Identification Number:
DI 30005 TN 43
Intended Audience:See Transmittal Sheet
Originating Office:OARO Office of Quality Review
Title:Adjudicating Component Actions on Deficient Cases
Type:POMS Transmittals
Program:All Programs
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. 43, 08/24/2020

Audience

PSC: DE, DEC;
OCO-OEIO: CR, FDE, RECONE;
DQB: DE, PA, PL, TL;
OCO-ODO: DC, DE, DS, RECONE;
ODD-DDS: ADJ, DHU;

Originating Component

OQR

Effective Date

Upon Receipt

Background

This is a Quick Action Transmittal. These revisions do not change or introduce new policy or procedure. This POMS is being revised to restore information and notes that were inadvertently left off of the latest revision that was published on 7/20/2020. This POMS is the counterpart to GN 04440.204, Group II Deficiencies.

Summary of Changes

DI 30005.204 Group II Deficiencies

In Section A., second sentence, we:

Added, "that is material i.e., the different date has the potential to affect the month of entitlement (MOE), the primary insurance amount (PIA), or the earnings freeze," after the word "determination", as this information was left off of the latest revision.

In Section A.2., just after A.2.d., we:

Added a note that reads, "When sufficient documentation exists to support a different established onset date (EOD) or there is insufficient evidence to support the EOD, the reviewer's deficiency is based on the potential impact of the adjudicator not following policy. As explained in DI 25501.300, the EOD impacts the PIA, MOE, and the disability freeze." This note was added as the information was left off the latest revision of this POMS and provides additional clarification for information already provided.

In Section B., at the very end of this POMS, we:

Added a note that reads, "After the review component has already cited a group II work activity documentation deficiency, they may review the Modernized Claims System (MCS) or Modernized Supplemental Security Income Claims System (MSSICS) remarks screen, the report of contact screen, DWO1, or continuation pages, to determine if the FO resolved and electronically documented the work activity issue. The review component MAY NOT cite a deficiency based on information in MCS or MSSICS. However, they may resolve the onset issue using this information." This note was added as the information was left off the latest revision of this POMS and provides clarification for information already provided.

DI 30005.204 Group II Deficiencies

A. Definitions of group II decisional deficiencies

There are two types of group II deficiencies, decisional and documentation. A group II decisional deficiency is a substantive deficiency in which the evidence supports a different onset, ending, or cessation date for a disability determination that is material i.e., the different date has the potential to affect the month of entitlement (MOE), the primary insurance amount (PIA), or the earnings freeze. A group II documentation deficiency is a substantive deficiency in which the evidence is insufficient and obtaining additional evidence has the potential to change the onset, ending, or cessation date for a disability determination.

1. Group II decisional deficiencies

The review component will cite a group II decisional deficiency based on the following issues:

a. Onset date (category 71)

The adjudicating component allows a disability claim, but evidence supports a different onset date. In potential reopening situations, cite this deficiency when the adjudicating component:

  • should have reopened, but did not (even when the established onset date (EOD) is correct),

  • should not have reopened, but did (even when EOD is correct), or

  • correctly reopened, but established an incorrect onset date that is material.

b. Ending date (category 72)

The adjudicating component allows a disability claim:

  • for a closed period, but evidence supports a different ending date,

  • for a closed period, but evidence is sufficient to show disability did not end, or

  • for an open period, but evidence is sufficient to show disability ended.

c. Cessation date (category 73)

The adjudicating component ceases an individual’s disability benefits, but evidence supports a different cessation date.

2. Group II documentation deficiencies

The review component will cite a group II documentation deficiency based on the following issues:

a. Onset date (category 81)

The adjudicating component allows a disability claim, but evidence is insufficient to support the onset date. This includes situations where the adjudicating component’s EOD falls within a previously adjudicated period, and there is insufficient evidence to determine whether the prior denial determination can be reopened.

The review component should not cite a Group II onset date documentation deficiency when the field office (FO) did not inform the adjudicating component of a prior determination, and there was no indication of a prior determination in the certified electronic folder (CEF).

b. Ending date (category 82)

The adjudicating component allows a disability claim for a closed period, but evidence is insufficient to support the ending date.

c. Cessation date (category 83)

The adjudicating component allows a disability claim, but evidence is insufficient to determine the correct cessation date.

d. Unresolved work activity that has potential to affect the period of disability (category 85)

The adjudicating component allows a disability claim, but evidence is insufficient to determine either the correct onset or ending date because of unresolved work activity.

