TN 15 (02-11)

A. Introduction to reviewing cases that have been inadvertently effectuated

The review component performs quality reviews (QRs) before the determination is effectuated; however, some cases selected for the sample may be inadvertently effectuated before the review. For paper cases, on occasion, a request for an appeal, i.e., a request for reconsideration or a hearing, is filed while an effectuated sample case is undergoing review. Appeal requests can be associated and filed with an effectuated case still undergoing QR. For an explanation of adjudicating component action, refer to DI 30005.413.

B. Reviewing effectuated cases

• Review and process the case as expeditiously as possible to avoid possible overpayment or nonpayment of benefits.

• Base the review on the sample record (i.e., the National Disability Determination Services System determination input by the adjudicating component at the time they cleared the case and it was selected for QR), regardless of whether the entries on the SSA-831-C3/U3 (Disability Determination and Transmittal), SSA-832-C3/U3 (Cessation or Continuance of Disability or Blindness Determination and Transmittal – Title XVI), and SSA-833-C3/U3 (Cessation or Continuance of Disability or Blindness Determination and Transmittal – Title II) in the case differ from those on the sample record.

• For paper cases, hand-carry the folder through each step of the process if a request for an appeal has been associated with the case file.

C. Procedure when no appeal is filed

1. General review policy

Cite all applicable group I and group II deficiencies on cases that have been inadvertently effectuated. If correcting the case will result in a change in the disability determination or in the onset, ending or cessation date, you must follow the rules on reopening and revising determinations.

2. Review policy for adverse reopenings

Apply the medical improvement review standard (MIRS), which includes consideration of both medical improvement (MI) and the exceptions to MI, to any adverse reopening that would result in the termination of benefits or in a less favorable ending or cessation date.

With rare exceptions, this means:

• a determination of allowance or continuance may only be changed (based on medical or vocational factors) to a determination of denial, closed period of disability, or cessation; or

• an ending date or cessation date may only be changed (based on medical or vocational factors) to a less favorable date, if the case meets one of the group I error exceptions or the group II fraud or similar fault exception to MIRS.

For more information on the effect of MIRS on reopening and revision and exceptions, see DI 27501.005B.4. and DI 28020.000.

3. Fully favorable determination made by the adjudicating component with a group I or group II documentation deficiency

If the case contains a group I or group II documentation deficiency, take the following action.

• Return the case to the adjudicating component by SSA-1774-U5 (Request for Corrective Action) and request corrective action.

• Cite the group I or group II documentation deficiency.

• Include the following statement on the SSA-1774-U5 if the deficiency is a group I documentation deficiency:

  We have cited a group I documentation deficiency. If the documentation you obtain changes the disability determination, follow existing adverse reopening procedures. Return the case to the review component for completion of the review.

Refer to GN 04440.250C.2. regarding the application of MIRS in an adverse reopening situation.

NOTE: MIRS does not apply to reopening and revision to a later onset date per DI 27501.005B.4.b. and DI 28005.001D.2.c.

4. Fully favorable determination made by the adjudicating component with a group I decisional deficiency

If the case contains a group I decisional deficiency, take the following actions.

• Return the case to the adjudicating component by SSA-1774-U5 and request corrective action.

• Cite the group I decisional deficiency.

• Include the following statement on the SSA-1774-U5 when a MIRS group I or group II exception to MI does not apply:

  We have cited a group I decisional deficiency in this case. However, we do not believe the determination can be reopened under the fraud or error exceptions to MIRS. Therefore, no further action is necessary at this time. After your review, return the case to the review component.

• When an MIRS exception applies, tailor the return to the situation. Remind the adjudicating component to follow the adverse reopening procedures and to return the case to the review component for completion of the review.

5. Fully favorable determination made by the adjudicating component with a group II decisional deficiency

If the case contains a group II onset date decisional deficiency, return the case to the adjudicating component by SSA-1774-U5 and advise the adjudicating component to follow existing reopening procedures. Note that MIRS does not apply to reopening and revision to a later onset date per DI 27501.005B.4.b. and DI 28005.001D.2.c.

6. Less than fully favorable determination made by the adjudicating component with a group I or group II documentation deficiency

If the case contains a group I or group II documentation deficiency, take the following actions.

• Return the case to the adjudicating component by SSA-1774-U5 and request corrective action.

