporated into sections GN 04440.230, GN 04440.231 and GN 04440.232.

 

GN 04440.241 Correcting Unsigned Consultative Examination (CE) Reports

This section is being archived because the information in this section has been incorporated into sections GN 04440.230, GN 04440.231 and GN 04440.232.

 

GN 04440.242 Correcting Cases with Essential Evidence that is Missing or Illegible

This section is being archived because the information in this section has been incorporated into sections GN 04440.230, GN 04440.231 and GN 04440.232.

 

GN 04440.243 Correcting Cases with a Capability Development Technical Corrective Action (TCA)

This section is being archived because the information in this section has been incorporated into sections GN 04440.230, GN 04440.231 and GN 04440.232.

 

GN 04440.947 Definitions of Other Technical Corrective Actions (TCA)

This section is being archived because the information in this section has been incorporated into sections GN 04440.230, GN 04440.231 and GN 04440.232.

 

GN 04440.951 Exhibit of Other Technical Corrective Action (TCA) Codes in the Office of Quality Review (OQR) Legacy System

This section is being archived because the information in this section has been incorporated into sections GN 04440.230, GN 04440.231 and GN 04440.232.

Conversion Table
Old POMS ReferenceNew POMS Reference
GN 04440.230GN 04440.230
GN 04440.231GN 04440.231
GN 04440.232GN 04440.232
GN 04440.233GN 04440.230
GN 04440.234GN 04440.230
GN 04440.235GN 04440.230
GN 04440.236GN 04440.230
GN 04440.237GN 04440.230
GN 04440.238GN 04440.230
GN 04440.239GN 04440.230
GN 04440.240GN 04440.230
GN 04440.241GN 04440.230
GN 04440.242GN 04440.230
GN 04440.243GN 04440.230
GN 04440.947GN 04440.230
GN 04440.951GN 04440.230

+

GN 04440.230 Introduction to Technical Corrective Actions (TCAs)

A. TCAs

A TCA is an instance of noncompliance with statutory, regulatory, or administrative requirements that impact effective program administration. There is no expectation for TCAs to affect the disability determination or the period of disability, but non-compliant policy case actions must be corrected. TCAs are:

  • Identified during the review process, but not covered by the formal group I or group II deficiency definitions; or

  • Identified in a non-sample case, regardless of whether the group I or group II deficiency definitions cover the incorrect action.

B. Substantive TCAs

A substantive TCA alters some element related to the conclusion in the case. Substantive TCAs include the regulation basis code TCA and incorrect actions in a non-sample case where the group I or group II deficiency definitions cover the incorrect action.

See GN 04440.231 for definitions, handling and correction of substantive TCAs.

C. Non-substantive TCAs

A non-substantive TCA does not have an impact on the conclusion of the determination.

Types of non-substantive TCAs include, but are not limited to:

  • 12-month medical evidence of record (MER)

  • Diary entry

  • Medical or vocational documentation

  • Notice

  • Determination form

  • Medical assessment form

  • Un-imaged disability determination explanation (DDE)

  • Mental impairment case

  • Unsigned consultative exam (CE)

  • Illegible or missing essential evidence

  • Capability development

  • Collateral estoppel documentation

See GN 04440.232 for definitions, handling and correction of non-substantive TCAs.

Regardless of whether the TCA is substantive or non-substantive, both types MUST be corrected.

GN 04440.231 Substantive Technical Corrective Actions (TCAs)

A. Substantive TCA definitions

A substantive TCA alters some element related to the conclusion in a case. The two types of substantive TCAs are discussed below.

1. Regulation basis code TCAs

A regulation basis code TCA, also known as a decision basis code TCA, occurs when the adjudicating component completes the regulation basis code incorrectly on either the:

  • SSA-831-C3/U3 (Disability Determination and Transmittal---Item 22, Regulation Basis Code),

  • SSA-832-C3/U3 (Cessation or Continuance of Disability or Blindness Determination and Transmittal-Title XVI---Item 11 or 12, “Reason For Continuance” or “Reason For Cessation), or

  • SSA-833-C3/U3 (Cessation or Continuance of Disability or Blindness Determination and Transmittal-Title II---Item 11 or 12, “Reason For Continuance” or “Reason For Cessation".

2. Group I or group II deficiencies in a non-sample case

Group I or group II deficiencies in a non-sample case (e.g., the non-sample claim in a concurrent title II/title XVI claim selected for the quality assurance sample) are considered a TCA.

See GN 04440.945 through GN 04440.946 for definitions of group I and group II deficiencies.

B. Correcting Substantive TCAs

Substantive TCAs are either corrected by the review component or returned to the adjudicating component for correction. The sections below explain the procedures for correcting substantive TCAs.

