Identification Number:
GN 04440 TN 81
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. 81, 11/13/2019

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. These revisions do not change or introduce new policy or procedure.

Summary of Changes

GN 04440.015 Federal Quality Review of Certified Electronic Folder (CEF) Cases

References to paper cases were deleted to subsections B and E because OQR no longer reviews paper cases.

GN 04440.015 Federal Quality Review of Certified Electronic Folder (CEF) Cases

A. Introduction to the federal quality review

The Office of Quality Review (OQR) conducts a federal quality review of disability cases in OQR review components located in the 10 regions and OQR Baltimore. The OQR review components were formerly called disability quality branches.

B. Official folder is a modular disability folder (MDF) or CEF

Federal quality review of adjudicating component disability determinations provides general quality review processing instructions for review components to use when returning or correcting deficient Certified Electronic Folder (CEF) cases.

C. Quality review sample selection

The automated sample selection process selects OQR’s quality review sample cases during the adjudicating component’s case closure process and prior to effectuation of the determination.

  • The adjudicating component receives an alert during the case closure process, via the National Disability Determination Services System (NDDSS), when a CEF case is selected for Federal quality review.

  • Both NDDSS and eView display an indicator when the case has been selected for Federal quality review. NDDSS only shows that the case has been selected for review and the original review component as the destination. Some CEF cases are automatically transferred to other review components and this change only shows in eView. The only place to see where a case is being, or has been, reviewed is in eView.

  • CEF cases selected for federal quality review are electronically transferred to the appropriate review component for quality review (e.g., quality assurance review, pre-effectuation review, special studies, etc.).

For information regarding eView, refer to DI 81005.005.

D. Results of OQR quality review

Results of Federal quality reviews are as follows:

1. Non-deficient (correct) cases:

The review component completes the quality review and case processing system coding and clears the CEF case to the field office (FO), program service center, National Records Center, or PC7 for effectuation of the determination.

2. Deficient cases:

  • The review component returns jurisdiction of the CEF to the adjudicating component for corrective action or

  • The review component takes the corrective action and clears the CEF to the FO to effectuate the determination.

Refer to General Rules for Routing and Correcting Deficient Cases in GN 04440.201.

3. FO action needed:

The review component may request assistance from the FO for additional development (e.g., substantial gainful activity development) prior to completing the review. Refer to GN 04440.510, Completing the SSA-5524-U3, Request for Assistance, for additional information regarding requesting FO assistance.

E. Process for federal quality review

For CEF cases, OQR quality reviews may be electronically redirected to an “out-of-region” review component or the “home” review component.

For further information, refer to Disability Case Adjudication and Review System (DICARS) User Tools: Folder Indicators – Certified Electronic Folder (CEF) DI 81030.115 and Federal Quality Review (QR) DI 81020.135.

F. Adjudicating component and review component disagreement when a paper MDF is the agency's official folder and no CEF exists

The adjudicating component follows OQR's established rebuttal process, as described in GN 04440.401 through GN 04440.425 and DI 30005.501 through DI 30005.550.

G. Adjudicating component and review component disagreement when the CEF is the agency's official folder

The adjudicating component follows the Office of Disability Policy (ODP) Request for Program Consultation (RPC) process, as described in DI 30007.000.

H. Adjudicating component and review component disagreement when a CEF exists with a paper MDF

ODP generally accepts, as an RPC, any adjudicating component and review component disagreement case when all evidence used by the adjudicating component and review component is viewable in the CEF.

If the CEF is not documented with the appropriate evidence, a member of ODP's RPC staff contacts the adjudicating component or review component to clarify.

If ODP denies the request for an RPC, they notify the adjudicating component and the adjudicating component may use OQR's established rebuttal process to resolve the disagreement.


GN 04440 TN 81 - Federal Quality Review of Disability Determinations - 11/13/2019