Identification Number:
EM-10090
Intended Audience:All RCs/ARCs/ADs/FOs/TSCs/PSCs/OCO/OCO-CSTs/ODARHQ
Originating Office:DCO OPSOS
Title:Case Processing Information on the Pre-effectuated Cases Sampled By the New ODAR Appeals Council Quality Review Branch—One-Time- Only Instructions
Type:EM - Emergency Messages
Program:Disability
Link To Reference:See References at the end of this EM.
 
Retention Date : March 18, 2017

Retention Date : March 18, 2016
Retention Date : September 23, 2015
Retention Date: November 22, 2014

A. Introduction

This message provides case processing information to Field Offices and Processing Centers on cases selected for review by the ODAR Appeals Council (AC) Quality Review Branch (QRB). ODAR AC/QRB is instituting a pre-effectuation review of ALJ favorable and partially favorable decisions. They have already pulled approximately 50 cases for their initial review. The AC/QRB expects to sample approximately 3500 cases per year, equally divided among all regions, when at full capacity.

B. Cases for AC/QRB Review

The AC/QRB will consider under own motion review a random sample of unappealed favorable or partially favorable decisions in Certified Electronic Folder (CEF) cases. These will be limited to disability cases.

C. Cases Excluded from AC/QRB Review

The following cases are excluded from review
    • Critical/TERI cases
    • Compassionate allowances
    • DSI claims
    • CDRs.
    • EDCS Exclusion/Modular Disability Folder claims

D. Process for reviewing randomly selected cases for AC/QRB Review
    1. After an ALJ renders a hearing decision on a CEF case and inputs the decision data
      • CPMS/ARPS will show when a case is selected for review by the AC/QRB. These cases should have a cover notice advising the claimant that the AC/QRB may review the decision within 60 days after the date of the ALJ hearing.
      • An ARPS record is established with a workload type: Unappealed Review – Reversal (URR).
      • The action will provide the alerts to effectuating components that payments cannot begin until the AC/QRB has completed its action on the case. For Title II selected claims, the normal PSC alert is suppressed.
          • For Title XVI selected claims, an alert has been added to EDCS that advises the field office to not effectuate the claim, (AC Own Motion Review-Do Not Effectuate).
          • In addition, in E-view, under the Status/History tab, the Claims Action History will show “AC Unappealed Review”. You can also query ARPS and it will show the status and location of the claim.
      • a request for review is filed on a case selected for own motion review before the AC/QRB takes any action, a new ARPS record for the request for review will be created through reactivation procedures

    2. If the AC/QRB concludes that the decision is supported:
      • It will send the case for payment.
      • An alert will go out to the PSC
      • Do Not Effectuate instructions are removed from EDCS. A new action item “ALJ Disposition Added”, displays and it is dated after the action item “Do Not Effectuate”.
    3. If the decision is not supported
      • The AC/QRB will notify the claimant and representative, before the end of the 60 days, that it is reviewing the decision on its own motion, and will:

        Either issue its own decision or
        Remand the case to an Administrative Law Judge for further proceedings and a new decision. (Administrative Law Judge’s original favorable decision should not be effectuated)
      • AC staff releases the own motion or reopening notice to the claimant and representative (if represented). However, after mailing the notice the Division Director’s Office controls appeals file for potential interim benefits and program analyst that handles interim benefits receives the file. After the controls are established, branch returns the appeals file for system control inputs (ARPS) and diary, establishing controls for potential interim benefits.

    4. AC/QRB Final Disposition
      • If the AC/QRB issues a favorable (partial or fully) decision, staff updates ARPS with the case close out information. This action will cause an EDCS action item “AC Disposition Added” and an alert to the PSC for effectuation.
      • If final disposition involves unfavorable decisions, staff scans the appropriate copy into the CEF, mails the cover notice and decision to the claimant and representative, updates ARPS, and holds the appeals file in the branch for one year (awaiting potential court action). If the ACQRB issues either a favorable or an unfavorable decision, it becomes the final decision of the Commissioner.
      • If final dispositions involve remands, staff scans the appropriate copy into the CEF, mails the cover notice and the remand order to the claimant and representative, update ARPS, which automatically notifies the HO.
    5. For those regions using WEB ALJ

      • Annotate subsequent decisions in EDCS Action List, and these should appear on WEB ALJ.
      • SI 04040.010 explains the Appeals Council (AC) Role in the SSI Administrative Review Process.
      • SI 02007.001 explains Interim Benefits in Cases of Delayed Final Decisions-SSI SI 02007.001C. Step 3 explains ODAR will contact the field office if we need to start Interim Benefits.
      • If the Appeals Council sends this back to the ALJ for another decision and the ALJ makes a fully favorable decision, it will again be loaded into the WEB ALJ program.
Direct all program–related and technical questions to your RO support staff or PSC OA staff. RO support staff or PSC OA staff may refer questions or problems to their Central Office contacts.

References:
GN 03104.350 - Appeals Council (AC) Jurisdiction
GN 03104.370 - Subsequent Application Filed While a Request for Review is Pending at the Appeals Council (AC) on Prior Claim – Title II or XVI
GN 03104.400 - Processing Appeals Council (AC) Decisions – Title II or Title XVI
SI 04040.010 - Appeals Council (AC) Role in the SSI Administrative Review Process
SI 02007.001 - Interim Benefits in Cases of Delayed Final Decisions – SSI
EM-10090 - Case Processing Information on the Pre-effectuated Cases Sampled By the New ODAR Appeals Council Quality Review Branch—One-Time- Only Instructions - 12/20/2010