TN 28 (09-16)

A. Introduction to the OQR rebuttal process

The OQR rebuttal process resolves disagreements between the adjudicating and the reviewing components for cases involving:

• modular disability folder (MDF) “paper” cases

• certified electronic folder (CEF) cases that involve a prior paper folder with evidence not copied into the CEF, and

• all other cases that the Office of Policy Consultation and Analysis (OPCA) determines cannot be resolved by the Request for Program Consultation (RPC) process (e.g., an electronic folder (EF) case not appropriately documented with all the paper evidence used by the adjudicating and reviewing components).

The OQR rebuttal process applies to quality assurance (QA) and pre-effectuation (PER) group I and group II deficiencies, other technical corrective actions (TCA), and special study cases.

B. Policy for the OQR rebuttal process

1. Objectives of the OQR rebuttal process

The main objective is to resolve deficiency disagreements between the adjudicating and the reviewing components quickly. Other objectives include:

• protects claimants and beneficiaries from incorrect determinations;

• protects the Social Security Disability Insurance program and the Supplemental Security Income program from incorrect determinations;

• identifies and rescinds incorrectly cited deficiencies;

• achieves a consistent review process;

• ensures OQR review policies are clear;

• enables OQR to obtain clarifications from other policy components in a timely manner; and

• ensures a credible and objective review.

2. Division of Disability Quality (DDQ) review process

DDQ is part of OQR’s central office operations and is separate from the DQBs, which are under OQR’s field operations. DDQ receives all rebuttal cases for final resolution when the reviewing component affirms the deficiency. The DDQ reviewer consults with other policy components as necessary, prior to presenting the case for the DDQ policy team discussion. The purpose of this discussion is to provide a consistent resolution.

DDQ reviews:

• rebuttals affirmed by the reviewing component;

• evidence available at the time of the adjudicating component’s determination, to determine whether the deficiency cited by the reviewing component is supported,

• subsequent documentation, which is not used to determine whether the deficiency citation was appropriate, and

• all appropriate policy guidance.

3. The DDQ resolution

DDQ resolves all deficiency citation disagreements and issues. If DDQ determines a deficiency is present, but the reviewing component cites the incorrect deficiency, i.e., wrong deficiency type, the deficiency citation is corrected to reflect the appropriate deficiency type (e.g., the reviewing component cites a decisional deficiency when the evidence supports a documentation deficiency). This correction will still not result in more than one chargeable deficiency on the case.

There is no appeal of the DDQ findings and resolution including:

• requests for specific adjudicating component development, documentation, or determination as a part of the case resolution;

• affirmations, modifications, or rescissions of deficiencies.

4. When the adjudicating component prepares a rebuttal

The adjudicating component:

• should not use the Federal quality review administrative procedure of probability of reversal, as defined in GN 04440.110 and GN 04440.112, as a basis for rebuttal of a documentation deficiency;

• may use substitution of judgment, as defined in GN 04440.118 and GN 04440.119, as a basis for the rebuttal of a decisional deficiency, but not as a basis for the rebuttal of a documentation deficiency;

• is not required to take the development actions requested on the SSA-1774-U5, Request for Corrective Action, or SSA-847, SSA Request for Case Action, before submitting a rebuttal, except for those development actions not in dispute; but

• is required to take all development actions addressed in the DDQ resolution.

See Details

• GN 04440.110 The Probability of Reversal (POR) Rule and Clarifying Documentation Deficiencies

• GN 04440.112 When the Probability of Reversal (POR) Rule Cannot be Used

• GN 04440.118 Substitution of Judgment (SOJ) in the Quality Review (QR) Process

• GN 04440.119 Determining Whether Substitution of Judgment (SOJ) is at Issue

5. Specified time frames for submitting and processing OQR rebuttals

The adjudicating and reviewing components strive to meet the following time frames:

• Adjudicating component rebuttal submittals

The adjudicating component’s goal is to submit a rebuttal to the reviewing component within 30 calendar days beginning with the date the reviewing component sends the deficiency. The reviewing component will accept rebuttals submitted after the 30-calendar day period expires only when the adjudicating component provides a full explanation of the unusual circumstances, and the reviewing component determines that the delay results from the unusual circumstances.

• Rebuttal responses

The goal for the reviewing component and DDQ is to resolve rebuttals within a total of 30 calendar days after receipt of the rebuttal by the reviewing component. However, rebuttals requiring policy clarification from other components may not be resolved within 30 calendar days. If the need for policy clarification will result in a delay in processing the rebuttal, DDQ will notify the involved adjudicating and reviewing components by email.

