TN 25 (12-14)

A. Introduction to routing and correcting deficient cases

The review components send cases with group I and group II deficiencies to the adjudicating components for correction and adjudicating components return the cases to the review component before effectuation. Sections GN 04440.201 through GN 04440.243 provide instructions for correcting group I and group II deficiencies and technical corrective actions (TCAs).

B. Policy for routing and correcting deficient cases

1. Group I deficiencies

Return all group I decisional deficiencies and documentation deficiencies to the adjudicating component or the field office (FO) for correction.

2. Group II deficiencies

Return group II period of disability deficiencies to the adjudicating component or FO for correction. However, in certain instances, the review component will correct group II onset date and ending date decisional deficiencies. See GN 04440.216 for information on correcting group II deficiencies.

NOTE: In Group II deficiencies, if there is missing or inadequate documentation involves a relatively simple question, (e.g., when did the claimant actually stop work) the review component has the option to telephone, email, or fax the request to the FO rather than preparing an SSA-5524-U3. When using this expedited process, the review component must document the conversation and outcome on an SSA-5002 (Report of Contact) and add it to the folder.

For an explanation of adjudicating component corrective action in group II work activity documentation deficiencies, see DI 30005.228.

3. Technical Corrective Action (TCA)

The adjudicating component or the review component will correct some TCAs. However, some TCAs do not require any corrective action; e.g., a medical documentation TCA. See GN 04440.230 for information on TCAs.

4. Split routing in certified electronic folders (CEF)

The review component can split route CEF claims, except electronic continuing disability review claims, in the Office of Quality Review (OQR) legacy system if the following apply:

• Case 1 to the adjudicating component with Controlled Return = Y or N and other cases to the FO with Controlled Return = N; or

• Case 1 to the FO with Controlled Return = Y and other cases to FO with a Controlled Return = N.

C. Routing determination forms in paper cases

Whenever the review component prepares a new SSA-831 determination form in a paper case, or makes a change in the “medical coding” on a determination form prepared by the adjudicating component, a copy of the new or amended determination form must be sent to the Wilkes-Barre Data Operations Center (WBDOC), except for certified electronic file (CEF) cases.

See GN 04440.150B.2., GN 04440.150B.5, and GN 04440.150C for filing and routing the determination form. See GN 04440.941 for a list of the fields on the SSA-831 which, when changed, require that a copy of the revised determination form be sent to the WBDOC.

D. Deficiency transmittal forms

1. Types of deficiency transmittal forms

a. Deficiency transmittal forms

There are three deficiency transmittal forms:

• SSA-1774-U5 (Request for Corrective Action);

• SSA-847-U3 (SSA Request for Case Action); and

• SSA-5524-U3 (Request for Assistance).

b. Informational returns

A deficiency transmittal form is an “informational” return when no deficiency is recorded in OQR’s legacy system. In these cases, the deficiency transmittal form is annotated “informational.” Informational returns occur when the incorrect action:

• is not covered by the defined group I deficiencies, group II deficiencies, or TCAs; or

• occurs in a non-sample case.

Note: OQR does record deficiencies that are not counted in performance accuracy calculations on the database (e.g., a deficiency covered by a grace period). Consequently, the deficiency transmittal form is not an “informational” return. However, for these returns, the transmittal form indicates that OQR will not count the deficiency in performance accuracy statistics (or similar language). See GN 04440.123G.3. for review component procedures for reviewing cases involving a grace period.

2. When to use the SSA-1774-U5

Prepare an SSA-1774-U5 to send deficient cases to the adjudicating component in cases with a:

• group I or group II deficiency (unless otherwise noted in corrective action instructions),

• group I or group II deficiency in conjunction with another deficiency, or

• substantive deficiency. See GN 04440.235C.1.

Refer to GN 04440.501B for specific instructions on completing the SSA-1774-U5 and GN 04440.901 for an exhibit of the SSA-1774-U5.

3. When to use the SSA-847-U3

Prepare an SSA-847-U3 to send deficient cases to the adjudicating component in cases with a:

• TCA; or

• deficiency that is not substantive. See GN 04440.236 - GN 04440.243 for specific instructions on non-substantive deficiencies.

