Effective Dates: 9/16/2025 - Present

Identification Number:
QR 04440 TN 24
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. 24, 09/16/2025

Originating Component

OQR

Effective Date

Upon Receipt

Background

We updated these sections to correct broken hyperlinks and improve clarity and readability for Quality Review instructions and procedures.

Summary of Changes

QR 04440.130 Medical Review in Quality Review (QR)

We corrected inactive hyperlinks throughout the section and updated Subsection D 1-3 to clarify appropriate form use in medical reviews.

QR 04440.250 Reviewing Cases That Have Been Inadvertently Effectuated

Subsection A: Removed language associated with an archived reference.

Subsection C: Clarified procedure headings and corrected inactive hyperlink references.

Subsection D: Removed language associated with an archived reference and corrected inactive hyperlink references.

Subsection E: Deleted for obsolete content.

QR 04440.130 Medical Review in Quality Review (QR)

 

A. Medical review in the federal review component

The review component performs quality reviews of all sampled cases to ensure policy compliance and to determine whether a medical contractor (MC) or psychological contractor (PC) review is required or is discretionary.

B. MC and PC review criteria

Based on the instructions below, the reviewer determines whether a case requires review by, and input from, an MC and/or PC.

1. Cases requiring medical review

The reviewer is required to obtain a review by an MC or PC for:

  1. a. 

    any case with a group I medical deficiency, unless the file contains NO medical evidence or the case is a continuing disability review (CDR) case without any current medical evidence;

  2. b. 

    any case or workload required per instructions from the Associate Commissioner of Quality Review, or designee;

  3. c. 

    any case where QR assumes jurisdiction. (See QR 04440.244 Assuming Jurisdiction.)

2. Discretionary medical review

If review by an MC or PC is not required, reviewers may use their judgment in deciding whether to seek medical consultation.

  1. a. 

    The reviewer may obtain review by an MC or PC in cases with questions or issues regarding:

    • •

      impairment severity

    • •

      inconsistencies in the evidence

    • •

      the claimant’s ability to sustain a normal workday or workweek

    • •

      medical improvement

    • •

      duration, onset, end or cessation dates, or closed periods

    • •

      whether the medical evidence in file is sufficient

    • •

      symptom evaluation and limitations to function

    • •

      psychiatric review technique (PRT), residual functional capacity (RFC) or mental residual functional capacity (MRFC) assessment(s)

  2. b. 

    The reviewer generally does not need review by, or input from, an MC or PC for cases with:

    1. 1. 

      Group I non-medical deficiencies such as:

      • •

        clear evidence that the individual is engaging in substantial gainful activity (SGA) (code 10)

      • •

        incorrect determination regarding vocational factors (code 20)

      • •

        incorrect determination regarding onset relative to Title II eligibility period (code 23)

      • •

        incorrect determination regarding collateral estoppel (code 26)

      • •

        unresolved work activity that could affect the determination (code 30)

      • •

        insufficient vocational documentation to determine the claimant’s age (code 51)

      • •

        insufficient vocational documentation to determine the claimant’s education (code 52)

      • •

        insufficient vocational documentation to determine the claimant’s work history (code 53)

      • •

        failure to obtain a prior folder or copy of an administrative law judge or appeals council ruling when required by an acquiescence ruling (code 60)

      • •

        whereabouts unknown procedures not compliant with SSA policy (code 65)

      • •

        failure or refusal to cooperate procedures not compliant with SSA policy (code 66)

    2. 2. 

      Cases with group II onset deficiencies such as:

      • •

        documented period of SGA after proposed onset (code 71)

      • •

        failure to reopen a prior determination when onset falls within a previously adjudicated period and there is no medical issue to address (code 71)

      • •

        clear-cut onset date errors involving traumatic onset (code 71)

      • •

        incorrect onset decision based on vocational factors where the medical assessment is correct (e.g. borderline age (code 71))

      • •

        incorrect cessation date (CDR involving failure to cooperate or whereabouts unknown)(code 73)

      • •

        unresolved work activity that could affect onset (with no unresolved medical issue) (code 85)

    3. 3. 