• Cite the group I or group II documentation deficiency.

• Include the following statement on the SSA-1774-U5:

  We have cited a group I (group II) documentation deficiency. If the documentation you obtain changes the disability determination (onset or ending date) to an unfavorable determination (less favorable ending date), follow existing adverse reopening procedures. Return the case to the review component for completion of the review.

Refer to GN 04440.250C.2. regarding the application of MIRS in an adverse reopening situation.

NOTE: MIRS does not apply to reopening and revision to a later onset date per DI 27501.005B.4.b. and DI 28005.001D.2.c.

7. Less than fully favorable determination made by the adjudicating component with a group I decisional deficiency

If the case contains a group I decisional deficiency, take the following actions.

• Return the case to the adjudicating component by SSA-1774-U5 and request corrective action.

• Cite the group I decisional deficiency.

• Include the following statement on the SSA-1774-U5 if the determination should be unfavorable and an MIRS group I or group II exception to MI does not apply:

  We have cited a group I decisional deficiency in this case. However, we do not believe the determination can be reopened under the fraud or error exceptions to MIRS. Therefore, no further action is necessary at this time. Return the case to the review component for completion of the review.

• When an MIRS exception applies, tailor the return to the situation. Remind the adjudicating component to follow the adverse reopening procedures and to return the case to the review component for completion of the review.

For review policy on adverse reopening when no appeal is filed, see GN 04440.250C.2.

8. Less than fully favorable determination made by the adjudicating component with a group II decisional deficiency

If the case contains a group II onset date decisional deficiency, return the case by SSA-1774-U5 and advise the adjudicating component to follow existing reopening procedures.

MIRS does not apply to reopening and revision to a later onset date per DI 27501.005B.4.b. and DI 28005.001D.2.c.

MIRS applies to a group II ending or cessation date that is less favorable than the ending or cessation date established in the effectuated determination.

9. Unfavorable determination made by the adjudicating component with a group I or group II documentation deficiency

If the case contains a group I or a group II documentation deficiency, take the following actions.

• Return the case to the adjudicating component by SSA-1774-U5 and request corrective action.

• Cite the group I or group II documentation deficiency.

• Include the following statement on the SSA-1774-U5:

  We have cited a group I (group II) documentation deficiency. If the documentation you obtain changes the disability determination (or the cessation date), follow existing reopening procedures. Return the case to the review component for completion of the review.

NOTE: If you propose a less favorable cessation date, you have to establish MI from the last comparison point decision (CPD) to the proposed cessation date to revise the cessation date if no exceptions to MI apply.

See DI 28005.205D.2. for cessation month and error exception cases.

10. Unfavorable determination made by the adjudicating component with a group I decisional deficiency

If the case contains a group I decisional deficiency, take the following actions.

• Return the case to the adjudicating component by SSA-1774-U5 and request corrective action.

• Cite the group I decisional deficiency.

• Include the following statement on the SSA-1774-U5:

  We have cited a group I decisional deficiency in this case. Please reopen and revise the determination following existing reopening procedures. Return the case to the review component for completion of the review.

11. Unfavorable determination made by the adjudicating component with a group II decisional deficiency

If the case contains a group II decisional deficiency, take the following action.

• Return the case to the adjudicating component by SSA-1774-U5.

• Cite the group II decisional deficiency.

• Advise the adjudicating component to follow the existing procedures for reopening and revision. (For cessation month and error exception cases, see DI 28005.205D.2.)

NOTE: If you propose a less favorable cessation date, and no exceptions to MI apply, MI from the last CPD to the proposed cessation date would have to be established in order to revise the cessation date.

References

• For an explanation of reopenings and revisions, see DI 27501.000.

• For preparation of a revised SSA-831-C3/U3, see DI 27530.000.

• For an explanation of MIRS and when it applies, see DI 28005.000.

• For exceptions to MIRS, see DI 28020.000.

• For preparation of a revised SSA-832-C3/U3 or SSA-833-C3/U3, see DI 28501.000.