1. Regulation basis code TCA occurs in adverse reopenings, cessations or reconsiderations of adverse reopenings or cessations

The review component will:

  • notify the adjudicating component of the needed correction, via an SSA-847-U3, SSA Request for Case Action, and

  • return the case to the adjudicating component for correction.

2. Regulation basis code TCA occurs in all other types of cases

The review component will:

  • assume jurisdiction and prepare an amended determination.

  • prepare a new notice and rationale, if necessary.

  • enter the statement “SSA jurisdiction exercised. This amends the unapproved adjudicating component determination of MM/DD/YY”, in item 34 of the SSA-831 for initial or reconsideration claims.

  • enter the statement “SSA jurisdiction exercised. This amends the unapproved adjudicating component determination of MM/DD/YY", on the SSA-832 or SSA-833 for CDR claims.

  • prepare an SSA-847-U3, SSA Request For Case Action, explaining the reason for the regulation basis code change.

EXCEPTION: If the incorrect regulation basis code is due to an obvious typographical error, the review component may correct the regulation basis code entry on the determination form without assuming jurisdiction.

3. Group I and II deficiencies identified in a non-sample case

If the incorrect action occurs in a non-sample claim and the group I or group II deficiency or TCA definitions cover the incorrect action, the review component follows the corrective action procedures indicated for that deficiency or TCA.

NOTE: If an SSA-1774-U5 (Request For Corrective Action) is required, it will be labeled "Informational Only" and the review component will not code a deficiency in the disability case processing system.

See GN 04440.204 through GN 04440.220 for information regarding group I and group II deficiencies and GN 04440.232 for additional information regarding TCAs.

GN 04440.232 Non-substantive Technical Corrective Actions (TCAs)

A. Non-substantive TCA definitions

Non-substantive TCAs do not have an impact on the outcome of a disability determination, but must still be corrected. The most common types of non-substantive TCAs are defined below.

1. 12-month medical evidence of record (MER) TCA

An unfavorable or a less than fully favorable determination, without a group I or group II documentation deficiency, that does not contain 12-months of MER as required by policy and does not contain documentation to indicate that every reasonable effort was made to obtain the MER. (DI 22505.001)

2. Diary entry TCA

The established diary and the correct diary dates differ by more than three months.

3. Medical or vocational documentation TCA

The case file contains sufficient medical evidence to support the disability determination and the onset, ending, or cessation date, but the medical or vocational documentation does not conform to specific requirements in current operating policies and procedures.

4. Notice TCA

A personalized notice is required and the notice is:

  • missing,

  • incorrect,

  • unacceptable according to the best judgment of the quality reviewer, or

  • a special notice option, for an individual alleging blindness or a visual impairment, is required and there is no evidence to show the adjudicating component honored the individual’s preference.

5. Determination form TCA

There are non-substantive missing, incomplete or incorrect entries on the determination form. This includes:

  • SSA-831-C3/U3 (Disability Determination and Transmittal),

  • SSA-832-C3/U3 (Cessation or Continuance of Disability or Blindness Determination and Transmittal), or

  • SSA-833-C3/U3 (Cessation or Continuance of Disability or Blindness Determination and Transmittal).

6. Medical assessment form TCA

A group I decisional deficiency does not exist, but the medical assessment form is either incorrect, missing, incomplete or not applied to the case. This includes:

  • SSA-416 (Medical Evaluation)

  • SSA-2506-BK (Psychiatric Review Technique)

  • SSA-4734-BK (Physical Residual Functional Capacity Assessment)

  • SSA-538 (Childhood Disability Evaluation Form)

  • SSA-4734-F4 SUP (Mental Residual Functional Capacity Assessment)

7. Un-imaged disability determination explanation (DDE) TCA

The adjudicating component does not upload the DDE to the case upon closure.

8. Mental impairment case TCA

The determination is unfavorable, or less than fully favorable, the evidence in file indicates a mental impairment exists, and a qualified psychiatrist or psychologist in the adjudicating component did not review the case.

9. Unsigned consultative exam (CE) TCA

The determination is unfavorable, or less than fully favorable, and the case folder contains an unsigned CE report or a CE report signed by someone other than the provider.

10. Illegible or missing essential evidence TCA

Evidence critical to the determination is missing or illegible. Evidence is considered missing and essential when:

  • it is listed on the case development summary as obtained,

  • it is apparent from references in file that it was obtained, or

  • the image is illegible.

11. Capability development TCA

An allowance or continuance was proposed, but there is no capability development in file in accordance with current policy (DI 23001.005). This includes situations in which:

  • capability is unresolved, and the adjudicating component does not undertake the necessary development.

