TN 115 (07-20)

GN 04440.008 Quality Review Process

A. Introduction to the quality review process

The Office of Quality Review (OQR) examines a sample of cases selected from adjudicating components, prior to effectuation, to ensure determinations comply with federal guidelines. Quality reviewers follow the guidelines in section B below.

B. Steps of the quality review process

Quality reviewers follow steps 1 through 8 below, as the facts of each case dictate.

  1. 1. 

    Determine whether the case meets the criteria for exclusion, as outlined in GN 04440.004 (Quality Review Exclusions). If the case is an exclusion, and does not warrant quality review, follow the procedures in the bullets below. If the case is not an exclusion, skip to step 2.

    • Identify the reason for exclusion.

    • Code the case processing system with the appropriate exclusion code.

    • Effectuate the determination, when applicable.

    • Date and release the Personalized Disability Explanation (PDE), per the instructions in DI 27025.001, if appropriate.

    • Route the folder to the field office (FO).

  2. 2. 

    Open and review all case documents. The order of document review is at the discretion of the quality reviewer.

  3. 3. 

    After initial review, determine if the adjudicating component’s determination complies with the Regulations, Social Security Rulings, and other written guidelines, such as the Program Operations Manual System (POMS). The evidence in the case must be sufficient and support the adjudicating component's determination. If the adjudicating component's determination is policy compliant and sufficient, OQR considers this a clean case. If a deficiency is suspected, and the case needs additional input, continue to step 4. If the case is clean, clear the case following the procedures in the bullets below.

    • Verify that all determination information is correct on the SSA-831-C3/U3 (Disability Determination and Transmittal).

    • Code the case processing system.

    • Effectuate the determination, when applicable.

    • Date and release the PDE, as appropriate.

    • Route the folder to the FO.

      Potential issues to consider:

      1. a. 

        It is possible that the determination and onset for a case are policy compliant, but the information on the SSA-831 is incorrect. In these instances, upload a modified SSA-831 with the correct information. Note any changes made in the "Remarks" section (Item 34) of the SSA-831.

      2. b. 

        Be sure that the case processing system coding matches the information on the SSA-831.

  4. 4. 

    Determine if you need a consultation from a medical contractor (MC) or psychological contractor (PC).

    Address questions pertinent to the medical issues in file using the medical referral in the case processing system. Be sure to address the issues to the MC or PC in a clear and concise manner. Issues that often require review by an MC or PC include questions regarding the sufficiency of evidence, onset, evaluation of medical opinions, and assessing the accuracy of the symptom evaluation completed by the adjudicating component. (See GN 04440.130 for more information regarding medical review policy.)

    NOTE: When the quality reviewer and the MC or PC cannot reach agreement on the medical findings and conclusions, or both, expressed in the formal assessment, that assessment must remain in the official claims folder, even when it is contrary to the final conclusion(s) made by the quality reviewer. In that situation, quality reviewers must prepare a rationale explaining why the medical findings and conclusions, or both, in a specific medical assessment(s), are not reflected in the final disposition of the case (e.g., the assessment(s) contains incorrect conclusions, it does not address issues that need resolution, etc.).

  5. 5. 

    Determine if any type of deficiency is present. If any deficiency is present, continue to the steps below.

    1. a. 

      Deficiencies fall into three categories:

      1. (1) 

        Group I deficiencies, as defined in GN 04440.202 (Group I Decisional Deficiencies) and GN 04440.203 (Group I Documentation Deficiencies), have the potential to reverse the determination from unfavorable to favorable or from favorable to unfavorable.

      2. (2) 

        Group II deficiencies, as defined in GN 04440.204 (Group II Deficiencies), have the potential to change the period of disability; that is, when disability started, ended, or ceased.

      3. (3) 

        Technical corrective actions (TCAs), as explained in GN 04440.230 (Introduction to Technical Corrective Actions (TCAs)), GN 04440.231 (Substantive Technical Corrective Actions (TCAs)), and GN 04440.232 (Non-substantive Technical Corrective Actions (TCAs)), are instances of non-compliance with procedural requirements that do not impact the basic determination to allow or deny or the period of disability.

    2. b. 

      Group I and group II deficiencies are further classified as decisional or documentation.

      1. (1) 

        Decisional deficiencies exist when adjudicating components sufficiently document a case to support a determination, but the evidence contradicts the determination.

        Potential issue to consider:

        Consider Substitution of Judgment (SOJ), as explained in GN 04440.118, when a group I or group II decisional deficiency exists. MCs and PCs must be aware of SOJ, as a review principle, to ensure they do not perform a "de novo" case review. If SOJ is considered, reviewers must document this in the case processing system (note section).

      2. (2) 

        Documentation deficiencies exist when medical evidence in a case is insufficient to support a disability determination or to determine the correct onset, ending, or cessation date.

        Potential issue to consider:

        It is the quality reviewer’s role to consider Probability of Reversal (POR), as explained in GN 04440.110, when a group I or group II medical or vocational documentation deficiency exists. The MCs and PCs have a limited role in the POR determination process. Reviewers may ask MCs or PCs to provide an opinion, but this opinion is not binding. Quality reviewers make the final POR determination. Reviewers must provide a rationale whenever POR is considered or applied.

  6. 6. 

    Provide a clear and concise explanation of the deficiency to the adjudicating component and request, or take, corrective action. If taking corrective action is appropriate, correct the claim and follow the procedures in step 3 of the quality review process. If taking corrective action is not appropriate, control the return, as explained in GN 04440.202 (Controlling Deficient Disability Cases), code the case processing system to reflect why the case is not policy compliant, and continue to step 7.

  7. 7. 

    Send the case back to the adjudicating component. Prepare a summary of the case, including an explanation of why the case does not comply with policy. Notify the adjudicating component and/or FO, when applicable, of the deficiency and the required corrective action(s) as follows:

    1. a. 

      Use Form SSA-1774-U5 (Request for Corrective Action) to return cases with group I or group II deficiencies, or TCAs which may affect the disability determination or the period of disability, to the adjudicating component.

    2. b. 

      Use Form SSA-5524-U3 (Request for Assistance) to request development from the FO.

    3. c. 

      Use Form SSA-847-U3 (SSA Request for Case Action) to return cases with TCAs to the adjudicating component.

  8. 8. 

    When the adjudicating component and/or FO, as applicable, corrects the deficient case or completes the required development and returns the case to OQR for review, the quality reviewer should reevaluate the full case record. Ensure that the adjudicating component has made the requested corrections and/or that the FO has provided the needed development. Determine if the case is now policy compliant or if a subsequent return, as explained in GN 04440.205, to the adjudicating component is warranted. If the case is policy compliant, clear the case following the procedures outlined above in step 3.

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GN 04440.008 - Quality Review Process - 05/03/2019
Batch run: 07/22/2020