Identification Number:
DI 30005 TN 25
Intended Audience:See Transmittal Sheet
Originating Office:OARO Office of Quality Review
Title:Adjudicating Component Actions on Deficient Cases
Type:POMS Transmittals
Program:Disability
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. 25, 08/13/2019

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

The Office of Quality Review (OQR) is making editorial changes and completing updates throughout the quality review sections of POMS to improve consistency, add clarity, and ensure conformance with Plain Language Guidelines.

Summary of Changes

DI 30005.001 The Quality Review Process

We changed the title to, "Introduction to the Federal Quality Review Process", to better reflect the content of the section.

We removed Subsection A, in its entirety, as it is largely redundant and does not accurately reflect the information in the subsequent subsections.

The existing Subsection B was changed to Subsection A.

In Subsection A, we:

Added the word "the" after "of" in the title and spelled out "quality review" as "QR" is not an acronym recognized by OQR.

In Subsection A.1, we:

Changed the title to "The sample selection process".

Deleted the first two sentences entirely and reworded the first and second paragraphs to improve clarity and provide more detail regarding the sample selection process.

In A.2, we:

Changed the title from "OQR return criteria" to "Office of Quality Review (OQR) review criteria", as cases are reviewed first and then returned, if appropriate.

Replaced the verbiage with information related to review criteria.

In A.3, we:

Changed the title of the subsection to "OQR return criteria".

Changed verbiage to reflect information related to the title.

Added A.4 as a new section due to the addition of the first paragraph for sample selection.

The existing Subsection C was changed to Subsection B.

In Subsection B, we:

Changed the title from "Glossary of terms" to "Glossary of common quality review terms", to indicate that list was not intended to be all inclusive.

In B.1., we:

Changed the word "we" to "OQR" in several places.

Corrected verb tenses, where appropriate.

Changed the word "them" to "deficiencies" in the first sentence.

Reworded and reorganized the paragraph for clarity purposes.

Deleted the last sentence and moved that information to a "NOTE" under the paragraph.

In B.2, we:

Reworded the first sentence to improve clarity.

Made editorial changes in both bullets to increase clarity and improve sentence structure.

Removed the last sentence as it is not related to the section topic.

Section B.3 was removed as it is not related to the subsection topic.

"Group I deficiencies" was moved up to B.3.

In the new B.3, we:

Added "are substantive deficiencies that" after "Group I deficiencies" and changed the word "decision" to "determination" in the first sentence.

Removed the second sentence and the two bullets that follow, as that information is redundant.

Changed the word "types" to the phrase, "additional information regarding", and removed the word "of" following that phrase.

Added POMS reference GN 04440.003J. so the reader could see the definition of "substantive deficiencies".

"Group II deficiencies" was moved up from B.5 to B.4.

In the new B.4, we:

Removed the second sentence and the two bullets that follow, as that information is redundant.

Added POMS references for group II decisional and documentation deficiencies. (DI 30005.125 and DI 30005.126

"TCAs" was moved up from B.6 to B.5.

In the new B.5, we:

Removed the phrase, "formerly called group III deficiencies", as that name has been obsolete for years.

Made minor editorial changes to the first sentence to improve clarity and remove unnecessary verbiage.

Removed the comma from the end of the first bullet and replaced it with the bolded word "or".

"Performance accuracy" was moved up from B.7 to B.6.

In the new B.6, we:

Made editorial changes throughout the section to improve clarity and sentence structure.

"Probability of reversal" was moved up from B.8 to B.7.

In the new B.7, we:

Added the acronym "POR" to the title as this is the first reference to this phrase.

Removed "Probability of reversal" and the parentheses from the acronym "POR" in the first sentence as it is now defined in the title.

Made minor editorial changes to improve the clarity of the information.

"Review component" was moved up from B.9 to B.8.

In the new B.8, we:

Added the word "federal" after "SSA" and added verbiage to explain what constituted a "review component".

Added a new sentence to make it clear that internal quality assurance reviews by adjudicating components do not meet the definition of a "review component".

"Substitution of judgment in the QR process" was moved up from B.10 to B.9.

In the new B.9, we:

Added the acronym "SOJ" to the title as this is the first reference to this phrase.

Removed the acronym "QR" and replaced it with "quality review", as "QR" is not an acronym recognized by OQR.

Replaced "QR" with "quality review" in the first sentence.

Removed capitalization of the word "federal" where it was not appropriate.

Changed "consultant" to "contractor" throughout the section, as that is the updated term used by OQR.

Made editorial changes throughout the section to improve clarity and sentence structure.

Added a third paragraph to better explain the intent of SOJ.

Removed the POMS reference GN 04440.119, as that section is being archived when the new SOJ POMS is published.

"Determination supported or supportable" was moved up from B.11 to B.10.

In the new B.10, we:

Added quotation marks around the words "supported" and "supportable" in the first sentence.

Removed the example in the parentheses as it added little value to the subsection.

Changed the presented information from a paragraph into three bullets to improve clarity and add emphasis.

Added a closing sentence regarding deficient determinations.

Made editorial changes throughout the subsection to increase the clarity of the presented information.

 

DI 30005.001 Introduction to the Federal Quality Review Process

A. Description of the quality review process

1. The sample selection process

Federal quality reviews are national reviews of disability determinations that involve only certified electronic folder (CEF) cases. Prior to effectuation of a determination, an automated sampling process selects cases for federal quality review during an adjudicating component's case closure process.

When a case is selected for federal quality review, the adjudicating component receives an alert, via the National Disability Determination Services System (NDDSS). NDDSS and eView display an indicator when the case has been selected. Cases that are selected for quality review are electronically transferred to a federal review component.

