• •

  QR selects a random sample of cases each month.

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  Quality reviewers in QR field sites throughout the country conduct reviews on the selected cases.

• •

  The quality review consists of one or more of the following actions by QR:

  1. a. 

     A review of the SSI claim or RZ or LI folder and other documents and records related to the SSI case;

  2. b. 

     A contact (mail or telephone) with the SSI recipient or representative payee; and

  3. c. 

     Contacts with third-party collateral sources of information.

• •

  QR prepares reports for publication and develops corrective action recommendations based on the review data. Recommendations may take the form of changes to the law, regulations, or policy and procedures.

QR field sites contact members of the public to complete their reviews.

1. a. 

   For Stewardship Reviews, the QR reviewer sends the SSI recipient or representative payee an appointment letter to schedule a telephone interview and explain the purpose of the review. The appointment letter or request notice provides the quality reviewer's name and a telephone number in the QR field site that the SSI recipient or representative payee can call with questions regarding the SSI QR.

2. b. 

   For TAR, the reviewer may send a request notice to the recipient or representative payee if they need further development for an issue.

The SSI recipient or representative payee may contact the field office (FO) or teleservice center (TSC) to verify the authenticity of the SSI QR or identity of the QR employee. When the TSC receives an inquiry, follow the instructions in TC 00101.035. When the FO receives an inquiry, the FO should follow the steps below to verify the identity of the interviewer and provide the individual with further assistance or information regarding the QR:

• •

  Open Outlook Exchange System and access the address book, known as the “Global Address List” (GAL). Use the GAL in Outlook to confirm that the reviewer is an employee of QR.

• •

  Did you verify the employee’s name?

  • –

    If yes, advise the caller that the individual is a QR employee who is responsible for contacting beneficiaries. Assure the caller that QR does request documents and or forms by mail for reviews.

  • –

    If no, treat this as a suspicious contact and prepare a report via the Allegation Referral Intake System (ARIS). Users may access ARIS from SSA's IMAIN page, select the ARIS - Allegation Referral Intake System link. The link to ARIS is also on the Fraud Security and PII and the Office of Program Integrity homepages.

You can find contact information for QR field sites at this link: QR Field Sites.

Quality Review (QR) requests field office (FO) folders for Stewardship review in limited situations to resolve coding issues, for analytical purposes, and to determine the accuracy of payments (e.g., recipient refuses to cooperate or cannot be located).

QR requests FO folders for Transaction Accuracy Review (TAR) sample cases where the Modernized System Indicator field of the Supplemental Security Record is coded “1” or “4” (indicating the FO established the case or processed a transaction outside of the Modernized SSI Claims System. FOs should forward any paper case file to the appropriate QR field site as shown on the email. Discuss problems in locating or sending the cases with the appropriate QR contact. If the FO is still developing the case, they should photocopy the case file materials needed in the FO and send the originals to QR.

QR makes all requests for FO action through the SSA-93 Quality Review website on an SSA-93 feedback form. There is a block in the response area of the website for each case called “Other” which states “Only Use If Applicable”. When the FO responds to an assistance request from QR for issues like those above, they select “Other” and use the comments area to reply to QR.

When finished, the website sends an automated email reply to QR and moves the case to the completed list. A copy of the SSA-93 is available on the website via a link if needed. Refer to the SSA-93 User Guide for more information.

TAR : When requested, reconstruct initial claims per GN 03105.010 and forward the case file to QR.

TAR : Attach a copy of the email notification to each folder as a transmittal slip and forward the case file to QR. Circle or highlight the name and account number of the folder sent.

Stewardship and TAR : If one of the following criteria applies, do not send the folder. Annotate the email with the criteria met, attach the supporting documentation, and send it to QR.

• •

  Reconsideration or hearing is pending with no decision. Attach a query showing an appeal is pending or a copy of the SSA-561-U2 or HA-501-U5.

• •

  An allegation of fraud has been referred to the Office of the Inspector General (OIG) through the Allegation Referral Intake System (ARIS). (Completed fraud allegations and status can be checked on the ARIS home page.)

• •

  Non-medical denial is input when a medical denial also exists. Attach a copy of Form SSA-831-U5.

• •

  Disability Quality Branch or Disability Determination Services reverses a medical allowance. Attach a query showing the claim in medical denial status.

If the FO agrees with the deficiency citation, the FO takes corrective action and reports completion via the Seattle SSA-93 Quality Review website. The FO must complete corrective action within 90 days from the date QR transmits the SSA-93 to the Quality Review website.

If the FO disagrees with an error, the FO should rebut the issue following the procedures outlined in GN 04461.030. The FO delays corrective action only on the contested issue.

If a recipient rebuts any determination of ineligibility, overpayment, or underpayment, the FO takes the necessary action to resolve the disagreement. If the results of the FO action are a reversal or modification of QR’s determination, the FO returns the development results to QR via the SSA-93 website so they can modify their database. The FO uses the comments area in the website to describe the necessary action and provides the location of any evidence stored electronically.

There may be situations, for example a system limitation exists, where the FO cannot correct the case in the manner requested on the SSA-93. This may occur if the Supplemental Security Record was in current pay when QR sent the SSA-93 but the record is now in terminated status and the FO must correct it using a different method. When this type of situation exists, the FO should document the file and the comments area of the SSA-93 website explaining why their action differs from the SSA-93.

If the FO agrees with QR’s findings, take corrective action within 90 days of the SSA-93 transmission to the Quality Review website. FO management must confirm all actions were taken before annotating the case is complete on the SSA-93 website.