Refer to GN 04440.505 for specific instructions on completing the SSA-847-U3 and GN 04440.910 for an exhibit of the form.

4. When to use the SSA-5524-U3

Prepare an SSA-5524-U3 to send cases directly to the FO. Notify the adjudicating component if you refer the case to the FO for additional development prior to adjudication. See GN 04440.510 for instructions on how to complete the SSA-5524-U3 and GN 04440.915 for an exhibit of the form.

E. Deficiency transmittal return language

In the deficiency return:

• Give a thorough explanation of why the case is deficient.

• Explain the corrective action that is necessary.

• Ask the adjudicating component or FO to correct all deficiencies.

• Specify where the adjudicating component should send the case upon completion of all corrective actions.

NOTE: If you are requesting additional medical documentation, do not direct the adjudicating component to purchase a consultative examination (CE). Instead, describe the specific evidence needed; e.g., x-rays, range of motion studies, without directing the method the adjudicating component should use to obtain it. The adjudicating component follows the instructions in the POMS subchapter DI 22505.000 and in DI 28030.020, which contain explicit instructions about the approach the adjudicating component should use when developing medical evidence.

1. Deficiency return flag for paper cases

Attach a deficiency return flag to the front of every paper case folder you return to the adjudicating component. Remove the flag upon completion of all corrective actions. See GN 04440.920 for an exhibit of the deficiency flag.

NOTE: The deficiency return flag has an entry for a telephone number the adjudicating component can use when they are unable to complete the corrective action by a specified due date. If OQR management prefers, they can specify follow-up by fax or email rather than by telephone.

If the case is a continuing disability review and the beneficiary is participating in a vocational rehabilitation or similar program, and the return has the potential to result in a cessation, annotate the routing transmittal “Potential 301 Case.”

2. FO notification

Complete the FO Alert Screen, as appropriate.

NOTE: The FO receives an electronic alert for claims we return to them as well as notification of all claims we return to adjudicating components for corrective action.

See SI 00603.020 and DI 11010.340 for specific instructions or use established regional procedures.

3. Regional Center for Disability (CD) notification

The regional CD accesses a weekly-automated report listing the deficiencies the review components cite during that week.

F. Procedure for returning a deficiency involving only the adjudicating component

When a case requires corrective action by the adjudicating component only:

• Code the review screens prior to creating the eForms so the information propagates into the eForm.

• Prepare an SSA-1774-U5 or SSA-847-U3.

• Indicate the necessary corrective action.

• Inform the adjudicating component which component they should transfer jurisdiction to upon completion of their actions.

• Control the return, if appropriate.

• Clear the case to the adjudicating component. This action transfers jurisdiction to the adjudicating component.

• Send the SSA-1774-U5 or SSA-847-U3 to the CEF during the clearance process, or print out and add the form to the paper folder.

• For controlled returns, input results data when the adjudicating component returns the corrected case.

NOTE: Follow guidelines in GN 04440.201 - GN 04440.243 for instructions regarding whether to control the return.

G. Procedure for returning a deficiency involving the adjudicating component and FO

When a case contains a group I work activity procedural documentation deficiency per GN 04440.211, Correcting Group I Work Activity Procedural Documentation Deficiencies, or a group II work activity documentation deficiency per GN 04440.228, Correcting Group II Work Activity Documentation Deficiencies, and there is another returnable deficiency:

• Code the review screens prior to creating the eForms so the information propagates into the eForm.

• Prepare an eForm SSA-5524–U3 (Request for Assistance) and ask the FO to develop work activity and document the CEF.

• Prepare an SSA-1774-U5 and notify the adjudicating component of the deficiency.

• Control the return.

• Clear the case to the FO.

• Send the SSA-5524 and SSA-1774-U5 to the CEF during the clearance process.

NOTE: The Review Component (RC) retains jurisdiction of the CEF in pending status. RC clearance stops processing time from accruing on the case while the FO completes the requested development. Follow DI 81030.021E.1., DI 81030.021E.2. or DI 81030.021E.3. for review component action after receiving the FO completed development.

H. Procedure for returning a deficiency involving only the FO

1. Group I substantial gainful activity (SGA) decisional deficiency

When there is clear evidence of SGA, and a FO SGA determination is required per GN 04440.210, Correcting Group I Substantial Gainful Activity Decisional Deficiencies, take the following action:

• Code the review screens prior to creating the eForms so the information propagates into the eForm.

