Effective Dates: 8/14/2025 - Present

Identification Number:
QR 04440 TN 18
Intended Audience:OQR
Originating Office:OARO Office of Quality Review
Title:Federal Quality Review of Disability Det
Type:POMS Full Transmittals
Program:All Programs
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM

Part QR – Quality Review

Chapter 044 – Quality Appraisal

Subchapter 40 – Federal Quality Review of Disability Det

Transmittal No. 18, 08/14/2025

Originating Component

OQR

Effective Date

Upon Receipt

Background

Quality Review is moving content from Part GN Chapter 044 to the appropriate Part QR Chapter 044. This transmittal does not change policy or introduce new procedure.

Summary of Changes

QR 04440.118 Substitution of Judgment (SOJ) in the Quality Review Process

We copied GN 04440.118 to establish QR 04440.118

QR 04440.501 Completion of the SSA-1774-U5, Request for Corrective Action

We copied GN 04440.501 to establish QR 04440.501

QR 04440.505 Completing the SSA-847-U3, SSA Request for Case Action

 

We copied GN 04440.505 to establish QR 04440.505

QR 04440.118 Substitution of Judgment (SOJ) in the Quality Review Process

 

Federal quality reviewers assess the conformance of disability determinations to the Social Security Administration's (SSA's) regulations, rulings, Program Operations Manual System (POMS) policy and instructions, and to the documented facts in the case.

Federal quality reviewers cite deficiencies when:

  • •

    the adjudicating component's disability determination is inconsistent with the evidence,

  • •

    the evidence is insufficient to support a policy-compliant determination, or

  • •

    the determination does not meet a specific procedural or technical policy requirement.

A. Defining SOJ

The disability determination process is inherently judgmental. Sometimes, adjudicating and reviewing components reach different disability conclusions, in a case that is fully documented per policy, after considering the same facts and evidence. In the absence of any of the three issues listed above, a differing opinion and/or disability conclusion from a quality reviewer, regional office medical contractor (ROMC), or medical advisor is SOJ and contrary to SSA policy.

EXAMPLE 1 of SOJ

An adjudicating component requested medical evidence, followed up with all of the claimant's treating sources per policy guidelines, obtained a complete vocational history, and obtained functional information from the claimant. The case is fully documented in accordance with SSA policy.

The adjudicating component medical consultant reviewed all of the evidence in the file and determined the claimant retained the physical capacity to lift and carry 20 pounds occasionally and 10 pounds frequently and stand, walk, and sit 6 hours in an 8-hour workday. The adjudicating component medical consultant found no additional limitations and explained all supporting evidence findings on the residual functional capacity (RFC) form. This proposed assessment would result in an allowance.

The ROMC reviewed all of the evidence in the file and determined the claimant retained the physical capacity to lift and carry 50 pounds occasionally and 25 pounds frequently. The ROMC affirmed the capacities to stand, walk, and sit for 6 hours in an 8-hour workday. This proposed assessment would result in a denial.

The ROMC explained the disagreement with the adjudicating component, but did not indicate that the adjudicating component medical consultant overlooked material findings or evidence or misapplied any SSA policy. In other words, the ROMC did not provide any evidence or policy-based reason not to accept the assessment proposed by the adjudicating component medical consultant.

The ROMC and the adjudicating component medical consultant used the same evidence to arrive at different RFC assessments and, ultimately, different disability determinations. This constitutes SOJ by the ROMC and is prohibited by SSA policy. In this example, the ROMC must accept the adjudicating component medical consultant assessment and affirm the proposed allowance.

EXAMPLE 2 of SOJ

The claimant is advanced age with an RFC for unskilled light work.

On the SSA-3369, the claimant reported one relevant job as a cashier at a retail store, listing the following duties: used a cash register to total purchases; issued receipts to customers; received cash/credit card payments; verified that cash provided by customers matches the items purchased; cashed checks; processed refunds; counted money in cash drawer and prepared reports of transactions; stocked shelves once a month.

