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GN 04440: Federal Quality Review of Disability Determinations

Effective Dates: 02/26/2014 - Present

TN 14 (12-10)

The deficiencies are listed in the same sequence as in DI 30005.121 – DI 30005.126; the numbers on the left correspond to the defined deficiencies in those sections.

A. Group I decisional deficiencies

OQR Legacy System Code	An incorrect decision regarding:
10	1. Substantial gainful activity (SGA) – clear evidence the claimant is engaging in SGA
11	2. Impairment Severity
12	3. Duration
13	4. Medical improvement (MI) and whether MI affects the ability to work
13	5. MI exceptions, including :
14	Whether an individual is a beneficiary of advances in medical or vocational therapy or technology,
15	Whether an individual has successfully undergone vocational therapy,
16	Whether new or improved diagnostic techniques demonstrate that an individual's impairment is not as disabling, as of the last determination,
17	Whether a prior determination was made in error, or
18	Whether the prior determination was based upon fraudulent circumstances.
19	6. Residual Functional Capacity (RFC)
20	7. Evaluation of vocational factors including age, education, transferable skills, ability to do past relevant work, or ability to do other work
21	8. Failure to follow prescribed treatment
22	9. Drug addiction and alcoholism (DAA) materiality
23	10. Onset of disability, relative to a Title II eligibility period
25	11. Incorrectly adopting, or not adopting a prior administrative law judge (ALJ) or appeals council (AC) finding when adjudicating a subsequent disability claim.
26	12. Collateral estoppel

B. Group I medical documentation deficiencies

	The medical documentation is insufficient to determine:
41	1a. Impairment severity
42	1b. Duration
43	1c. MI, including whether MI affects the ability to work
43	1d. MI exceptions including:
49	Whether an individual is a beneficiary of advances in medical or vocational therapy or technology, or
48	Whether new or improved diagnostic techniques demonstrate that an individual's impairment is not as disabling, as of the last determination
44	1e. RFC
45	1f. Failure to follow prescribed treatment
46	1g. DAA materiality
47	1h. Onset of disability relative to a Title II eligibility period

C. Group I vocational documentation deficiencies

	The vocational documentation is insufficient to determine the effect of the following on an individual's ability to engage in SGA:
51	2a. Age
52	2b. Education, literacy, or the ability to communicate in English
53	2c. Work history, including transferable skills, physical, mental, and environmental demands of past work and the relevance of past work
54	2d. Advances in medical or vocational therapy or technology when there is new medical evidence and a new RFC but no MI
55	2e. Vocational therapy

D. Group I medical evaluation deficiency involving vocational documentation

31	3. An incorrect assessment of impairment severity or RFC makes additional vocational documentation necessary to determine disability

E. Group I procedural documentation deficiencies

	The documentation is insufficient to show conformance to prescribed procedures for a determination based on the following:
30	4a. Work activity
60	4b. Failure to obtain a prior folder or copy of the ALJ/AC ruling under an acquiescence ruling
61	4c. The prior determination was in error
62	4d. Failure to follow prescribed treatment
65	4e. Whereabouts unknown
66	4f. Failure to cooperate

F. Group I documentation deficiency involving collateral estoppel

36	5. There is insufficient documentation to determine if collateral estoppel applies, or an incorrect collateral estoppel adoption makes medical or vocational documentation necessary to determine disability on the current claim.

G. Group II period of disability decisional deficiencies

	The case contains sufficient documentation to support a different:
71	1. Onset date
72	2. Ending date
73	3. Cessation date

H. Group II period of disability documentation deficiencies

	The case contains insufficient documentation to support the:
81	1. Onset date
82	2. Ending date
83	3. Cessation date
85	4. Unresolved work activity that has potential to affect the period of disability

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GN 04410: RSI Claims Quality Appraisal System

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GN 044: Quality Appraisal

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GN 04442: The Quality Assurance Review of Railroad Disability Claims

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