NOTE:When sufficient documentation exists to support a different established onset date (EOD), or if there is insufficient evidence to support the EOD, the reviewer's deficiency is based on the potential impact of the adjudicator not following policy. As explained in DI 25501.300, the EOD impacts the PIA, MOE, and the disability freeze.

B. Correcting group II deficiencies

The review component handles group II deficiencies differently depending on the specific deficiency involved and the circumstances of the case. The review component either returns the case to the adjudicating component for correction, contacts the FO for resolution, or corrects the case.

1. Case returned to the adjudicating component for corrective action

Group II onset and ending date documentation deficiencies, and all cessation date deficiencies, are returned to the adjudicating component for correction. In these cases, the review component will:

a. code the deficiency in the case processing system,

b. notify the adjudicating component, via an SSA-1774-U5, Request For Corrective Action, to explain why the determination is not policy compliant and to request the adjudicating component to undertake appropriate development,

c. route the case to the adjudicating component for correction as a controlled return, and

d. follow-up with the adjudicating component in 60 days if the corrected determination has not been returned to the review component.

2. Case corrected in the review component

Group II onset and ending date decisional deficiencies are corrected by the review component. In these cases, the review component will:

a. annotate all of the adjudicating component’s original determination and medical assessment forms, as well as notices, in the CEF as “Do Not Process” or “Do Not Release”, as applicable,

b. code the deficiency in the case processing system,

c. notify the adjudicating component, via an SSA-1774-U5, Request For Corrective Action, to explain why the determination is not policy compliant,

d. correct the onset or ending date,

e. prepare and release any necessary personalized notices, and

f. route the case to the FO for effectuation

EXCEPTION: If the case has another deficiency or technical corrective action requiring correction by the adjudicating component, or changing the ending date results in an adverse reopening of either an initial or a reconsideration case, the review component will follow the instructions in GN 04440.204B.1 above, to return the case to the adjudicating component for correction.

NOTE: All of the adjudicating component’s original determination and medical assessment forms, as well as notices, must remain in the CEF as part of the audit trail.

3. Correcting group II SGA documentation deficiencies

For group II documentation deficiencies based on SGA, the review component will:

  1. a. 

    annotate all of the adjudicating component’s original determination and medical assessment forms, as well as notices, in the CEF as “Do Not Process” or “Do Not Release”, as applicable,

  2. b. 

    code the deficiency in the case processing system,

  3. c. 

    notify the FO, via an SSA-5524-U3, Request for Assistance, to explain that SGA development is needed,

  4. d. 

    notify the adjudicating component, via an SSA-1774-U5, Request For Corrective Action, to explain why the determination is not policy compliant and that the case will be routed to the FO for SGA development, and

  5. e. 

    route the case to the FO.

NOTE: All of the adjudicating component’s original determination and medical assessment forms, as well as notices, must remain in the CEF as part of the audit trail.

After the FO resolves the work activity issue, if the onset date remains the same, the FO will:

  • effectuate the allowance,

  • prepare and release any necessary personalized notices, and

  • notify the review component of the outcome.

After the FO resolves the work activity issue, if the onset date changes, the review component will:

  • annotate all of the adjudicating component’s original determination and medical assessment forms, as well as notices, in the CEF as “Do Not Process” or “Do Not Release”, as applicable,

  • code the deficiency in the case processing system,

  • correct the onset or ending date on the SSA-831,

  • prepare and release any necessary personalized notices, and

  • route the case to the FO for effectuation.

NOTE: All of the adjudicating component’s original determination and medical assessment forms, as well as notices, must remain in the CEF as part of the audit trail.

If the FO determines an earlier onset date may be possible, and further medical development is necessary to establish the onset date, the review component will:

  • prepare an informational SSA-1774-U5, Request For Corrective Action, to explain why the case is not policy compliant and to request the adjudicating component to undertake appropriate development,

  • route the case to the adjudicating component for correction as a controlled return, and

  • follow-up with the adjudicating component in 60 days if the case has not been returned to the review component.

NOTE: After the review component has already cited a group II work activity documentation deficiency, they may review the Modernized Claims System (MCS) or Modernized Supplemental Security Income Claims System (MSSICS) remarks screen, the report of contact screen, DWO1, or continuation pages, to determine if the FO resolved and electronically documented the work activity issue. The review component MAY NOT cite a deficiency based on information in MCS or MSSICS. However, they may resolve the onset issue using this information.


DI 30005 TN 43 - Adjudicating Component Actions on Deficient Cases - 8/24/2020