Effective Dates: 09/10/2026 - Present Previous | Next

TN 39 (09-26)

QR 04440.130 Medical Review in Quality Review (QR)

A. Medical review in the federal review component

Disability Quality Review (DQR) performs quality reviews of all sampled cases to ensure policy compliance and to determine whether a medical contractor (MC) or psychological contractor (PC) review is required or is discretionary.

B. MC and PC review criteria

Based on the instructions here, the federal quality reviewer (FQR) determines whether a case requires review by, and input from, an MC or PC.

1. Cases requiring medical review

The FQR is required to obtain a review by an MC or PC for:

  1. a. 

    any case with a group I medical deficiency, unless medical assessment is completed using Medical Authority for Quality Reviewers (MAQR), the file contains NO medical evidence, or the case is a continuing disability review (CDR) case without any current medical evidence;

  2. b. 

    any case or workload required per instructions from the Associate Commissioner of Disability Quality Review, or designee; and

  3. c. 

    any case where DQR assumes jurisdiction, see Assuming Jurisdiction QR 04440.244.

2. Discretionary medical review

If review by an MC or PC is not required, reviewers may use their judgment in deciding whether to seek medical consultation.

  1. a. 

    The reviewer may obtain review by an MC or PC in cases with questions or issues regarding:

    • •

      impairment severity

    • •

      inconsistencies in the evidence

    • •

      the claimants ability to sustain a normal workday or workweek

    • •

      medical improvement

    • •

      duration, onset, end or cessation dates, or closed periods

    • •

      whether the medical evidence in file is sufficient

    • •

      symptom evaluation and limitations to function

    • •

      psychiatric review technique (PRT), residual functional capacity (RFC) or mental residual functional capacity (MRFC) assessment(s)

  2. b. 

    The FQR generally does not need review by, or input from, an MC or PC for cases with:

    1. 1. 

      Group I non-medical deficiencies such as:

      • •

        clear evidence that the individual is engaging in substantial gainful activity (SGA) (code 10)

      • •

        incorrect determination regarding vocational factors (code 20)

      • •

        incorrect determination regarding onset relative to Title II eligibility period (code 23)

      • •

        incorrect determination regarding collateral estoppel (code 26)

      • •

        unresolved work activity that could affect the determination (code 30)

      • •

        insufficient vocational documentation to determine the claimants age (code 51)

      • •

        insufficient vocational documentation to determine the claimants education (code 52)

      • •

        insufficient vocational documentation to determine the claimants work history (code 53)

      • •

        failure to obtain a prior folder or copy of an administrative law judge or appeals council ruling when required by an acquiescence ruling (code 60)

      • •

        whereabouts unknown procedures not compliant with SSA policy (code 65)

      • •

        failure or refusal to cooperate procedures not compliant with SSA policy (code 66)

    2. 2. 

      Cases with group II onset deficiencies such as:

      • •

        documented period of SGA after proposed onset (code 71)

      • •

        failure to reopen a prior determination when onset falls within a previously adjudicated period and there is no medical issue to address (code 71)

      • •

        clear-cut onset date errors involving traumatic onset (code 71)

      • •

        incorrect onset decision based on vocational factors where the medical assessment is correct (e.g. borderline age (code 71))

      • •

        incorrect cessation date (CDR involving failure to cooperate or whereabouts unknown)(code 73)

      • •

        insufficient documentation to support the onset date (with no unresolved medical issue) (code 81)

      • •

        unresolved work activity that could affect onset (with no unresolved medical issue) (code 85)

    3. 3. 

      Cases with technical corrective actions (TCA) such as:

      • •

        12-month medical evidence of record

      • •

        diary entry

      • •

        notice

      • •

        collateral estoppel documentation

For more information, see Introduction to Technical Corrective Actions (TCAs) QR 04440.230.

