An unfavorable or a less than fully favorable determination, without a group I or group II documentation deficiency, that does not contain 12-months of MER as required by policy and does not contain documentation to indicate that every reasonable effort was made to obtain the MER. (DI 22505.001)

The established diary and the correct diary dates differ by more than three months.

The case file contains sufficient medical evidence to support the disability determination and the onset, ending, or cessation date, but the medical or vocational documentation does not conform to specific requirements in current operating policies and procedures. (See GN 04440.110)

A personalized notice is required, and the notice is:

• •

  missing,

• •

  incorrect,

• •

  otherwise non-compliant with one or more of the subsections in DI 26535.000, DI 27030.000, and/or DI 28095.000, or

• •

  a special notice option, for an individual alleging blindness or a visual impairment, is required and there is no evidence to show the adjudicating component honored the individual’s preference.

There are non-substantive missing, incomplete or incorrect entries on the determination form. This includes:

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  SSA-831-C3/U3 (Disability Determination and Transmittal),

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  SSA-832-C3/U3 (Cessation or Continuance of Disability or Blindness Determination and Transmittal - Title XVI), or

• •

  SSA-833-C3/U3 (Cessation or Continuance of Disability or Blindness Determination and Transmittal - Title II).

Example: Onset is established prior to the date first insured (DFI) in order to establish duration; however, our regulations state that onset of disability cannot be prior to the DFI. Correcting this established onset issue is a non-substantive change as it has no effect on payments or potential freeze.

A group I decisional deficiency does not exist, but the medical assessment form is either incorrect, missing, incomplete or not applied to the case. This includes:

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  SSA-416 (Medical Evaluation)

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  SSA-2506-BK (Psychiatric Review Technique)

• •

  SSA-4734-BK (Physical Residual Functional Capacity Assessment)

• •

  SSA-538 (Childhood Disability Evaluation Form)

• •

  SSA-4734-F4 SUP (Mental Residual Functional Capacity Assessment)

The determination is unfavorable, or less than fully favorable, the evidence in file indicates a mental impairment exists, and a qualified psychiatrist or psychologist in the adjudicating component did not review the case.

The determination is unfavorable, or less than fully favorable, and the case folder contains an unsigned CE report or a CE report signed by someone other than the provider.

Evidence is missing or illegible. Evidence is considered missing when:

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  it is listed on the case development summary as obtained but not in file,

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  evidence relevant to the determination is not in the file,

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  it is apparent from references in file that it was obtained but not in file, or

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  the image is illegible.

An allowance or continuance was proposed, but there is no capability development in file in accordance with current policy (DI 23001.005). This includes situations in which:

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  capability is unresolved, and the adjudicating component does not undertake the necessary development.

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  capability is resolved, and the adjudicating component incorrectly notifies the field office that capability development is necessary, either because they were unaware of, or overlooked, medical evidence in file indicating whether the claimant is capable.

• •

  capability development is complete, but the adjudicating component did not enter the capability statement in item 34 of the SSA-831 or items 24 of the SSA 832/833.

In some cases, it is necessary for the review component to contact the adjudicating component and request they take a corrective action after the case is pulled for sample selection, but before completion of the quality review. The review component may not be able to complete an accurate and thorough review because necessary documentation is not present in the case and the review component is not able to correct the issue themselves. These types of TCAs include:

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  Illegible or missing evidence

• •

  Unsigned CE report

When these TCAs occur, the review component will:

1. retain the case,

2. notify the adjudicating component contact found at OQR DDS Contacts by email, to request the necessary documentation be added to the file, and

3. request the adjudicating component add or secure the information requested within 10 business days.

4. continue the quality review as per normal policies and procedures once the information has been obtained from the adjudicating component and/or added to the case file.

5. complete an SSA-847-U3 SSA Request For Case Action, and route the case to the adjudicating component for correction, if the adjudicating component is unresponsive to the request for necessary documentation or is unable to obtain the documentation within a reasonable amount of time, i.e., 10 business days.

When the case contains a medical or vocational documentation TCA, the quality reviewer will:

1. a. 

   make a probability of reversal (POR) determination,

2. b. 

   complete the required POR rationale, and

3. c. 

   route the case back to the field office.

See GN 04440.110 for specific POR instructions.

NOTE: If the review component is unable to determine whether missing medical or vocational documentation is likely to change the determination or period of disability, a group I or II documentation deficiency exists.

The review component does not need to notify the adjudicating component when the case contains one of the following types of TCAs:

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  Diary entry

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  Notice

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  Capability development

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  Determination form

When these TCAs occur, the review component will:

1. make the correction.

2. annotate corrections made to the determination form in item 34 on the SSA-831 or item 24 on the SSA-832/833 and identify the review component, if applicable.

3. annotate the incorrectly prepared notice “Do Not Release” in the electronic folder, if applicable.

4. annotate the incorrectly completed determination form “Do Not Process” in the electronic folder, if applicable.

5. route the case to the field office.

The review component must return the case to the adjudicating component, along with an SSA-847-U3, SSA Request For Case Action, when a 12-month MER TCA exists.

For a 12-month MER TCA, the review component will:

1. a. 

   notify the adjudicating component, via an SSA-847-U3, SSA Request For Case Action, explaining what MER is missing and requesting the adjudicating component make every reasonable effort to obtain the missing MER and

2. b. 

   route the case to the adjudicating component for correction.

The review component must notify the adjudicating component, via SSA-847-U3, SSA Request For Case Action, when the case contains a medical assessment form TCA or mental impairment TCA.

When these TCAs are present in the case, the review component will:

1. assume jurisdiction,

2. obtain needed correction(s) from a regional office medical or psychological contractor, as appropriate,

3. notify the adjudicating component of the correction, via SSA-847-U3 SSA Request For Case Action, and

4. route the case to the field office.

See GN 04440.244 for more specific information about assuming jurisdiction.

NOTE: Do not assume jurisdiction for cases when the next level of appeal is a disability hearing at reconsideration. This includes:

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  continuing disability review medical cessations,

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  adverse reopenings of favorable initial determinations based on medical factors,

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  adverse reopenings of reconsideration reversals based on medical factors and

• •

  adverse reopenings of cessations that change only the basis for the cessation.

If a TCA occurs in these types of cases, the review component must notify the adjudicating component of the correction needed, via SSA-847-U3, SSA Request For Case Action, and return the case to the adjudicating component for correction.