2. Office of Quality Review (OQR) review criteria

OQR reviews sampled cases to ensure that the evidence supports the determination and the determination conforms to the Social Security Administration's (SSA) policies and procedures. When reviewing determinations, quality reviewers use the same policy and procedural guidelines adjudicating components use. For an explanation of the types of quality review samples, see DI 30005.005.

3. OQR return criteria

OQR may return a claim with a deficiency, or a technical corrective action (TCA), to the adjudicating component when the proposed corrections could affect the disability determination or period of disability, or when the overall determination does not adhere to certain technical requirements. For the definition of specific types of deficiencies and TCAs, see DI 30005.121 through DI 30005.127. For a description of the procedures for correcting deficiencies, see DI 30005.201 through DI 30005.241.

4. Adjudicating component rebuttal criteria

The adjudicating component may use the Informal Resolution Request (IRR) process, submit a Request for Program Consultation (RPC), or use the OQR rebuttal process, for any initial return group I or group II deficiency, when the adjudicating component does not agree with the review component. Adjudicating components may also use the IRR process for disagreements involving technical corrective actions (TCAs). However, adjudicating components may not submit TCA disagreements to RPC.

For instructions on rebuttal procedures, including IRR, see DI 30005.501 through DI 30005.510.

For RPC procedures, see DI 30007.000.

B. Glossary of common quality review terms

1. Deficiencies

Deficiencies are specified instances of noncompliance with SSA policies and procedures. OQR categorizes deficiencies as either group I or group II, according to their impact, or potential impact, on the disability determination. OQR further categorizes group I and group II deficiencies as either decisional or documentation deficiencies.

NOTE: TCAs are not categorized as deficiencies. See B.5. below for additional information on TCAs.

2. Categories of group I and group II deficiencies

Group I and group II deficiencies can be categorized as decisional or documentation deficiencies.

  • Group I and group II deficiencies are categorized as decisional deficiencies when a case is fully documented according to policy, but the adjudicating component made an incorrect determination to allow or deny or established an incorrect period of disability.

  • Group I and group II deficiencies are categorized as documentation deficiencies when the case requires additional medical and/or vocational development of evidence to make the correct determination or to determine the correct onset, ending, or cessation date.

3. Group I deficiencies

Group I deficiencies are substantive deficiencies that affect, or have the potential to affect, the basic determination to allow, deny, continue, or cease disability benefits.

For additional information regarding group I decisional and documentation deficiencies, see DI 30005.121 and DI 30005.123.

See GN 04440.003J. (Explanation of Quality Review Terms) for additional information regarding substantive deficiencies.

4. Group II deficiencies

Group II deficiencies are substantive deficiencies that affect only the onset date, ending date, or cessation date.

For additional information regarding group II decisional and documentation deficiencies, see DI 30005.125 and DI 30005.126.

5. TCAs

TCAs involve instances of noncompliance with procedural requirements that may impact effective disability program administration.

TCAs are incorrect actions:

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

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

TCAs may be either substantive or non-substantive.

For the TCA categories, see DI 30005.127.

6. Performance accuracy

Performance accuracy refers to the percentage of disability determinations not returned to adjudicating components for further development or correction and represents the reliability of the adjudicating component’s determinations. The definition of performance accuracy includes the measurement of factors with the potential to affect a determination and the accuracy of the determination, as explained in 20 CFR, §404.1643.

OQR only uses data from group I deficiencies, in initial quality assurance sample cases, to compute an adjudicating component’s performance accuracy rate, as explained in 20 CFR §404.1645.

7. Probability of reversal (POR)

POR is an administrative tool that only federal quality reviewers may use to distinguish returnable group I or group II documentation deficiencies from TCAs. The determining factor is whether obtaining missing documentation is likely to reverse the disability determination or change the period of disability. For a complete explanation of POR, see DI 30005.110 and GN 04440.110.

8. Review component

A review component is any SSA federal component that reviews disability determinations for accuracy and policy compliance as a primary job duty. Internal quality assurance reviews by adjudicating components do not meet this definition.

9. Substitution of judgment (SOJ) in the quality review process

One of the principles of quality review is that federal quality reviewers and regional medical contractors (MC) or psychological contractors (PC) must not substitute their judgment for that of the adjudicating component's MCs, PCs, or disability examiners. Federal quality reviewers and regional MCs and PCs must be aware of the SOJ concept, as a review principle, to ensure that they do not perform de novo case reviews. (For an explanation of de novo review, see GN 04440.003D.) Quality reviewers must be aware of SOJ, as a review principle, in potential decisional deficiency considerations.

When the adjudicating component's disability determination is compliant with SSA policy, federal quality reviewers and regional MC and PC staff must avoid substituting their judgment. In instances of SOJ, the review component will not cite a group I or group II decisional deficiency even if, after considering all the facts, they believe that the evidence directs a different determination.

The intent of the SOJ policy is to ensure that the review component does not cite a decisional deficiency, unless the adjudicating component has clearly not followed specific policy or procedure, or the evidence of record does not support the determination. If the adjudicating component's determination does not comply with SSA disability program policy, or if the evidence in a fully documented file does not support the determination, the review component will cite a group I or group II decisional deficiency.

For a complete explanation of SOJ, see GN 04440.118. For an explanation of SOJ and the medical review, see GN 04440.130B.

10. Determination supported or supportable

A determination is "supported" or "supportable" if it:

  • complies with SSA policy,

  • is not internally inconsistent, and

  • is substantiated by the preponderance of the evidence in file.

The review component will find a determination is deficient when it does not meet the supported or supportable determination standards.


DI 30005 TN 25 - Adjudicating Component Actions on Deficient Cases - 8/13/2019