C. Preparing the medical referral(s) for review by an MC or PC

Once the FQR has determined a case requires review by an MC or PC, the FQR will submit a medical referral(s) through the case processing system. The referral should:

  • •

    identify medical issues in the case that require medical advice or clarification,

  • •

    state specific questions or frame issues for the MC or PC to review and address, and

  • •

    include information about technical issues or work issues only as they relate to the medical aspects of the case.

D. Medical review by an MC or PC

A medical review includes assessing impairment severity, the RFC, and related medical issues. The MC or PC reviews the adjudicating component's medical assessment and may independently arrive at a different assessment of impairment severity or RFC than the adjudicating component. It is NOT a de novo review. If the adjudicating components assessment complies with SSA disability program policy, and the evidence in file fully supports and documents the assessment, the MC or PC must not substitute their judgment.

As part of their medical and response, the MC or PC should:

  • •

    respond to the medical referral completed by the disability quality reviewer requesting MC or PC review, medical advice, or clarification of a medical issue and offer an explanation or guidance as to the course of action recommended. The advice or recommendation should be more detailed when it is not consistent with the reviewers guidance or possible expectations,

  • •

    provide an opinion on probability of reversal (POR) determinations, as needed. MCs and PCs must limit their opinions to the potential effect of missing documentation on impairment severity or RFC only,

  • •

    complete appropriate forms to respond to the medical referral,

  • •

    code results of a medical review in the case processing system.

The documentation in the file must fully explain the discrepancy or disagreement with the adjudicating component. MCs and PCs may prepare an SSA-3023-F3 (Medical Consultant's Review of Psychiatric Review Technique Form), SSA-392 (Medical Consultant's Review of Physical Residual Functional Capacity Assessment), or SSA-392-SUP (Medical Consultant's Review of Mental Residual Functional Capacity Assessment), to express findings of agreement or disagreement with an adjudicating components proposed PRT, RFC, or MRFC assessment(s).

MCs and PCs generally prepare an SSA-416 to provide medical comments if a determination should have been made on a medical-only basis (i.e., non-severe impairment(s) or impairment(s) meets/equals a listing) or the case is insufficient to establish a severe medically determinable impairment.

NOTE: For a discussion of de novo review and substitution of judgment, see QR 04440.003 - Explanation of Quality Review Terms and QR 04440.118 - Substitution of Judgment (SOJ) in the Quality Review Process.

1. When the PC should not use an SSA-3023-F3

The PC may not complete an SSA-3023-F3 when:

  • •

    the adjudicating component should have prepared a PRTF, but did not, or

  • •

    the PRTF in file is unsigned.

NOTE: The PC must use an SSA-416 (Case Analysis) to address the above issues. If DQR assumes jurisdiction, the reviewing PC completes an SSA-2506-BK.

2. When the MC should not use an SSA-392

The MC may not complete an SSA-392 when:

  • •

    The adjudicating component prepared an SSA-4734-BK, but MC review establishes that the adjudicating component should have made the disability determination on a medical basis only (i.e., the impairment is a not severe physical impairment, or the impairment is of listing-level severity), or

  • •

    The disability determination is not supported by sufficient evidence and additional medical evidence is needed (i.e., a medical documentation deficiency), regardless of whether the adjudicating component decided the case on a medical-vocational basis.

NOTE: For the above situations, the MC should record case analysis and disagreement(s) with the RFC determination on an SSA-416. Otherwise, the reviewing MC will prepare the assessment on an SSA-4734-BK when an RFC is not in the file, but one is required. The reviewing MC should not use the SSA-392 to prepare an RFC assessment.

3. When the PC should not use an SSA-392-SUP

The PC may not complete an SSA-392-SUP when:

  • •

    The adjudicating component prepared an SSA-4734-F4-SUP, but PC review establishes that the adjudicating component should have made the disability determination on a medical basis only, (i.e., the impairment is a not severe mental impairment, or the impairment is of listing-level severity.), or

  • •

    The disability determination is not supported by sufficient medical evidence and additional medical evidence is needed (i.e., a medical documentation deficiency), regardless of whether the adjudicating component decided the case on a medical-vocational basis.