The adjudicating component provided a rationale noting that Occubrowse shows several cashier related jobs, but the combination of cashier duties and occasional stocking duties in a retail setting resemble Dictionary of Occupational Titles (DOT) 211.462-014 (Cashier-Checker, SVP 3, Strength – Light). Therefore, the claimant does not meet the mental demands associated with the Cashier-Checker job, which results in an allowance.

The review component indicated the DOT counterpart proposed by the adjudicating component is not supported and DOT 211.462-010 (Cashier II, SVP 2, Strength – Light) is a more appropriate match. This DOT counterpart is within the confines of the claimant’s physical and mental RFC. While the proposed DOT alternative would lead to a step four denial, the review component did not identify any vocational assessment oversights or instances of policy noncompliance.

The adjudicating and review components arrived at conflicting determinations despite a shared evidentiary basis. This constitutes SOJ by the review component. Given the absence of a valid policy-related justification for challenging the step four conclusion, the review component must endorse the adjudicating component’s vocational analysis and affirm the proposed allowance.

B. Policy on SOJ

When the adjudicating component's disability determination is compliant with SSA policy, federal quality reviewers, ROMCs, and medical advisors must avoid SOJ. Federal quality reviewers will not cite group I or group II decisional deficiencies when SOJ is at issue.

The intent of the SOJ policy is to ensure that federal quality reviewers do not cite decisional deficiencies unless the adjudicating component has not followed specific policy or procedure, or the evidence does not support the determination. Federal quality reviewers may only cite decisional deficiencies when the adjudicating component's proposed determination does not comply with disability program policy.

NOTE: The concept of SOJ applies only when determining whether a group I or group II decisional deficiency exists. SOJ does not apply when determining whether a documentation deficiency exists.

C. Recognizing SOJ

Federal quality reviewers should accept the adjudicating component's determination when all of the following are true:

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    The adjudicating component has documented the file according to current disability program policy (e.g., all impairments addressed, all evidence requested and followed up per policy).

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    The adjudicating component has provided a rationale of clear intent explaining the determination and free of any material inconsistencies that were not explained and/or resolved. For guidance on materially inconsistent evidence refer to DI 22515.003 and DI 24501.016 .

  • •

    Both the adjudicating and review component determinations or assessments are supported by the evidence in file and are policy compliant.

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    The review component, after considering all the documented facts, believes the evidence directs a different assessment and/or determination than that of the adjudicating component.

If all of the above factors are present, a federal quality reviewer would be substituting judgment by citing a group I or group II decisional deficiency. Any material change to the assessment of severity or determination, or change that necessitates additional development by the adjudicating component, represents SOJ.

D. When SOJ may be an issue

Before citing a group I or group II decisional deficiency, federal quality reviewers must be alert to the possibility of SOJ in a highly judgmental adjudicative issue, especially when disability program policy explicitly acknowledges that the issue is judgmental. For example, situations in which subtle differences in RFC (e.g., standing and walking reduced to four hours versus six hours) are material to the finding of disability or borderline age situations. (For additional information, see Borderline Age DI 25015.006.)

E. When SOJ is not an issue

Federal quality reviewers should cite a group I or group II decisional deficiency when any of the following situations occur and the situation meets the criteria of one of the listed deficiencies in GN 04440.202 (Group I Decisional Deficiencies) or GN 04440.204A1 (Group II Decisional Deficiencies):

  • •

    The adjudicating component's determination contradicts the evidence (e.g., the adjudicating component based their determination on an erroneous interpretation of a medical test or result, the determination is contrary to accepted medical knowledge, the evidence in file belongs to an individual other than the claimant).

  • •

    The adjudicating component has misrepresented the evidence in the rationale for the determination.

  • •

    The adjudicating component's determination does not comply with SSA policy, the adjudicator did not provide a rationale to explain the determination, and the review component reached a different conclusion that is supported by SSA policy.

