Identification Number:
GN 04440 TN 129
Intended Audience:See Transmittal Sheet
Originating Office:OARO Office of Quality Review
Title:Federal Quality Review of Disability Determinations
Type:POMS Transmittals
Program:All Programs
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM
Part GN – General
Chapter 044 – Quality Appraisal
Subchapter 40 – Federal Quality Review of Disability Determinations
Transmittal No. 129, 11/10/2020

Audience

PSC: DE, DEC;
OCO-OEIO: FDE;
DQB: DE, PL;
OCO-ODO: DE, DEC, DS, RECONE;

Originating Component

OQR

Effective Date

Upon Receipt

Background

This is a Quick Action Transmittal for GN 04440.004. We clarified criteria for exclusion code 10 in subsection C. These revisions do not change or introduce new policy or procedure.

 

Summary of Changes

GN 04440.004 Quality Review Exclusions

Subsection C: "Code 10: The file contains supportable FO documentation of a"

Added "NOTE: Where applicable, do not release adverse onset notice at case clearance."

GN 04440.004 Quality Review Exclusions

A. Introduction to quality review exclusions

The Office of Quality Review (OQR) conducts reviews on determinations made by adjudicating components and selected for pre-effectuation review (PER), quality assurance review (QA), targeted denial review (TDR), and other special samples. Quality review exclusions are incorrectly sampled cases or cases that do not meet the criteria for quality review.

B. Quality review exclusion policy

The first step in the quality review process is to determine if the sampled case is an exclusion. The OQR excludes cases that meet the criteria of an exclusion as identified in GN 04440.004C in this section. Code cases excluded from quality review in the OQR case processing system.

C. Quality review exclusions and codes

Exclude the following types of cases from quality reviews:

  • Code 01: Non-State cases selected for review – If the OQR inadvertently receives a case from a non-sampled federal site, do not conduct the quality review.

  • Code 02: Number holder attains full retirement age in the waiting period or dies within five months of the alleged onset date and no earlier onset date is possible.

  • Code 03: Supplemental Security Income (SSI) only and the applicant dies prior to adjudication.

  • Code 05: Number holder/applicant does not want to continue development of claim – regulation basis codes M7/M8 and N38.

  • Code 06: Informal remands.

  • Code 07: Field office (FO) jurisdiction – Whereabouts Unknown (WU) – Exclude a WU case from the QA or PER sample when the FO has jurisdiction of the case. The OQR does not review a case that is not under an adjudicating component’s jurisdiction.

  • Code 08: Invalid PER selection – The selected claim is a Title II denial, Title II continuing disability review (CDR), or Title XVI Disabled Child. The PER samples are composed of adult initial and reconsideration allowances only.

  • Code 09: Pre-hearing CDR reconsideration cessations.

  • Code 10: The file contains supportable FO documentation of a substantial gainful activity or technical denial – no medical determination needed.

NOTE: 

Where applicable, do not release adverse onset notice at case clearance.

  • Code 12: Medicare only cases when death precludes entitlement.

  • Code 13: Res judicata – Refiling of a claim denied for the same period. (For additional information on res judicata, see matrix chart in GN 04440.004D in this section.)

  • Code 14: Adjudication by a component other than the jurisdictional adjudicating component – Exclude a case when site A has jurisdiction, site B does the development and makes the determination, but the case clears from site A. If we do not exclude these cases from review, it may unfairly affect the accuracy rating of site A.

  • Code 15: PER only claim involving a reconsideration or reopening of onset or ending date in a prior allowance – If the adjudicating component clears an allowance case then reopens that case to change the onset or ending date only, exclude the case from OQR review.

  • Code 17: Sample selection not received within required time frame.

  • Code 18: Case meets exclusion criteria, however, issues noted that require correction.

  • Code 19: QA reopening of a prior reconsideration determination – In the QA sample, a reopening of a prior reconsideration determination includes appeal rights to a disability hearing and the sampled reopening may actually be a disability hearings officer decision. The level would not be distinguishable from a determination made by an adjudicating component examiner.

  • Code 20: Concurrent claim selected for SSI PER.

  • Code 21: Multi-category case – SSI recipient filing only to change to another category (e.g. disabled individual to blind individual).

  • Code 22: Paper case – The OQR does not sample paper cases or cases with an associated paper folder.

  • Code 88: Other – None of the other exclusions apply. These cases are subject to supervisory approval and you MUST explain the reason in the Notes section of the OQR case processing system (e.g., reactivated case sampled and previously reviewed by the OQR).

D. Res Judicata matrix for quality review cases

The matrix in this section provides quality reviewers with instructions on whether to exclude, review, or cite a deficiency on a res judicata case:

Field Office (FO)

Adjudicating Component

OQR

Deficiency or Exclude

Res Judicata

Res Judicata

No Res Judicata

Exclude

Res Judicata

No Res Judicata

Res Judicata

Exclude

No Res Judicata

No Res Judicata

Res Judicata

Exclude

No Res Judicata

Res Judicata

No Res Judicata

Deficiency

Res Judicata

Res Judicata

Res Judicata

Exclude

No Res Judicata

No Res Judicata

No Res Judicata

Regular Review

No Res Judicata

Res Judicata

Res Judicata

Exclude

E. Processing excluded quality review cases

If a quality reviewer makes a determination to exclude a case from review, he or she must:

  • Fill out the appropriate fields in the OQR case processing system;

  • Indicate the appropriate exclusion code (see case processing system Help screen for codes);

  • Effectuate the determination, when applicable; and

  • Release the Personalized Disability Explanation in file, if applicable.

F. Handling deficient quality review exclusion cases

In some instances, you may complete a full or partial quality review to determine that a case is an exclusion. If you determine that a case is deficient, but the case meets exclusion criteria, you must not cite a deficiency. However, the OQR must address all issues discovered during the quality review process to protect the integrity of the review.

If you discover a deficiency in an excluded case:

  • Do not record a deficiency in the OQR case processing system;

  • Create and complete the appropriate return document per, GN 04440.201D., and explain the deficiency;

  • Indicate that the deficiency is informational only and is not chargeable;

  • Take one of the following actions:

    • Make any necessary correction(s);

    • Forward the case to the adjudicating component for correction(s); or

    • Route to the FO for processing

  • Effectuate the determination, if appropriate.


GN 04440 TN 129 - Federal Quality Review of Disability Determinations - 11/10/2020