NOTE: For situations above, the PC records case analysis and disagreement(s) with the MRFC determination on an SSA-416, Case Analysis

E. FQR actions after MC or PC review

Once the MC or PC completes the medical review, the FQR is responsible for:

  • •

    reviewing all medical responses and requesting clarification or additional information, when necessary,

  • •

    ensuring the responses adequately address all medical issues identified and the findings by the MC or PC comply with SSA regulations, rulings, Program Operations Manual System (POMS), and the documented facts of the case, i.e., the quality review standard (QR 04440.003G - Explanation of Quality Review Terms),

  • •

    confirming the MC or PC adequately explained their findings and prepared any necessary medical assessment forms,

  • •

    leaving all original forms completed by the adjudicating component (i.e. PRT, RFC) in the file, as part of the audit trail, even when DQR assumes jurisdiction of a case,

  • •

    ensuring that MC or PC coding in the case processing system accurately reflects the findings by the MC or PC,

  • •

    uploading all of the final forms completed by the MC or PC into eView,

  • •

    resolving discrepancies between MC or PC review findings by explaining the basis for supporting one opinion over another, and

  • •

    confirming MC or PC signatures on the determination forms are correct when assuming jurisdiction.

F. Medical Assessment under MAQR for Federal Quality Reviewers

MAQR allows qualified FQRs to complete medical assessments in an applicable documentation deficiency instead of obtaining medical review by an MC or PC.

1. When MAQR may be used

MAQR may be used for adult disability claims in which the FQR determines a documentation deficiency exists within categories 41, 42, 44, 47, or 81. See QR 04440.203 and QR 04440.204. Use of MAQR is allowed when Agency policy directs additional documentation is required.

Example: The adjudicating component (AC) assessed a light RFC for a 54-year-old claimant and denied the claim without requesting all medical records. MAQR could be used for the required medical assessment in a category 44 deficiency because the AC did not follow policy requirements to develop a complete medical history consistent with DI 22505.001.

Example: A 52-year-old claimant with no past relevant work is assessed a sedentary RFC and found disabled by the AC without full development of all medical sources. The FQR determines the sedentary RFC is not supported. However, before finding the claimant not disabled, the missing medical sources must be contacted. MAQR should be used to prepare the SSA-416 noting the sedentary is not supported and that additional development is required.

2. When MAQR cannot be used

MAQR may not be used in the following situations:

  1. a. 

    Decisional deficiencies;

  2. b. 

    Other documentation deficiency categories not specified under section F1;

  3. c. 

    TCAs in which DQR assumes jurisdiction;

  4. d. 

    Disabled Child (DC) cases; or

  5. e. 

    Continuing Disability Review (CDR) cases.

3. Medical Assessments by MAQR qualified FQRs

DQR management will monitor and perform MAQR eligibility determinations for FQRs, and request that qualified FQRs receive the MAQR task within the Quality Review Case Processing System (QRCPS). FQRs with the MAQR task may complete and sign their own SSA-416 and other medical assessments as needed for the applicable documentation deficiencies.

4. Use of General Referrals by FQRs who do not qualify for MAQR

All FQRs may create a “MAQR Review” within the General Referral section of QRCPS. The MAQR Review referral must generally follow the preparation requirements in QR 04440.130C. The referral must also include a brief statement describing why use of MAQR versus MC/PC referral is appropriate. Qualified members of DQR management and designees will review MAQR referrals. In their discretion, these DQR management members may:

  • •

    complete the MAQR assessments,

  • •

    return referrals for FQR action, or

  • •

    initiate requests for MC or PC reviews.

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/1304440130
QR 04440.130 - Medical Review in Quality Review (QR) - 09/10/2026
Batch run: 09/10/2026
Rev:09/10/2026