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GN 04440.004: Quality Review Exclusions

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  • Effective Dates: 08/22/2014 - Present
  • Effective Dates: 05/31/2018 - Present
  • TN 22 (08-14)
  • TN 32 (05-18)
  • GN 04440.004 Quality Review Exclusions
  • A. Introduction to quality review exclusions
  • The Office of Quality Review (OQR) conducts reviews on adjudicating component determinations selected for preeffectuation review (PER), quality assurance review (QA), targeted denial review (TDR), and other special samples. OQR may receive incorrectly sampled cases or cases that do not meet the criteria for quality review.
  • The Office of Quality Review (OQR) conducts reviews on determinations made by adjudicating components and selected for pre-effectuation review (PER), quality assurance review (QA), targeted denial review (TDR), and other special samples. Quality review exclusions are incorrectly sampled cases or cases that do not meet the criteria for quality review.
  • B. Quality review exclusion policy
  • The first step in the quality review process is to determine if the sampled case is an exclusion. OQR excludes cases that meet the criteria of an exclusion as identified in GN 04440.004C in this section. Cases excluded from quality review require OQR legacy system coding.
  • The first step in the quality review process is to determine if the sampled case is an exclusion. OQR excludes cases that meet the criteria of an exclusion as identified in GN 04440.004C in this section. Code cases excluded from quality review in the OQR legacy system.
  • C. Exclusion codes and definitions
  • C. Quality review exclusion reasons
  • The following table indicates all OQR legacy system codes for quality review exclusions and a description of each code.
  • Code
  • Exclusion Definitions
  • 01
  • Non-State Cases Selected for Review – If OQR inadvertently receives a case from a non-sampled federal site, we do not conduct the quality review. As we expand review of federal sites, this exclusion will become more rare. Reviewers may refer to management if they are unsure.
  • 02
  • Number holder attains full retirement age in the waiting period or dies within five months of the alleged onset date and no earlier onset date is possible
  • 03
  • Supplemental Security Income (SSI) Only – Applicant Dies Prior to Adjudication
  • 05
  • Number holder/Applicant does not want to continue development of claim – Regulation Basis Codes M7/M8-1516 and N38-916
  • 06
  • Informal Remands
  • 07
  • FO Jurisdiction – Whereabouts Unknown (WU) – Exclude a WU case from the QA or PER sample when the field office (FO) has jurisdiction of the case. We do not review a case that is not under the adjudicating component’s jurisdiction.
  • 08
  • Invalid PER Selection – Claim 1 is aTitle II Denial, Title II CDR, or Titl XVI Disabled Child, Per is composed of adult initial and reconsideration allowances only
  • 09
  • Reconsideration – continuing disability review (CDR) cessation
  • 10
  • FO Jurisdiction – No Medical Determination Needed
  • 12
  • Medicare Only – Death Precludes Entitlement
  • 13
  • Res Judicata – Refiling of a claim denied for the same period. (For additional information on res judicata see matrix chart in GN 04440.004D in this section.)
  • 14
  • Adjudication by a Component Other than the Jurisdictional Adjudicating Component – This exclusion code is for cases when Site A has jurisdiction, Site B does the development and makes the determination, but the case clears from Site A. If we do not exclude these cases from review, it may unfairly affect the accuracy rating of Site A.
  • 15
  • PER only Claim Involving Reconsideration or Reopening of Onset or Ending Date in a Prior Allowance – If the adjudicating component clears an allowance case, and then reopens that case to change the onset or ending date only, we exclude from OQR review.
  • 17
  • Sample Selection not Received in a 6-Month Timeframe – PER sample cases that are paper only
  • 18
  • Special Disability Workload (SDW) Claim Without Cadre Involvement
  • 19
  • QA Reopening of a Prior Reconsideration Determination – In the QA sample, a reopening of a prior reconsideration determination includes appeal rights to a disability hearing and the sampled reopening may actually be a Disability Hearings Officer decision. The level would not be distinguishable from a determination made by an adjudicating component examiner.
  • 20
  • Concurrent Claim Selected for SSI PER
  • 21
  • Multi Category Case – SSI recipient filing only to change to another category (e.g. DI to BI)
  • 22
  • Virtual Case – Non-receipt of essential current or prior paper folder
  • 23
  • Non CDR Paper Case – OQR does not select paper cases with the exception of the QA CDR sample
  • 88
  • Other – None of the other exclusion codes apply. Cases excluded with this code are subject to supervisory approval and reviewers MUST explain the reason in the Notes section of the OQR legacy system (e.g., reactivated case sampled and previously reviewed by OQR).
  • Exclude the following types of cases from quality reviews:
  • * Non-State cases selected for review – If OQR inadvertently receives a case from a non-sampled federal site, do not conduct the quality review.
  • * Number holder attains full retirement age in the waiting period or dies within five months of the alleged onset date and no earlier onset date is possible.
  • * Supplemental Security Income (SSI) only and the applicant dies prior to adjudication.
  • * Number holder/applicant does not want to continue development of claim – regulation basis codes M7/M8 and N38.
