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GN 04440.231: 12-Month Medical Evidence of Record (MER) Technical Corrective Action (TCA)

changes
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  • Effective Dates: 03/24/2017 - Present
  • Effective Dates: 02/02/2018 - Present
  • TN 13 (12-10)
  • TN 30 (02-18)
  • GN 04440.231 12-Month Medical Evidence of Record (MER) Technical Corrective Action (TCA)
  • A. Policy for a 12-month MER TCA
  • Corrective action is necessary only when the determination is unfavorable or less than fully favorable.
  • B. Procedure for a 12-month MER TCA
  • When an unfavorable or a less than fully favorable determination does not contain 12-month MER as required by DI 22505.001A.3. and the file is not documented to indicate that every reasonable effort was made to obtain the MER (see DI 22505.035), take the following action:
  • 1. Prepare a Form SSA-847-U3 (SSA Request for Case Action) to return the case to the adjudicating component.
  • Ask the adjudicating component to obtain the MER or to document the file to explain why they did not obtain the evidence.
  • * If the determination or basis code changes, prepare an amended determination and return the case to the review component; or
  • * If the determination does not change, release the case to the field office.
  • 2. Do not control the return.
  • If the missing MER has the potential to change the disability determination cite a group I medical documentation deficiency and a 12 month MER TCA. If the missing MER has the potential to change the period of disability, cite a group II medical documentation deficiency and a 12-month MER TCA.
  • If a 12-month MER TCA occurs concurrently with a medical documentation TCA, the Office of Quality Review legacy system records the medical documentation TCA.
  • When an unfavorable or a less than fully favorable determination does not contain 12-month MER as required by DI 22505.001A.3., and the file is not documented to indicate that every reasonable effort was made to obtain the MER, (see DI 22505.035) take the following actions:
  • * If the missing MER has the potential to change the disability determination, record a group I medical documentation deficiency and indicate that a 12-month MER TCA exists;
  • * If the missing MER has the potential to change the period of disability, record a group II medical documentation deficiency and indicate that a 12-month MER TCA exists;
  • * If it is unclear whether a group I or group II documentation deficiency is applicable; that is, you cannot ascertain what the missing MER may contain or address, take the following actions:
  • * prepare a Form SSA-847-U3 (SSA Request for Case Action) to return the case to the adjudicating component;
  • * include an explanation that a 12-month MER TCA exists;
  • * ask the adjudicating component to obtain the MER, and if applicable, prepare an amended determination;
  • * instruct the adjudicating component to return the case to the reviewing component upon completion of all actions; and
  • * control the return.
  • * If a 12-month MER TCA occurs concurrently with a medical documentation TCA (GN 04440.234), code the medical documentation TCA in the technical documentation deficiency field of the Office of Quality Review legacy system.
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