Identification Number:
GN 04440 TN 130
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. 130, 11/18/2020

Audience

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

Originating Component

OQR

Effective Date

Upon Receipt

Background

We are making changes to sections that have links to obsolete policy references.

Summary of Changes

GN 04440.111 Reopenings Certified Electronic Folders (CEF)

This is a QAT as there is no policy change. We have deleted the link in section C for GN 04440.227 since that section is now obsolete.

GN 04440.111 Reopenings Certified Electronic Folders (CEF)

A. eView Reopening Options

Those in the review component with the appropriate security profile and jurisdiction of the pending CEF may use the “reactivate” feature or the “reopen prior claim” feature to open and revise a prior closed CEF determination. See also DI 81020.115 (Processing Reopenings) and DI 81020.117 (Processing Medical Reactivations).

1. Reopen Prior Claim

  • Links the pending CEF with the prior closed CEF(s),

  • Brings the filing date of the oldest determination being reopened into the pending CEF as the “revised effective filing date,” and

  • Links and displays in the pending CEF’s Case Documents page all documents from the selected prior closed CEF(s) as “PF,” which indicates “prior folder.”

2. Reactivate

  • Changes a CEF claim from “closed,” “transferred,” or “manually cleared” status to “pending” status.

NOTE: 

Those in the review component with the appropriate security profile and jurisdiction of the pending CEF may also cancel an adjudicating component’s erroneous reopening of a prior CEF.

B. eView Requirements

1. To reopen a claim in eView, the following requirements must be met:

  • The user must have jurisdiction of the pending claim;

  • The pending claim cannot be a continuing disability review (CDR) case;

  • The prior determination being reopened cannot be a CDR case and must be the same claim type as the pending claim;

  • All intervening determinations:

    • cannot be a CDR denial;

    • must be the same claim type as the pending claim; and

    • must be eligible to be reopened, as well.

2. To reactive a claim in eView, the claim must be:

  • A CEF;

  • At the highest adjudicative level in the most recent electronic folder; and

  • In the “closed,” “transferred,” or “manually cleared” status.

NOTE: 

  • If these reopening and/or reactivation requirements are not met, electronic processing must cease, and the adjudicating component must create a paper folder.

  • Once it is determined that a reopening or cancellation of a reopening is needed and the requirements are met, the review component users with the appropriate security profile should follow the instructions outlined in DI 81020.115 . If a reactivation is needed, the review component users with the appropriate security profile should follow the instructions outlined in DI 81020.117 .

C. Reopening by the Review Component

Review component reopening situations may arise:

  • At the time of quality review; or

  • After a Request for Program Consultation (RPC) resolution does not affirm the review component’s Group 2 deficiency.

When the eView reopening and reactivation requirements are met, as outlined in GN 04440.111B, those with the appropriate security profile in the review component will utilize the eView “Reopen Prior Claim,” or “Reactivate,” functionality, as appropriate.

For more information on reopenings, see DI 27501.005 (Reopening and Revising a Determination or Decision); and DI 27505.001 (Conditions for Reopening a Final Determination or Decision).

NOTE: 

When the review component user selects “Reopen Prior Claim,” eView will display the prior filings that are available for reopening. eView will not display intervening CEFs, which have been made by the FO, an administrative law judge, the Appeals Council, or a Federal Court, or any CEF determinations prior to these intervening CEFs, as they are not available for eView reopening. Return to the adjudicating component when electronic reopening is not possible. See in DI 27510.005A, and DI 27510.005C2b regarding limited reopening authority.

1. Multiple Deficiencies

The review component does not electronically reopen and revise prior CEF determinations or cancel an erroneous adjudicating component’s reopening when also citing:

  • A group I deficiency; or

  • A group II deficiency with another necessary adjudicating component corrective action.

In these instances the review component will return these CEF cases to the adjudicating component for the corrective action.

2. Inadvertently Effectuated CEF

The review component will not reopen and revise an inadvertently effectuated CEF determination that has a group I deficiency. Return to the adjudicating component for their appropriate action. For reviewing cases that are inadvertently effectuated, see GN 04440.250.

Examples:

  • The FO inadvertently effectuates an adjudicating component’s denial determination; however, the review component reviews the sample case post-effectuation and decides there is a group I decisional deficiency because the case should be allowed. The review component prepares an SSA-1774-U5 (Request for Corrective Action) and returns the case to the adjudicating component to reopen and revise it to an allowance.

  • The FO inadvertently effectuates an adjudicating component’s allowance determination; however, the review component reviews the sample claim post-effectuation and decides that the determination should be a denial. The review component prepares an SSA-1774-U5 and returns the case to the adjudicating component for the appropriate action, including application of the medical improvement review standard.

NOTE: 

Return to the adjudicating component regardless of whether the adjudicating component’s case processing system has the functionality to keep the folder electronic. The adjudicating component is responsible for converting a current pending CEF to paper, if applicable.

D. Electronic Processing Overview

1. The adjudicating component failed to reopen prior CEF determination.

Reopen and revise the prior CEF determination electronically. However, if any of the situations in GN 04440.111C1 apply, return to the adjudicating component for all appropriate actions, including reopening and revision.

2. The adjudicating component erroneously reopened prior CEF determination.

Cancel the erroneous CEF reopening electronically. However, if any of the situations in GN 04440.111C1 apply, return to the adjudicating component for all appropriate actions, including cancellation of the reopening.

3. The adjudicating component selected the incorrect prior CEF determination to reopen.

Cancel the erroneous CEF reopening and reopen and revise the correct prior CEF determination electronically. However, if any of the situations in GN 04440.111C1, return to the adjudicating component for all appropriate actions, including cancellation and reopening and revision.

4. The adjudicating component reopened the correct prior CEF determination, but there are intervening paper folders that should also be reopened.

Exclude the case, cancel the electronic reopening, and return to the adjudicating component for all appropriate actions because electronic processing does not apply. The adjudicating component is responsible for converting the current pending CEF to paper.

5. RPC does not affirm group II deficiency.

Reactivate the prior closed CEF electronically, and reopen and revise the determination to correct the onset date or ending date in the following instances:

  • The RPC resolution affirms the adjudicating component’s onset date or ending date; or

  • The RPC resolution determines that the correct onset date or ending date is different from the dates determined by either the adjudicating component or review component.

NOTE: 

If the onset date or ending date is adverse, reactivate the case, and return to the adjudicating component for all appropriate actions.


GN 04440 TN 130 - Federal Quality Review of Disability Determinations - 11/18/2020