  • * Informal remands.
  • * Field office (FO) jurisdiction – Whereabouts Unknown (WU) – Exclude a WU case from the QA or PER sample when the FO has jurisdiction of the case. OQR does not review a case that is not under an adjudicating component’s jurisdiction.
  • * Invalid PER selection – Claim 1 is a Title II Denial, Title II continuing disability review (CDR), or Title XVI Disabled Child. The PER samples are composed of adult initial and reconsideration allowances only.
  • * Reconsideration of a CDR cessation.
  • * FO substantial gainful activity or technical denial – no medical determination needed.
  • * Medicare only cases when death precludes entitlement.
  • * Res judicata – Refiling of a claim denied for the same period. (For additional information on res judicata, see matrix chart in GN 04440.004D in this section.)
  • * Adjudication by a component other than the jurisdictional adjudicating component – Exclude a case when site A has jurisdiction, site B does the development and makes the determination, but the case clears from site A. If we do not exclude these cases from review, it may unfairly affect the accuracy rating of site A.
  • * PER only claim involving a reconsideration or reopening of onset or ending date in a prior allowance – If the adjudicating component clears an allowance case then reopens that case to change the onset or ending date only, exclude the case from OQR review.
  • * Sample selection not received within required timeframe.
  • * Case meets exclusion criteria, however, issues noted that require correction.
  • * QA reopening of a prior reconsideration determination – In the QA sample, a reopening of a prior reconsideration determination includes appeal rights to a disability hearing and the sampled reopening may actually be a disability hearings officer decision. The level would not be distinguishable from a determination made by an adjudicating component examiner.
  • * Concurrent claim selected for SSI PER.
  • * Multi category case – SSI recipient filing only to change to another category (e.g. disabled individual to blind individual).
  • * Paper case – OQR does not sample paper cases, or cases with an associated paper folder.
  • * Other – None of the other exclusions apply. These cases are subject to supervisory approval and you MUST explain the reason in the Notes section of the OQR legacy system (e.g., reactivated case sampled and previously reviewed by OQR).
  • D. Res Judicata matrix for quality review cases
  • The following matrix provides quality reviewers with instructions on whether to exclude, review, or cite a deficiency on a res judicata case:
  • The matrix in this section provides quality reviewers with instructions on whether to exclude, review, or cite a deficiency on a res judicata case:
  • Field Office (FO)
  • Adjudicating Component
  • OQR
  • Deficiency or Exclude
  • Res Judicata
  • Res Judicata
  • No Res Judicata
  • Exclude
  • Res Judicata
  • No Res Judicata
  • Res Judicata
  • Exclude
  • No Res Judicata
  • No Res Judicata
  • Res Judicata
  • Exclude
  • No Res Judicata
  • Res Judicata
  • No Res Judicata
  • Deficiency
  • Res Judicata
  • Res Judicata
  • Res Judicata
  • Exclude
  • No Res Judicata
  • No Res Judicata
  • No Res Judicata
  • Regular Review
  • No Res Judicata
  • Res Judicata
  • Res Judicata
  • Exclude
  • E. Processing an excluded quality review cases
  • E. Processing excluded quality review cases
  • If a quality reviewer makes a determination to exclude the case, he or she must:
  • If a quality reviewer makes a determination to exclude the case. When you exclude a case from review, you must:
  • * Fill out the appropriate fields in the OQR legacy system;
  • * Indicate the appropriate exclusion code;
  • * Indicate the appropriate exclusion code (see legacy system Help screen for codes);
  • * Effectuate the determination, when applicable; and
  • * Release Personalized Decision Notices (PDNs) in file, if applicable.
  • * Release Personalized Disability Explanation in file, if applicable.
  • F. Handling deficient quality review exclusion cases
  • If a quality reviewer determines that a case is deficient, but the case meets exclusion criteria, the quality reviewer will not cite a deficiency. OQR must address any issues discovered during the quality review process to protect the integrity of the review.
  • In some instances, you may complete a full or partial quality review to determine that a case is an exclusion. If you determine that a case is deficient, but the case meets exclusion criteria, you must not cite a deficiency. However, OQR must address all issues discovered during the quality review process to protect the integrity of the review.
  • If a quality reviewer discovers a deficiency in an excluded case, he or she must:
  • * Enter deficiency code 99 in the OQR legacy system;
  • * Create and complete Form SSA-847-U3 (Request for Case Action) and explain the deficiency;
  • * Indicate that the deficiency is information only and is not chargeable;
  • * If possible, OQR will make corrective action and route to the FO for processing. If corrections require adjudicating component action, forward the case to the appropriate component for completion; and
  • If you discover a deficiency in an excluded case:
  • * Do not record a deficiency in the OQR legacy system;
  • * Create and complete the appropriate return document per GN 04440.201D and explain the deficiency;
  • * Indicate that the deficiency is informational only and is not chargeable;
  • * Take one of the following actions:
  • * Make any necessary correction(s);
  • * Forward the case to the adjudicating component for correction(s); or
  • * Route to the FO for processing
  • * Effectuate the determination, if appropriate.
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