GN 04440: Federal Quality Review of Disability Determinations
TN 13 (12-10)
A. Standard used in QR
The review standard for QR cases is that the adjudicating component's determination must conform to:
Social Security regulations and rulings;
Other written guidelines, such as the Program Operations Manual System (POMS); and
The documented facts in each case, including the medical and administrative documentation in file, the rationales or explanations in all administrative forms, and notices in file. For an explanation of what constitutes documentation and documentation requirements, see GN 00301.285.
When evaluating if the evidence in file supports the disability determination, the quality reviewer follows the preponderance of evidence standard. Establishment of preponderance is that piece or body of relevant evidence that is more convincing when weighed against the evidence in opposition.
For a complete explanation of the preponderance of evidence standard see DI 23025.001B.5.
NOTE: If you are a quality reviewer who receives a case from the adjudicating component and the evidence is insufficient, even if the adjudicating component inadvertently cleared the case, contact the adjudicating component and request the missing evidence. If the adjudicating component does not fax the evidence necessary to make a disability determination into the folder, or the review component does not receive it within a reasonable amount of time, the quality reviewer may cite a deficiency. If the file references the missing essential evidence, follow the instructions in “Correcting Cases with Essential Evidence that is Missing or Illegible” GN 04440.242, and “Correcting Cases with Essential Evidence that is Missing or Illegible” DI 30005.241.
B. Procedure for deficiency citation and support
1. Deficiency citation
Cite a deficiency if the evidence:
is insufficient to support a determination; or
clearly contradicts the determination.
Determine the sufficiency of the documentation. Be sure the file contains sufficiently detailed reports on history, physical and mental examinations, laboratory studies, and any prescribed therapy and response to permit the quality reviewer to assess impairment severity and duration.
2. Deficiency support
Support the deficiency citation with specific references to:
the evidence in file;
the needed evidence; and
the specific, relevant POMS section(s).
NOTE: Regional POMS supplements are authorized policy/procedural vehicles for the region for which they are issued. A review component can cite a regional supplement as the basis for a return to an adjudicating component within the region that issued the supplement. The quality reviewer should not use Office of Disability Policy memorandums, adjudicating component’s Administrative Letters, Request for Program Consultation responses, or other similar written guidelines to justify or explain a deficiency. PolicyNet Questions & Answers (Q&As) that are designated as “Active” and have a “Due for Review” date in the future can be referenced as clarification following the citation of the base policy used to explain the deficiency. Other “Active” Q&As with an expired “Due for Review” date may be paraphrased, if applicable, in the explanation of the deficiency but may not be referenced. Emergency messages and administrative messages carry the weight of POMS and you may reference them in support of a deficiency citation.
3. Entries on case file SSA-831-C3/U3 (Disability Determination and Transmittal), 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) different from entries on the Office of Quality Review’s (OQR) legacy system
If the entries on the SSA-831-C3/U3, SSA-832-C3/U3, or SSA-833-C3/U3 in the case file differ from those on the download record (i.e., the data input by the adjudicating component when they clear the case that are passed on to OQR’s legacy system database), base your review on OQR’s legacy system record, unless the difference is due to an obvious keying error.
Base the citation of any deficiency on a disagreement with OQR’s legacy system record. Even if you agree with the entries on the disability determination that is in the case file, still cite a deficiency.
C. Use of queries
To properly document work history, the adjudicating component must address all material inconsistencies in a claimant’s work history. The adjudicating component:
May use SEQY, DEQY, or DISCO queries to address material work history inconsistencies.
Should only obtain a query when it is likely that the information the query contains will be useful in addressing the issue at hand (e.g., a material inconsistency in the claimant’s work history or in determining if a job is relevant).
Must place into the case file any query obtained to address material inconsistencies in the claimant’s work history.
Must explain the use of a query, if obtained or referenced.
Must address all material inconsistencies raised by a query, regardless of the reason the adjudicating component obtained or referenced the query.
Must address all material inconsistencies raised by a query that the adjudicating component did not obtain but are present in the case file.
1. Procedure when there is no query referenced or in file
When there is no query referenced or in file, the review component:
must not obtain a query, even if it appears that information from the query could resolve a material inconsistency in the claimant’s work history;
should return the case when material work history inconsistencies exist, specifying for the adjudicating component the inconsistencies they must resolve and explain; and
should not instruct the adjudicating component to obtain a query nor specify how the adjudicating component should address any material inconsistency identified by the review component.
2. Procedure when there is a query referenced or in file
When there is a query referenced or in file, the review component:
may use the query (but only the same query that is in the file, or a query the adjudicating component obtained, referenced, or clearly used) to conduct their case review; and
may cite deficiencies based on the information the query contains.
NOTE: If the query the adjudicating component used is not in file, identified, or clear from the case record, then the review component may use the SEQY, DEQY, or other queries in conducting the case review and may cite deficiencies based on the information the queries contain.
DI 22515.020 – Resolving Insufficient Vocational Evidence using a Detail Earnings Query (DEQY) or a Summary Earnings Query (SEQY)