      Cases with technical corrective actions (TCA) such as:

      • •

        12-month medical evidence of record

      • •

        diary entry

      • •

        notice

      • •

        collateral estoppel documentation

        See QR 04440.230 - Introduction to Technical Corrective Actions (TCAs) for more information.

C. Preparing the medical referral(s) for review by an MC or PC

Once the reviewer has determined a case requires review by an MC or PC, the reviewer will submit a medical referral(s) through the case processing system. The referral should:

  • •

    identify medical issues in the case that require medical advice or clarification,

  • •

    state specific questions or frame issues for the MC or PC to review and address, and

  • •

    include information about technical issues or work issues only as they relate to the medical aspects of the case.

D. Medical review by an MC or PC

A medical review includes assessing impairment severity, the RFC, and related medical issues. The MC or PC reviews the adjudicating component's medical assessment and may independently arrive at a different assessment of impairment severity or RFC than the adjudicating component. It is NOT a “de novo” review. If the adjudicating component’s assessment complies with SSA disability program policy, and the evidence in file fully supports and documents the assessment, the MC or PC must not substitute their judgment.

As part of their medical and response, the MC or PC should:

  • •

    respond to the medical referral completed by the quality reviewer requesting MC or PC review, medical advice, or clarification of a medical issue and offer an explanation or guidance as to the course of action recommended. The advice or recommendation should be more detailed when it is not consistent with the reviewer’s guidance or possible expectations,

  • •

    provide an opinion on probability of reversal (POR) determinations, as needed. MCs and PCs must limit their opinions to the potential effect of missing documentation on impairment severity or RFC only,

  • •

    complete appropriate forms to respond to the medical referral,

  • •

    code results of a medical review in the case processing system.

The documentation in the file must fully explain the discrepancy or disagreement with the adjudicating component. MCs and PCs may prepare a SSA-3023-F3 (Medical Consultant's Review of Psychiatric Review Technique Form), SSA-392 (Medical Consultant's Review of Physical Residual Functional Capacity Assessment), or SSA-392-SUP (Medical Consultant's Review of Mental Residual Functional Capacity Assessment), to express findings of agreement or disagreement with an adjudicating component’s proposed PRT, RFC, or MRFC assessment(s).

MCs and PCs generally prepare a SSA-416 to provide medical comments if a determination should have been made on a medical-only basis (i.e., non-severe impairment(s) or impairment(s) meets/equals a listing) or the case is insufficient to establish a severe medically determinable impairment.

NOTE: For a discussion of “de novo” review and substitution of judgment, see QR 04440.003 - Explanation of Quality Review Terms and QR 04440.118 - Substitution of Judgment (SOJ) in the Quality Review Process.

1. When the PC should not use an SSA-3023-F3

The PC may not complete an SSA-3023-F3 when:

  • •

    the adjudicating component should have prepared a PRTF, but did not, or

  • •

    the PRTF in file is unsigned.

NOTE: The PC must use an SSA-416 (Case Analysis) to address the above issues. If the review component assumes jurisdiction, the reviewing PC completes an SSA-2506-BK.

2. When the MC should not use an SSA-392

The MC may not complete an SSA-392 when:

  • •

    The adjudicating component prepared an SSA-4734-BK, but MC review establishes that the adjudicating component should have made the disability determination on a medical basis only (i.e., the impairment is a “not severe” physical impairment, or the impairment is of listing-level severity), or

  • •

    The disability determination is not supported by sufficient evidence and additional medical evidence is needed (i.e., a medical documentation deficiency), regardless of whether the adjudicating component decided the case on a medical-vocational basis.

NOTE: For the above situations, the MC should record case analysis and disagreement(s) with the RFC determination on an SSA-416. Otherwise, the reviewing MC will prepare the assessment on an SSA-4734-BK when an RFC is not in the file, but one is required. The reviewing MC should not use the SSA-392 to prepare an RFC assessment.