  • capability is resolved, and the adjudicating component incorrectly notifies the FO that capability development is necessary, either because they were unaware of, or overlooked, medical evidence in file indicating whether the claimant is capable.

  • capability development is complete, but the adjudicating component did not enter the capability statement in item 34 of the SSA-831 or items 24/24b of the SSA 832/833.

12. Collateral estoppel documentation TCA

A collateral estoppel determination missing either:

  • a final copy of the prior SSA-831-U3 or

  • a DDS case control query (DDSQ).

B. Correcting non-substantive TCAs

Corrections of non-substantive TCAs are handled in several ways depending on the case type, the type of TCA, or both. the sections below explain the procedures for correcting non-substantive TCAs.

1. Notification via email and correction before completion of review

In some cases, it is necessary for the review component to contact the adjudicating component and request they take a corrective action after the case is pulled for sample selection, but before completion of the quality review. The review component may not be able to complete an accurate and thorough review because necessary documentation is not present in the case and the review component is not able to correct the issue themselves. These types of TCAs include:

  • Un-imaged DDEs

  • Illegible or missing essential evidence

  • Unsigned CE report

When these situations occur, the review component will:

a. retain the case,

b. notify the adjudicating component contact found at OQR DDS Contacts, by email, to request the necessary documentation be added to the file,

c. set a reasonable deadline for adding or securing the information depending on the action required. For example, if a DDE needs to be closed and uploaded to the file, the adjudicating component would likely only need a couple of days to complete this action. If they have to secure another copy of essential MER, this may take more time and a longer deadline would be reasonable, and

d. continue the quality review as per normal policies and procedures once the information has been obtained from the adjudicating component and/or added to the case file.

e. complete an SSA-847-U3, SSA Request For Case Action, and route the case to the adjudicating component for correction, if the adjudicating component is unresponsive to the request for necessary documentation or is unable to obtain the documentation within a reasonable amount of time, i.e. 10 business days.

NOTE: The review component MAY still cite a group I or group II deficiency or another TCA after the documentation is secured.

2. No notification to adjudicating component needed, but a rationale is required

When the case contains a medical or vocational documentation TCA, the quality reviewer will:

a. make a probability of reversal (POR) determination,

b. complete the required POR rationale, and

c. route the case back to the field office.

See GN 04440.110 for specific POR instructions.

NOTE: If the review component is unable to determine whether missing medical or vocational documentation is likely to change the determination or period of disability, a group I or II documentation deficiency exists.

3. No notification to adjudicating component needed

The review component does not need to notify the adjudicating component when the case contains one of the following types of TCAs:

  • Diary entry

  • Notice

  • Capability development

  • Collateral estoppel

  • Determination form

When these TCAs occur, the review component will:

a. make the correction.

b. annotate corrections made to the determination form in item 34 on the SSA-831 or items 24/24b on the SSA-832/833 and identify the review component, if applicable.

c. annotate the incorrectly prepared notice “Do Not Release” in the electronic folder, if applicable.

d. annotate the incorrectly completed determination form “Do Not Process” in the electronic folder, if applicable.

e. route the case to the field office.

4. Case returned to the adjudicating component, along with an SSA-847-U3, SSA Request For Case Action, for correction

The review component must return the case to the adjudicating component, along with an SSA-847-U3, SSA Request For Case Action, when a 12-month MER TCA exists.

For a 12-month MER TCA, the review component will:

a. notify the adjudicating component, via an SSA-847-U3, SSA Request For Case Action, explaining what MER is missing and requesting the adjudicating component make every reasonable effort to obtain the missing MER and

b. route the case to the adjudicating component for correction.

5. Review component assumes jurisdiction and notifies adjudicating component via SSA-847-U3, SSA Request For Case Action, when the case is routed to the field office

The review component must notify the adjudicating component, via SSA-847-U3, SSA Request For Case Action, when the case contains a medical assessment form TCA or mental impairment TCA.

When these TCAs are present in the case, the review component will:

a. assume jurisdiction,

b. obtain needed correction(s) from a regional office medical or psychological contractor, as appropriate,

c. notify the adjudicating component of the correction, via SSA-847-U3, SSA Request For Case Action, and

d. route the case to the field office.

See GN 04440.244 for more specific information about assuming jurisdiction.

NOTE: Do not assume jurisdiction for cases when the next level of appeal is a disability hearing at reconsideration. This includes:

  • continuing disability review medical cessations,

  • adverse reopenings of favorable initial determinations based on medical factors,

  • adverse reopenings of reconsideration reversals based on medical factors and

  • adverse reopenings of cessations that change only the basis for the cessation.


GN 04440 TN 75 - Federal Quality Review of Disability Determinations - 8/08/2019