TN 13 (12-10)

A. Introduction to the QR process

This subchapter discusses SSA Federal QRs and provides instructions to the Office of Quality Review (OQR) review components for returning or correcting deficient QR cases; and for processing deficiencies rebutted by the adjudicating components. OQR conducts Federal QRs of disability cases in the OQR review components located in the 10 regions and OQR Baltimore.

The main QRs are:

• quality assurance reviews, and

• preeffectuation reviews.

For an explanation of the types of QRs and the reason we perform them, see GN 04440.005.

B. Description of QR process

The automated sample selection process selects QR sample cases when the adjudicating component inputs the determination and sends the case to the review component for review, prior to effectuating the determination.

Quality reviewers conduct a review of the adjudicating component's determination using the same policy and procedural guidelines the adjudicating components use. QR follows the steps of sequential evaluation and considers all of the evidence before citing a deficiency and returning a case to the adjudicating component.

The disability examiner records the review results, including any medical review, directly to OQR’s legacy system. The legacy system automatically transmits review data to OQR in Central Office, where the data are stored and used to produce national reports.

When the case contains no returnable deficiency and is otherwise correct, the review component effectuates the determination.

If the case is deficient, QR returns the case to the adjudicating component for correction, based on the criteria listed in GN 04440.002D. of this section.

If the adjudicating component disagrees with the deficiency return, they can rebut the deficiency (if the case involves paper) or file a Request for Program Consultation (RPC) if the case is fully electronic. See GN 04440.002E. in this section and Resolving Deficiency Disagreements GN 04440.401.

NOTE: If the quality reviewer identifies a potential disability fraud issue during review, the review component should send a fraud referral via an e8551 following local procedures. If the review component is returning the case to the adjudicating component for a returnable deficiency, they can instruct the adjudicating component to perform the fraud referral.

See Also:

DI 23025.000 for an explanation of fraud or similar fault.

GN 04111.065 for instructions on preparing the e8551.

C. Sample case review

OQR reviews sample cases to ensure the evidentiary record supports the determination, and that the evidence and the determination conform to SSA operating policies and procedures, as defined in GN 04440.007A.

D. Return criteria

OQR may return a deficiency to the adjudicating component when correcting the deficiency could affect the disability determination, the period of disability, or conformance to certain technical requirements.

Specific types of deficiencies and other technical corrective actions (TCA) are defined in DI 30005.121 - DI 30005.127.

Procedures for correcting deficiencies and TCAs are described in GN 04440.201 - GN 04440.243.

E. Rebuttal criteria

The adjudicating component may use the rebuttal procedure (for paper cases) or file an RPC (for fully electronic cases) for any group I or group II deficiency, or TCA with which the adjudicating component does not agree with the review component.

Rebuttal procedures are described in GN 04440.401 - GN 04440.410.

RPC procedures are described in subchapter DI 30007.000, and only apply when the case being reviewed is a certified electronic folder.