• Prepare an eForm SSA-5524 and ask the FO to develop work activity and document the CEF.

• Prepare an SSA-1774-U5 using eForms and notify the Adjudicative Component of the deficiency.

• Control the return.

• Clear the case to the FO.

• Send the SSA-5524 and SSA-1774-U5 to the CEF during the clearance process.

• NOTE: RC retains jurisdiction of the CEF in pending status. RC clearance stops processing time from accruing on the case while the FO completes the requested development.

• Follow DI 81030.021E.1. or DI 81030.021E.2. for RC action after receiving the FO completed development.

2. Group I or II documentation deficiency and no other returnable deficiency - work activity not documented on modernized claims system (MCS) or modernized supplemental security income claims system (MSSICS)

When there is a group I work activity procedural documentation deficiency or a group II work activity documentation deficiency, and no other returnable deficiency, and the work activity is not documented on MCS/MSSICS per GN 04440.211C.2.b. and GN 04440.228C.2.b.:

• Code the review screens prior to creating the eForms so the information propagates into the eForm.

• Prepare an SSA-5524 and ask the FO to develop work activity and document the CEF.

• Prepare an SSA-1774-U5 and notify the adjudicating component of the deficiency.

• Control the return.

• Clear the case to the FO.

• Send the SSA-5524 and SSA-1774-U5 to the CEF during the clearance process.

NOTE: In Group II deficiencies, if there is missing or inadequate documentation involves a relatively simple question, (e.g., when did the claimant actually stop work) the review component has the option to telephone, email, or fax the request to the FO rather than preparing an SSA-5524-U3. When using this expedited process, the review component must document the conversation and outcome on an SSA-5002 (Report of Contact) and add it to the folder.

For an explanation of adjudicating component corrective action in group II work activity documentation deficiencies, see DI 30005.228.

The review component retains jurisdiction of the CEF in pending status. The review component clearance stops processing time from accruing on the case while the FO completes the requested development. Follow DI 81030.021E.1., DI 81030.021E.2. or DI 81030.021E.3. for action after the FO completes development.

3. Non-recorded substantive deficiency

When the case contains a non-recorded substantive deficiency and the FO must take corrective action because the date last insured (DLI), prescribed period (PP) or attainment of age 22 is at issue, develop per GN 04440.235C.1.b., Correcting Non-Recorded Deficiencies, and take the following additional action:

• Code the review screens prior to creating the eForms so the information propagates into the eForm.

• Prepare an SSA-5524 and ask the FO to verify the DLI, PP or attainment of age 22 (whichever is at issue) and document the CEF.

• Prepare an informational SSA-1774-U5 and notify the adjudicating component of the non-chargeable deficiency.

• Control the return.

• Clear the case to the FO.

• Send the SSA-5524 and SSA-1774-U5 to the CEF during the clearance process.

NOTE: In Group II deficiencies, if there is missing or inadequate documentation involves a relatively simple question, (e.g., when did the claimant actually stop work) the review component has the option to telephone, email, or fax the request to the FO rather than preparing an SSA-5524-U3. When using this expedited process, the review component must document the conversation and outcome on an SSA-5002 (Report of Contact) and add it to the folder.

For an explanation of adjudicating component corrective action in group II work activity documentation deficiencies, see DI 30005.228.

The review component retains jurisdiction of the CEF in pending status. The review component clearance stops processing time from accruing on the case while the FO completes the requested development. Follow DI 81030.021E.1., DI 81030.021E.2. or DI 81030.021E.3. for action after the FO completes development.

I. Procedure after FO corrective action

1. FO determines that SGA denial is applicable

If the FO agrees that there is clear evidence of SGA (per DI 81030.021D.1.), or if after the group I work activity procedural documentation deficiency issue is resolved (per DI 81030.021C or DI 81030.021D.2.), the FO determines that an SGA denial determination is appropriate, the FO documents the CEF with their completed development.

When the FO responds to the review component's assistance request with completed development, the review component:

• Creates a Return Workload Unit (WU).

• Completes the applicable review screens, including entering “Y” in the FO determination required (FO Detn Reqd? Y/N) field.