3. When the PC should not use an SSA-392-SUP

The PC may not complete an SSA-392-SUP when:

  • •

    The adjudicating component prepared an SSA-4734-F4-SUP, but PC review establishes that the adjudicating component should have made the disability determination on a medical basis only, (i.e., the impairment is a “not severe” mental impairment, or the impairment is of listing-level severity.), or

  • •

    The disability determination is not supported by sufficient medical evidence and additional medical evidence is needed (i.e., a medical documentation deficiency), regardless of whether the adjudicating component decided the case on a medical-vocational basis.

NOTE: For situations above, the PC records case analysis and disagreement(s) with the MRFC determination on an SSA-416, Case Analysis

E. Reviewer actions after MC or PC review

Once the MC or PC completes the medical review, the reviewer is responsible for:

  • •

    reviewing all medical responses and requesting clarification or additional information, when necessary,

  • •

    ensuring the responses adequately address all medical issues identified and the findings by the MC or PC comply with SSA regulations, rulings, POMS, and the documented facts of the case, i.e., the quality review standard (QR 04440.003G, Explanation of Quality Review Terms),

  • •

    confirming the MC or PC adequately explained their findings and prepared any necessary medical assessment forms,

  • •

    leaving all original forms completed by the adjudicating component (i.e. PRT, RFC) in the file, as part of the audit trail, even when the review component assumes jurisdiction of a case,

  • •

    ensuring that MC or PC coding in the case processing system accurately reflects the findings by the MC or PC,

  • •

    uploading all of the final forms completed by the MC or PC into eView,

  • •

    resolving discrepancies between MC or PC review findings by explaining the basis for supporting one opinion over another, and

  • •

    confirming MC or PC signatures on the determination forms are correct when assuming jurisdiction.

QR 04440.250 Reviewing Cases That Have Been Inadvertently Effectuated

A. Introduction to reviewing cases that have been inadvertently effectuated

The review component performs quality reviews before the determination is effectuated; however, some cases selected for the sample may be inadvertently effectuated before the review. For paper cases, on occasion, a request for an appeal, i.e., a request for reconsideration or a hearing, is filed while an effectuated sample case is undergoing quality review. Appeal requests can be associated and filed with an effectuated case still undergoing quality review.

B. Reviewing effectuated cases

  • •

    Review and process the case as expeditiously as possible to avoid possible overpayment or nonpayment of benefits.

  • •

    Base the review on the sample record (i.e., the National Disability Determination Services System determination input by the adjudicating component at the time they cleared the case and it was selected for quality review), regardless of whether the entries on the SSA-831-C3/U3 (Disability Determination and Transmittal), SSA-832-C3/U3 (Cessation or Continuance of Disability or Blindness Determination and Transmittal – Title XVI), and SSA-833-C3/U3 (Cessation or Continuance of Disability or Blindness Determination and Transmittal – Title II) in the case differ from those on the sample record.

  • •

    For paper cases, hand-carry the folder through each step of the process if a request for an appeal has been associated with the case file.

C. Procedure when no appeal is filed

1. General review procedure

Cite all applicable group I and group II deficiencies on cases that have been inadvertently effectuated. If correcting the case will result in a change in the disability determination or in the onset, ending or cessation date, you must follow the rules on reopening and revising determinations.

2. Review procedure for adverse reopenings

Apply the medical improvement review standard (MIRS), which includes consideration of both medical improvement (MI) and the exceptions to MI, to any adverse reopening that would result in the termination of benefits or in a less favorable ending or cessation date.

With rare exceptions, this means:

  • •

    a determination of allowance or continuance may only be changed (based on medical or vocational factors) to a determination of denial, closed period of disability, or cessation; or

  • •

    an ending date or cessation date may only be changed (based on medical or vocational factors) to a less favorable date, if the case meets one of the group I error exceptions or the group II fraud or similar fault exception to MIRS.

For more information on the effect of MIRS on reopening and revision and exceptions, see DI 27501.005B.4. and DI 28020.000.

3. Fully favorable determination made by the adjudicating component with a group I or group II documentation deficiency

If the case contains a group I or group II documentation deficiency, take the following action.

  • •

    Return the case to the adjudicating component by preparing a Request for Corrective Action.

  • •

    Cite the group I or group II documentation deficiency.