C. Procedure for the adjudicating component

The adjudicating component:

• submits a formal rebuttal letter or memorandum with the case folder to the reviewing component that states why policy does not support the deficiency. A copy of the letter or memorandum will also be sent to the Center for Disability (CD) or Center for Disability Program Support (CDPS);

• provides medical consultant (MC), psychological consultant (PC), or vocational consultant (VC) analysis, as appropriate, supporting the rebuttal; and

• takes appropriate development actions on any issues not in dispute.

If DDQ’s resolution requires corrective actions, the adjudicating component must:

• take all corrective actions specified in the resolution; then

• send the MDF paper folder via an overnight carrier to the reviewing component.

See Details

DI 30005.510 The Office of Quality Review (OQR) Rebuttal Process

D. Procedure for the reviewing component

1. Receipt of the rebuttal

Take the following actions:

• handle rebuttals as priority cases;

• upon receipt of the rebuttal, establish and monitor the necessary internal controls; and

• review and respond to the rebuttal within 14 calendar days of its receipt in the reviewing component.

2. Referral of the rebuttal to a new review team

Upon receipt of the rebuttal, a new team reviews the case, the rebuttal rationale, and all new and existing evidence and documentation provided by the adjudicating component. The new review team must take the following actions:

• Complete an independent quality review of the evidence available at the time of adjudication to determine whether the determination originally proposed by the adjudicating component was policy compliant.

• Include an evaluation from the appropriate regional MC or PC if the basis for the rebuttal is a medical issue;

• Include an evaluation from the VC if the basis for the rebuttal is a vocational issue (if there is no VC on staff, or if the VC on staff reviewed the case previously, the evaluation can be made by a staff member with experience in vocational issues); and

• Address all medical or vocational issues the adjudicating component raises in the rebuttal letter or memorandum, as well as all MC or PC notes, VC statements, and single decision-maker (SDM) notes accompanying the rebuttal.

REMINDER: Adjudicating component single decision-makers (SDM) have the option of preparing the written medical analysis instead of obtaining one from the appropriate MC or PC(s), provided SDM authority applies to the case.

3. Preparation of the rebuttal resolution when rescinding the deficiency

Upon completion of the review:

• Prepare a concise resolution letter or memorandum that addresses the specific policy issues in dispute, and explain how the evidence supports the resolution to rescind the deficiency;

• Add the resolution letter or memorandum to the E. Disability Related Development (Blue) section of the electronic folder (EF) and a paper copy to the paper modular disability folder (MDF);

• Document the MDF paper folder and EF with all evaluation forms prepared by the reviewing component’s MC or PC, if the basis for the rebuttal is a medical issue, or VC if the basis for the rebuttal is a vocational issue;

• Code the results in OQR’s legacy system;

• Send copies of the resolution to the adjudicating and reviewing components, as well as the Center for Disability (CD) or Center for Disability Program Support (CDPS) involved; and

• Route the case to the appropriate component for effectuation.

4. Preparation of the rebuttal resolution when affirming or correcting the deficiency

Upon completion of the review:

• Prepare a concise resolution letter or memorandum that addresses the specific policy issues in dispute, and explain how the evidence supports the resolution to either affirm or correct the deficiency. The resolution should not restate the evidence, but address only specific issues the adjudicating component raises and the relevant policy issues.

NOTE: Do not sign the proposed resolution because the Director of OQR, DDQ will sign the resolution;

• Provide specific policy references for issues in dispute or discussed;

• Add the proposed resolution letter or memorandum to the C. Current Development/Temporary (Green) section of the EF and a paper copy to the MDF paper folder;

• Document the MDF paper folder and EF with all evaluation forms prepared by the reviewing component’s MC or PC, if the basis for the rebuttal is a medical issue, or VC if the basis for the rebuttal is a vocational issue; and

• Send the MDF paper folder via an overnight courier service to:

  Director of OQR, Division of Disability Quality
  5138 East High Rise
  6401 Security Boulevard
  Baltimore, MD 21235

  · Do not code results or clear the case in OQR’s legacy system. Reassign the rebuttal case within the OQR legacy system to the generic central office examiner which central office established for this purpose. Upon reassignment, the case will appear on the central office examiner queue, which DDQ will monitor daily. The reviewing component maintains jurisdiction of the case while DDQ reviews the case. Upon completion of the final review, DDQ designates a DDQ staff member to code and clear the case in the OQR legacy system.

5. Procedures for cases requiring additional actions by the adjudicating component following DDQ review

When the DDQ rebuttal resolution requires the adjudicating component to take additional actions, the adjudicating component returns the case to the reviewing component upon completion of all required actions.

The reviewing component should:

• Review the corrected case for accuracy and ensure completion of the actions identified in the rebuttal resolution;

• Notify DDQ when actions identified in the rebuttal resolution are not completed and informal attempts to resolve the issue with the adjudicating component is unsuccessful, or the corrected determination is inaccurate.