CAUTION: Federal quality reviewers should not cite a deficiency and return a case to the adjudicating component merely because the rationale for the determination is inadequate or missing. If the adjudicating component's rationale is inadequate or missing, and the determination is correct, the quality reviewer prepares a policy-compliant rationale and does not return the case to the adjudicating component. If the adjudicating component's rationale is inadequate or missing, and the determination is not policy compliant, the quality reviewer will cite the appropriate deficiency and return the case to the adjudicating component for correction.

The federal quality reviewer's notification of deficiency to the adjudicating component must explain:

  • •

    why the adjudicating component's determination does not comply with SSA policy and

  • •

    why the reviewing component's deficiency citation complies with SSA policy.

For both items listed above, the quality reviewer must include specific POMS references and citations.

F. References

GN 04440.003K. Explanation of Quality Review Terms, for additional information regarding SOJ

GN 04440.130 Medical Review in the Quality Review (QR), for an explanation of SOJ and the ROMC review

 

QR 04440.501 Completion of the SSA-1774-U5, Request for Corrective Action

 

A. Use of an SSA-1774-U5

Quality Review (QR) completes an SSA-1774-U5 to return group I and group II deficiencies, as well as some technical corrective actions, that may affect the disability determination or the period of disability, to the adjudicating component.

For additional information regarding the types of transmittal forms and an exhibit of the SSA-1774-U5, see the references:

B. Procedure for completing an SSA-1774-U5

The sections below explain how to complete the SSA-1774-U5 form.

1. How to complete the fields

Information from QR's case processing system electronically propagates sections 1 through 6 and 8 through 11 of the SSA-1774-U5. NOTE: The “date” field in section 1 does not automatically propagate and must be entered manually. See GN 04440.501B.4.

Manually enter onset information in section 7 for deficient initial and recon disability determinations. Complete the alleged onset (AOD) field. Enter the adjudicating component’s established onset date (EOD) for all allowance determinations. Complete the reviewer onset date (ROD) field when a group I decisional deficiency results in a favorable disability determination or a group II decisional deficiency warrants a different onset date.

For complete and accurate data propagation, quality reviewers must complete all QR case processing system coding prior to creating the SSA-1774-U5. Following completion of the appropriate review screens, quality reviewers must:

  • •

    Review the propagated fields for accuracy and make any necessary changes in QR’s case processing systems, as applicable.

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    Incorporate policy references into the case discussion.

2. How to format and organize the narrative discussion

The following sections explain how to complete the narrative fields on the SSA-1774-U5.

a. Narrative fields

The narrative fields on the SSA-1774-U5 include:

  • •

    Item 11 ("ACTION REQUESTED AND RATIONALE") on the first page and

  • •

    A 20,000 character maximum limit.

In item 11, summarize the relevant facts of the case and clearly state:

  • •

    the policy issue,

  • •

    reasons why the case is deficient, and

  • •

    necessary corrective action(s).

To explain or justify the deficiency, do not use:

  • •

    Disability Policy’s policy memorandums,

  • •

    PolicyNet Questions and Answers (Q & As) or

  • •

    other similar written guidelines that are not part of National policy.

NOTE: Quality reviewers cannot cite a Q & A as the sole basis for a deficiency, but may refer to a Q & A on the SSA-1774-U5, for clarification purposes only, as long as the Q & A is not expired or archived.

Acceptable references include:

  • •

    The Program Operations Manual System (POMS)

  • •

    The Social Security Act

  • •

    Regulations

  • •

    Social Security and Acquiescence Rulings

  • •

    Administrative and Emergency Messages

Follow the appropriate format when completing each section of the narrative discussion on the SSA-1774-U5, as explained here.

b. The header section of the SSA-1774-U5

The QR case processing system propagates the header section onto the SSA-1774-U5 form. The heading will differ based on the type of review and deficiency code.