D. Review component procedure when request for reconsideration is filed

1. General procedure for all paper cases

If the review component receives notice of a request for reconsideration or the Form SSA-3441-BK (Disability Report – Appeal) while a case is undergoing QR:

• associate the SSA-3441-BK or the notice of an appeal with the case;

• ensure the case receives expedited processing; and

• send the folder to the field office (FO) upon completion of the quality review. Use an SSA-5524-U3 (Request for Assistance) if FO development is necessary. Otherwise, use Form SSA-559 (Transmittal Slip for Claims Folders) to route the folder.

2. Procedure for deficient cases when reconsideration request filed in FO

If the request for reconsideration was filed in the FO:

• associate the appeals notice or SSA-3441-BK with the case;

• ensure the case receives expedited processing;

• prepare an SSA-1774-U5 and send it to the adjudicating component with the folder;

• instruct the adjudicating component to take corrective action and all reconsideration actions, including the preparation of the SSA-831-C3/U3, SSA-832-C3/U3, and SSA-833-C3/U3, if necessary;

• instruct the adjudicating component to return the case to the review component.

For an explanation of adjudicating component action in these situations, refer to DI 30005.413C. For an explanation of FO actions when a request for reconsideration is filed, see DI 12005.005 – DI 12005.020.

3. Procedure for deficient cases when reconsideration request not filed in FO

If you receive the request for reconsideration in the review component without the FO processing the request first:

• prepare a photocopied file;

• prepare an SSA-1774-U5 and send it to the adjudicating component with the photocopied file.

Instruct the adjudicating component to:

• take all reconsideration actions, including the preparation of the SSA-831-C3/U3, SSA-832-C3/U3, or SSA-833-C3/U3, if necessary;

• associate the original folder with the photocopied file, in the event of a reversal, before requesting any necessary development of reversal action; and,

• return the case to the review component before effectuation of the revised determination.

Then,

• send the original case file, with a copy of the SSA-1774-U5, to the FO for their necessary reconsideration action.

For an explanation of adjudicating component action in these situations, refer to DI 30005.413C. For an explanation of FO actions when a request for reconsideration is filed, see DI 12005.005 – DI 12005.020.

E. Review component procedure when request for hearing is filed

If the review component receives a request for a hearing, or notice that a request for a hearing has been filed, while a case is undergoing QR, review the case to determine if informal remand criteria are met (see DI 27520.001). Depending on whether the criteria for informal remand are or are not met, follow the procedure in GN 04440.250E.1. and GN 04440.250E.2.

1. Informal remand criteria not met

If review of the case indicates that the informal remand criteria in DI 27520.001 are not met, do not complete a QR of the case.

Annotate an SSA-559 indicating that the informal remand criteria are not met and forward the folder to the FO for their necessary action. Exclude the case from the QR sample using code "88."

2. Informal remand criteria met

If the informal remand criteria in DI 27520.001 are met, complete the following general review criteria.

• Complete your review within 3 working days, if possible.

• Alert the FO by annotating the transmittal form (e.g., SSA-559) that the informal remand criteria are met.

• Annotate the transmittal form (e.g., SSA-559) with the applicable criteria for reversal action, when appropriate (see DI 27520.001).

• Forward the folder to the FO for their necessary action.

See GN 04440.250E.3. if the case has a returnable deficiency.

3. Informal remand criteria met - deficient cases

If the case has a returnable deficiency, take the following actions.

• Photocopy the case file.

• Prepare an SSA-1774-U5.

• Send the original folder to the FO with a copy of the SSA-1774-U5 and with the SSA-559 annotated as in GN 04440.250E.2. for their necessary action.

• Send the SSA-1774-U5 and photocopied file to the adjudicating component.

Instruct the adjudicating component to:

• query the location of the folder and obtain the folder;

EXCEPTION: If the folder is in the Office of Disability Adjudication and Review (ODAR), advise the adjudicating component to return the SSA-1774-U5 and photocopied file to the review component and indicate that the folder is in ODAR and unavailable.

• associate the SSA-1774-U5 with the original folder, take corrective action, and process the informal remand; and

• return the folder to the review component if they are able to reopen and favorably revise the determination; or

• send the folder to ODAR in accordance with processing instructions in POMS subchapter DI 27520.000 if they are not able to reopen and favorably revise the determination; and

• notify the review component that the folder has been forwarded to ODAR.

See Details:

For adjudicating component action upon receipt of informal remand cases, see DI 27520.005.

When a request for reconsideration is filed while the case is in the review component, see DI 30005.413C.3.