If necessary, DDQ will advise the reviewing component to prepare a second return or assume jurisdiction, see GN 04440.203.

• Complete coding of the OQR legacy system to include affirming, correcting, or rescinding the deficiency as directed by DDQ;

• NOTE: If DDQ determines the reviewing component cited an incorrect (wrong) deficiency category, e.g., documentation vs. decisional or group I vs. group II, correct the deficiency to reflect the appropriate deficiency type. The deficiency is not rescinded.

• Clear and route the case following the usual procedures; then

• Send the MDF paper folder via an overnight courier, to the appropriate component; e.g., field office (FO), adjudicating component, program center, or L0(zero)E.

E. Procedure for DDQ

1. Receipt of the rebuttal

The branch chief or designee assigns the rebuttal for case review, and establishes the necessary case controls to ensure the actions necessary to review and respond to the rebuttal are completed within 14 calendar days of its receipt in DDQ.

2. Review staff actions

Take the following actions:

• Review the rebuttal rationale, proposed reviewing component resolution, and all evidence in the case.

• Research any policy issues; and as necessary, request policy clarification from the appropriate policy component(s).

• Following case review, DDQ will present the case to the DDQ policy team for policy compliance discussion and final resolution.

• If the reviewing component cited an incorrect (wrong) deficiency category, e.g., documentation vs. decisional or group I vs. group II, correct the deficiency type. There is no rescission of the deficiency.

3. Reviewing component resolution is supported

After the discussion and review, if the resolution prepared by the reviewing component is supported, DDQ will:

• Sign and move the reviewing component resolution from the C. Current Development/Temporary (Green) section of the EF to the E. Disability Related Development (Blue) section of the EF.

• Sign and place the paper copy of the reviewing component resolution and all related documents in the MDF paper folder to provide policy guidance and ensure policy compliance by subsequent reviewers;

• Retain all related documents in the MDF paper folder and EF in the appropriate sections to provide policy guidance and ensure policy compliance by subsequent reviewers;

• Forward the case to management or designee for final review and clearance; and

• Take any additional actions required

4. Reviewing component resolution is not supported

If the resolution prepared by the reviewing component is not supported, DDQ will:

• Modify the reviewing component resolution and provide a concise rationale of the policy issues that support the final resolution;

• Remove the draft review component resolution from the C. Current Development/Temporary (Green) section of the EF and place the signed OQR final resolution in the E. Disability Related Development (Blue) section of the EF;

• Add the paper copy of the reviewing component final resolution and all related documents to the MDF paper folder to provide policy guidance and ensure policy compliance by subsequent reviewers;

• Forward the case to management or designee for final review and clearance; and

• Take any additional actions required.

5. Clearance actions if additional development or action is necessary

If the resolution requires additional case development or action by the adjudicating component, DDQ will:

• Send the MDF paper folder via an overnight courier to the adjudicating component;

• Send copies of the resolution to the reviewing component and the Center for Disability (CD) or Center for Disability Program Support (CDPS) involved; and

• Code the case in the OQR legacy system as a controlled return

6. Clearance actions if no further action is necessary

• Designate staff to complete OQR’s legacy system coding to include affirming, correcting, or rescinding the deficiency;

• Send the MDF paper folder via an overnight courier, to the appropriate component; e.g., field office (FO), program center, or L0(zero)E; and

• Send copies of the resolution to the adjudicating component, reviewing component, and the CD or CDPS.

7. Actions after completion of the resolution

Once DDQ completes the resolution, they will:

• Designate staff to complete OQR’s legacy system coding to include affirming, correcting, or rescinding the deficiency;

• Send the MDF paper folder via an overnight courier, to the appropriate component; e.g., field office (FO), program center, or L0(zero)E; and

• Send copies of the resolution to the adjudicating component, reviewing component, and CD or CDPS.

• Release notices following usual procedures.

8. When to effectuate the determination

DDQ effectuates the disability determination when returning the case to the adjudicating component only if additional evidence obtained as a result of a deficiency citation identifies a previously unknown terminal illness (TERI), dire need case, or other priority handling resulting in the case being immediately designated for expedited processing per DI 23020.045.

NOTE: In all other case situations, do not effectuate the disability determination when returning the case to the adjudicating component.

9. How to effectuate the determination

In the case situation described in GN 04440.410E.8., DDQ will effectuate the determination as follows:

• faxes a copy of the disability determination to the FO and include the following remarks: “Rebuttal Case – Please effectuate the determination.

The case and the rebuttal response letter or memorandum has been sent to the adjudicating component for corrective action”;

• if benefit payments are due, ensures that the benefits have been triggered; and

• sends the case to the adjudicating component with the rebuttal response letter or memorandum has , and inform the adjudicating component the determination has been effectuated.