  • •

    Include the following statement on the Request for Corrective Action if the deficiency is a group I documentation deficiency:

    We have cited a group I documentation deficiency. If the documentation you obtain changes the disability determination, follow existing adverse reopening procedures. Return the case to the review component for completion of the review.

Refer to QR 04440.250C.2. regarding the application of MIRS in an adverse reopening situation.

NOTE: MIRS does not apply to reopening and revision to a later onset date per DI 27501.005B.4.b. and DI 28005.001D.2.c.

4. Fully favorable determination made by the adjudicating component with a group I decisional deficiency

If the case contains a group I decisional deficiency, take the following actions.

  • •

    Return the case to the adjudicating component by preparing a Request for Corrective action.

  • •

    Cite the group I decisional deficiency.

  • •

    Include the following statement on the Request for Corrective Action when a MIRS group I or group II exception to MI does not apply:

    We have cited a group I decisional deficiency in this case. However, we do not believe the determination can be reopened under the fraud or error exceptions to MIRS. Therefore, no further action is necessary at this time. After your review, return the case to the review component.

  • •

    When an MIRS exception applies, tailor the return to the situation. Remind the adjudicating component to follow the adverse reopening procedures and to return the case to the review component for completion of the review.

5. Fully favorable determination made by the adjudicating component with a group II decisional deficiency

If the case contains a group II onset date decisional deficiency, return the case to the adjudicating component by preparing a Request for Corrective Action and advise the adjudicating component to follow existing reopening procedures. Note that MIRS does not apply to reopening and revision to a later onset date per DI 27501.005B.4.b. and DI 28005.001D.2.c.

6. Less than fully favorable determination made by the adjudicating component with a group I or group II documentation deficiency

If the case contains a group I or group II documentation deficiency, take the following actions.

  • •

    Return the case to the adjudicating component by preparing a Request for Corrective Action.

  • •

    Cite the group I or group II documentation deficiency.

  • •

    Include the following statement on the Request for Corrective Action:

    We have cited a group I (group II) documentation deficiency. If the documentation you obtain changes the disability determination (onset or ending date) to an unfavorable determination (less favorable ending date), follow existing adverse reopening procedures. Return the case to the review component for completion of the review.

Refer to QR 04440.250C.2. regarding the application of MIRS in an adverse reopening situation.

NOTE: MIRS does not apply to reopening and revision to a later onset date per DI 27501.005B.4.b. and DI 28005.001D.2.c.

7. Less than fully favorable determination made by the adjudicating component with a group I decisional deficiency

If the case contains a group I decisional deficiency, take the following actions.

  • •

    Return the case to the adjudicating component by preparing a Request for Corrective Action.

  • •

    Cite the group I decisional deficiency.

  • •

    Include the following statement on the Request for Corrective Action if the determination should be unfavorable and an MIRS group I or group II exception to MI does not apply:

    We have cited a group I decisional deficiency in this case. However, we do not believe the determination can be reopened under the fraud or error exceptions to MIRS. Therefore, no further action is necessary at this time. Return the case to the review component for completion of the review.

  • •

    When an MIRS exception applies, tailor the return to the situation. Remind the adjudicating component to follow the adverse reopening procedures and to return the case to the review component for completion of the review.

For review policy on adverse reopening when no appeal is filed, see QR 04440.250C.2.

8. Less than fully favorable determination made by the adjudicating component with a group II decisional deficiency

If the case contains a group II onset date decisional deficiency, return the case by preparing a Request for Corrective Action and advise the adjudicating component to follow existing reopening procedures.

MIRS does not apply to reopening and revision to a later onset date per DI 27501.005B.4.b. and DI 28005.001D.2.c.

MIRS applies to a group II ending or cessation date that is less favorable than the ending or cessation date established in the effectuated determination.

9. Unfavorable determination made by the adjudicating component with a group I or group II documentation deficiency

If the case contains a group I or a group II documentation deficiency, take the following actions.

  • •

    Return the case to the adjudicating component by preparing a Request for Corrective Action.

  • •

    Cite the group I or group II documentation deficiency.