  • •

    QR’s case processing system propagates a heading that includes the deficiency group, deficiency category, deficiency sub-category, and primary/other deficiency.

c. How to complete the “ISSUE” section

Provide a brief summary to describe the basis of the deficiency. Two to three sentences is generally sufficient.

d. How to complete the "CASE DISCUSSION & POLICY ANALYSIS" section, including relevant policy citations

Follow the Federal Plain Language Guidelines, as enacted by the Plain Language Act of 2010, when writing the narrative discussion of the SSA-1774-U5.

If applicable to the return, the section should include:

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    A brief statement of the claimant's allegations and the alleged onset date.

  • •

    Discussion of the vocational issues, including incorporation of specific policy references to support any deficiency findings.

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    Discussion of the medical issues, with respect to sufficiency of documentation or medical severity, as it relates to listing requirements or impact on the claimant's residual functional capacity (RFC). Include incorporation of specific policy references.

  • •

    Discussion of symptom evaluation, medical source statements, all opinion evidence, and any related policy.

  • •

    Discussion of the earnings issue(s) or other work activity issues which requires development.

DO NOT:

  • •

    Cut and paste POMS sections into the return without providing a discussion of the policy interpretation and how it specifically applies to the cited deficiency.

  • •

    Provide a list of references or cite a range of POMS chapters.

  • •

    Cite a POMS table of contents or introductory section, unless the introductory section contains specific instructions related to the deficiency (e.g., introductory text in specific Listing of Impairments).

NOTE: Be very specific. Adjudicating components,Disability Policy's Request for Program Consultation staff, and subsequent reviewers must be able to identify the incorrectly applied policy to determine the proper course of corrective action(s).

e. How to complete the “REQUEST FOR CORRECTIVE” section

Explicitly state the action(s) necessary to correct the deficiency.

If documentation is necessary, specify the type of documentation. Do not direct the adjudicating component to purchase a consultative examination or otherwise tell them how to obtain the evidence. For additional information on routing and correcting deficient cases, see GN 04440.202,GN 04440.203, and GN 04440.204.

If the return does not require corrective action by the adjudicating component, include the statement, “No corrective action required”.

3. SSA-1774-U5 Signatures

The name of the person who creates the SSA-1774-U5 form will propagate in the "QR Quality Reviewer Signature" field at the bottom left of the QR Disability Determination Explanation (DDE).

The name of the person who approved the SSA-1774-U5 will propagate under the "Approved" field at the bottom of the Request for Corrective Action section.

 

QR 04440.505 Completing the SSA-847-U3, SSA Request for Case Action

 

A. Background on using the SSA-847-U3

Review components use the SSA-847-U3 to return technical corrective actions (TCAs) to adjudicating components and or field office.

For Details See:

NOTE: Review components do not return group I and group II deficiencies to adjudicating components using form SSA-847-U3. Quality reviewers cite all group I and group II deficiencies on an SSA-1774-U5, Request for Corrective Action, form.

B. Procedure for completing the SSA-847-U3

1. Field site completion of the SSA-847-U3

The Quality Review (QR) case processing system propagates the following information into the SSA-847-U3:

  • •

    claimant’s SSN,

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    claimant’s name,

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    claim type,

  • •

    claim level, and

  • •

    name of the adjudicating component.

For all other fields, quality reviewers mark the appropriate boxes and fill in the corresponding text, when appropriate.

2. Remarks for the SSA-847-U3

In the Remarks section of the SSA-847-U3, quality reviewers must include the following:

  • •

    a rationale for the return,

  • •

    appropriate policy references supporting the rationale,

  • •

    corrective action required (if applicable), and

  • •

    subsequent folder routing instructions.

3. Disposition of the SSA-847-U3

All disability components should be able to view the SSA-847-U3 in the certified electronic folder. Quality reviewers upload the SSA-847-U3 to QR's case processing system, at case clearance, using "Action" under the Forms Info tab.

NOTE: The QR Weekly Deficiency Report only includes information for TCAs recorded as regulation basis code changes. No other types of TCAs are reflected in the weekly report.

 


QR 04440 TN 18 - Federal Quality Review of Disability Det - 8/14/2025