There may be cases that require more than 90 days for correction. Examples include cases requiring;

• •

  cross component activities,

• •

  amended disability decisions, and

• •

  fraud or similar fault determinations.

• •

  To obtain more time for correction, the FO can request an extension past the 90-day deadline by submitting an email request to the ORC through the SSA-93 website with an estimate of the extra time needed, and a justification for the extension. Use the comments area of the website to record these items.

The ORC either grants or denies an extension request as follows:

• •

  document the SSA-93 website comments area with the determination and rationale for audit purposes, and

• •

  notify QR via email through the SSA-93 website with the name, SSN, reason for the extension, and the time granted.

• •

  the website will continue to send follow-ups at the regular scheduled intervals, however, there is an indicator to show that an extension was approved.

If the FO disagrees with QRs findings, they need to submit a rebuttal within 45 calendar days as outlined in GN 04461.030 and annotate the SSA-93 Quality Review website. If the final rebuttal decision affirms the deficiency, the FO takes corrective action within 90 days.

In order to ensure FOs take proper action on SSA-93 information, QR monitors the SSA-93 Quality Review website. QR reviews cases with a special indicator, known as High-Risk, when the FO annotates the case “complete” on the SSA-93 website.

The QR reviewer sends an email via the SSA-93 website to the responsible component within 20 calendar days including a description of the issue if;

• •

  The FO took no action, or

• •

  Their action was incomplete, or

• •

  The action was incorrect.

Upon receipt of the email, the FO should take the necessary action as timely as possible. The ORC/AC of OCO also receives a copy of the email to ensure the FO with jurisdiction completes the necessary action timely. The SSA-93 website sends a follow-up every 15 days. If the FO disagrees with the requested action, they should contact their regional office and have them contact QR for informal resolution of the issue.

When the QR reviewer determines all corrective actions are complete, they update the status of the case on the SSA-93 website to “Correct Action Taken” within 20 calendar days of receipt of the case. This moves the case to the completed listing.

In certain situations, QR may discover that the SSI recipient is potentially entitled or eligible for other benefits. The FO develops the potential entitlement or eligibility per SI 00510.000 and updates the SSA-93 Quality Review website. Review the website to ensure all corrective actions are complete.

QR uses Evidence Portal (EP) to scan the wage verification to NDRED or attaches it to the SSA-93. QR includes complete wage documentation for the period covered by the QR review so the FO does not have to re-contact the recipient or the employer and redevelop the same period(s).

However, in some cases, there may be additional development required to update wages for months within the administrative finality period that were not included in QR’s period of review. The SSA-93 identifies this additional development as an informational issue that the FO must complete.

If the QR field site disagrees with the FO rebuttal or revises the error but FO corrective action is still required, they annotate the SSA-93 website. The QR field site also directs an email via the website to the Division of Title 16 Quality and Service Evaluation (DT16QSE) in QR central office stating the rationale for affirming the original determination in the website comments area within 15 calendar days after the receipt of the rebuttal.

The website also notifies the FO and ORC via email that the case was referred to DT16QSE for a final review and determination.

If, through informal discussions, the FO subsequently agrees with the QR decision, the QR field site notifies DT16QSE by email of the FO agreement. DT16QSE updates the website to affirm the error finding and return jurisdiction to the FO for necessary action.

If the QR field site reverses its decision, they make any necessary changes to the QR system and notifies the FO and the ORC of the modified decision by email via the SSA-93 website within 15 calendar days after receipt of the rebuttal.

If the QR field site agrees that the decision is unsupported and needs additional development, they complete the development. When finished, QR issues a revised SSA-93 to the FO establishing a new potential rebuttal period if FO corrective action is required.

When QR requests assistance, the FO should attempt to locate the recipient.

Respond to the QR SSA-93 via the SSA-93 website using the “Other” option indicating one of the following in the comments area:

• •

  FO contacted the recipient – include the current residence address, mailing address, and telephone number; and the recipient agreed to cooperate with QR;

• •

  FO contacted the recipient – include the current residence address, mailing address, and telephone number; and the recipient refuses to cooperate with QR; or

• •

  FO cannot locate the recipient, they suspended the recipient’s benefits, or they referred the case to the Office of the Inspector General.

The FO interviews the recipient or representative payee and takes the following actions:

• •

  Determines the reason for refusal to cooperate, attempts to dispel any fears;

• •

  Obtains a promise of future cooperation. Inform the recipient or representative payee that QR will re-contact them to complete the interview. Document the FO’s interview on a Report of Contact (RC);

• •

  Responds to the QR SSA-93 using the “Other” option with an explanation of the actions taken in the comments area of the SSA-93 website, include the location of the RC, and the following;

• •

  Indicate whether the:

  1. a. 

     recipient or representative payee refuses to cooperate with the FO,

  2. b. 

     FO suspended benefits;

  3. c. 

     FO appointed a new payee; or

  4. d. 

     FO referred the case to OIG (For due process, see SI 02301.300); and

• •

  Refer to the electronic location of any relevant documentation.

If QR finds that the recipient cannot complete an interview or provide evidence, they will request FO assistance. Upon receiving a request for assistance, the FO should:

• •

  Contact the recipient and determine if payee development is necessary.

• •

  Use the “Other” option on the SSA-93 website to provide QR with the name and telephone number of the person who will act on the recipient's behalf, or indicate that the recipient is now able to respond.

When finished, send an email reply to QR through the website. A copy of the SSA-93 is available on the website via a link if needed. Refer to the SSA-93 User Guide for more information.