• Clears the case to the FO.

NOTE: Once the review component clears the case, OQR’s legacy system automatically transfers jurisdiction of the CEF to the FO in pending status.

• The FO takes the appropriate actions to complete the SGA denial.

2. FO determines SGA denial is inappropriate

If the FO does not agree that the claimant is engaging in SGA (per DI 81030.021D.1.), or if after the group I work activity procedural documentation deficiency issue is resolved (per DI 81030.021C or DI 81030.021D.2.), the FO documents the CEF with their completed development.

When the FO responds to the review component's assistance request with completed development:

a. If you do not need the adjudicating component to take corrective action:

• Create a Return WU.

• Complete the applicable screens. Make changes to the SSA-831 (Disability Determination and Transmittal) and notice, as appropriate.

• Clear the case as you normally would for completed cases or second returns, as appropriate.

NOTE: Once the case is cleared, OQR’s legacy system automatically transfers jurisdiction of the CEF to the FO in closed status, or

b. If you need corrective action from the adjudicating component:

• Create a Return WU.

• Code the review screens prior to creating the eForms so the information propagates into the eForm.

• Prepare a new SSA-1774-U5 using eForms, and:

• Indicate the necessary corrective action;

• Inform the adjudicating component which component they should transfer jurisdiction to upon completion of their actions.

• Control the return, if appropriate.

• Clear the case to the adjudicating component. This action transfers jurisdiction to the adjudicating component.

• Send the SSA-1774-U5 to the CEF during the clearance process.

• For controlled returns, input the results data when the adjudicating component returns the corrected case.

NOTE: Follows guidelines in GN 04440.201 through GN 04440.243 for instructions regarding whether to control the return.

3. Onset or ending date

If, after the work activity (per DI 81030.021C or DI 81030.021D.2.) Date Last Insured (DLI), Prescribed Period (PP) or attainment of age 22 (per DI 81030.021D.3.) issues are resolved, the onset/ending date remains the same, or onset or ending date changes, the FO documents the CEF with their completed development.

When the FO responds to your assistance request with completed development:

a. If you do not need the adjudicating component to take corrective action:

• Create a Return WU.

• Complete the applicable screens. Makes changes to the SSA-831 and notice, as appropriate.

• Clear the case as you normally would for completed cases or second returns, as appropriate.

NOTE: Once the case is cleared, OQR’s legacy system automatically transfers jurisdiction of the CEF to the FO in closed status, or

b. If you need the adjudicating component to take corrective action:

• Create a Return WU.

• Code the review screens prior to creating the eForms so the information propagates into the eForm.

• Prepare a new SSA-1774-U5 using eForms, and:

• Indicate the necessary corrective action;

• Inform the adjudicating component which component they should transfer jurisdiction to upon completion of their actions.

• Control the return, if appropriate.

• Clear the case to the adjudicating component. This action transfers jurisdiction to the adjudicating component.

• Send the SSA-1774-U5 to the CEF during the clearance process.

• For controlled returns, input the results data when the adjudicating component returns the corrected case.

NOTE: Follows guidelines in GN 04440.201 through GN 04440.243 for instructions regarding whether to control the return.

4. Onset is after DLI, PP, or attainment of age 22

If, after the FO documents or verifies DLI, PP or attainment of age 22 (per DI 81030.021D.3.), the FO finds that the established onset date (EOD) is after DLI, PP or attainment of age 22, the FO documents the CEF with their completed development.

When the FO responds to your assistance request with completed development:

• Create a Return WU.

• Code the review screens prior to creating the eForms so the information propagates into the eForm.

• Prepare a new informational SSA-1774-U5 using eForms, and:

• Inform the adjudicating component to prepare the denial determination if the EOD cannot be established prior to the DLI (per DI 25501.300A.8., and DI 25501.320A.1.); the EOD cannot be established later then the last day of the prescribed period (See DI 25501.350A.3. and DI 25501.360A.2.); established onset date for Childhood Disability Benefits claims (per DI 25501.330).

• Inform the adjudicating component not to return the case to the review component.

• Do not control the return.

• Clear the case to the adjudicating component. This action transfers jurisdiction to the adjudicating component.

• Send the SSA-1774-U5 to the CEF during the clearance process.