  • •

    Include the following statement on the Request for Corrective Action:

    We have cited a group I (group II) documentation deficiency. If the documentation you obtain changes the disability determination (or the cessation date), follow existing reopening procedures. Return the case to the review component for completion of the review.

NOTE: If you propose a less favorable cessation date, you have to establish MI from the last comparison point decision (CPD) to the proposed cessation date to revise the cessation date if no exceptions to MI apply.

See DI 28005.205D.2. for cessation month and error exception cases.

10. Unfavorable determination made by the adjudicating component with a group I decisional deficiency

If the case contains a group I decisional deficiency, take the following actions.

  • •

    Return the case to the adjudicating component by preparing a Request for Corrective Action.

  • •

    Cite the group I decisional deficiency.

  • •

    Include the following statement on the Request for Corrective Action:

    We have cited a group I decisional deficiency in this case. Please reopen and revise the determination following existing reopening procedures. Return the case to the review component for completion of the review.

11. Unfavorable determination made by the adjudicating component with a group II decisional deficiency

If the case contains a group II decisional deficiency, take the following action.

  • •

    Return the case to the adjudicating component by preparing a Request for Corrective Action.

  • •

    Cite the group II decisional deficiency.

  • •

    Advise the adjudicating component to follow the existing procedures for reopening and revision. (For cessation month and error exception cases, see DI 28005.205D.2.)

NOTE: If you propose a less favorable cessation date, and no exceptions to MI apply, MI from the last CPD to the proposed cessation date would have to be established in order to revise the cessation date.

References

  • •

    For an explanation of reopenings and revisions, see DI 27501.000.

  • •

    For preparation of a revised SSA-831-C3/U3, see DI 27530.000.

  • •

    For an explanation of MIRS and when it applies, see DI 28005.000.

  • •

    For exceptions to MIRS, see DI 28020.000.

  • •

    For preparation of a revised SSA-832-C3/U3 or SSA-833-C3/U3, see DI 28501.000.

D. Review component procedure when request for reconsideration is filed

1. General procedure for all paper cases

If the review component receives notice of a request for reconsideration or the Form SSA-3441-BK (Disability Report – Appeal) while a case is undergoing quality review:

  • •

    associate the SSA-3441-BK or the notice of an appeal with the case;

  • •

    ensure the case receives expedited processing; and

  • •

    send the folder to the field office (FO) upon completion of the quality review. Prepare a Request for FO Assistance if FO development is necessary. Otherwise, use Form SSA-559 (Transmittal Slip for Claims Folders) to route the folder.

2. Procedure for deficient cases when reconsideration request filed in FO

If the request for reconsideration was filed in the FO:

  • •

    associate the appeals notice or SSA-3441-BK with the case;

  • •

    ensure the case receives expedited processing;

  • •

    prepare a Request for Corrective Action and send it to the adjudicating component with the folder;

  • •

    instruct the adjudicating component to take corrective action and all reconsideration actions, including the preparation of the SSA-831-C3/U3, SSA-832-C3/U3, and SSA-833-C3/U3, if necessary

  • •

    instruct the adjudicating component to return the case to the review component.

For an explanation of FO actions when a request for reconsideration is filed, see DI 12005.005 – DI 12005.020.

3. Procedure for deficient cases when reconsideration request not filed in FO

If you receive the request for reconsideration in the review component without the FO processing the request first:

  • •

    prepare a photocopied file;

  • •

    prepare a Request for Corrective Action and send it to the adjudicating component with the photocopied file.

Instruct the adjudicating component to:

  • •

    take all reconsideration actions, including the preparation of the SSA-831-C3/U3, SSA-832-C3/U3, or SSA-833-C3/U3, if necessary;

  • •

    associate the original folder with the photocopied file, in the event of a reversal, before requesting any necessary development of reversal action; and,

  • •

    return the case to the review component before effectuation of the revised determination.

  • •

    send the original case file, with a copy of the Request for Corrective Action, to the FO for their necessary reconsideration action.

For an explanation of FO actions when a request for reconsideration is filed, see DI 12005.005 – DI 12005.020.


QR 04440 TN 24 - Federal Quality Review of Disability Det - 9/16/2025