GN 04440: Federal Quality Review of Disability Determinations
TN 15 (02-11)
A. Introduction to DHU cases
Section 205(b)(2) of the Social Security Act (as amended by sections 4 and 5 of P. L. 97-455 make available a face-to-face evidentiary hearing (i.e., a disability hearing) at the reconsideration level of appeal for claimants who receive medically based cessation determinations or medically based adverse reopening determinations.
DHU jurisdiction cases are:
reconsideration level medical cessations; and,
adverse reopenings of favorable initial and reconsideration determinations revised for medical reasons.
NOTE: An established onset date (EOD) after the alleged onset date is adverse to the claimant unless the EOD is set at date first insured.
If the claimant requests a disability hearing, process the case in the following order.
Initially, send the case to the adjudicating component to ascertain if a fully favorable determination can be made.
Subsequently, send the case to the DHU for a disability hearing when the adjudicating component cannot make a fully favorable determination.
B. Procedure for paper and certified electronic folder (CEF) deficient DHU jurisdiction cases
The DHU has jurisdiction of the case if the claimant:
elects to receive a disability hearing and has a fully favorable continuing disability review (CDR) reconsideration determination (i.e., continuance); or,
a fully favorable reconsideration determination of an adverse reopening contains a group I or group II deficiency and correction of the deficiency results in a cessation or less than fully favorable determination.
1. DHU jurisdiction
Consider the case as having DHU jurisdiction if:
The adjudicating component prepares a fully favorable CDR reconsideration determination; and during the quality review,
the review component identifies a group I or group II deficiency that would, or could, result in a cessation or less than fully favorable determination for the claimant.
2. Preparing the SSA-1774-U5, Request for Corrective Action
Include the following language on the SSA-1774-U5:
If, after you correct the deficiency, your decision is still a (continuance or fully favorable determination), return the case to us to complete the review. If the determination is (a cessation or not fully favorable), prepare and route the case for a disability hearing. Please advise us of the final outcome of the disability hearing so that we may code the results data.
Consider a determination fully favorable:
for CDR cases, when there is no break in payments; and
for reconsideration cases of adverse reopening determinations, the EOD is the same as the date the claimant alleged, or earlier, or set at date first insured or the ending date is the same as the date the claimant alleged, or later. See NOTE in GN 04440.310A in this section.
3. Diary control
Do not clear the diary control until final disposition of the case is received or determined; e.g., the adjudicating component telephones the results of the disability hearing or sends a copy of the disability determination, a query of eView reflects the disability determination. For paper cases, if the review component experiences difficulty in obtaining the final disposition, query the system for the disability determination and code the results data based on the query (see GN 04440.202C.3.).
C. References
For an explanation of disability hearing procedures, see DI 29001.000 and DI 33010.000.
For an explanation of the adjudicating component’s corrective action procedures in deficient quality review cases that may become DHU jurisdiction cases, see DI 30005.407.