TN 8 (04-04)

A. Introduction

The following instructions apply to QA and PER sample cases which have been inadvertently effectuated prior to QR and subsequently require corrective action as a result of the review. In some instances, the claimant or beneficiary files a request for reconsideration or hearing while the case is still undergoing QR.

B. Process - review component review

1. General

When the review component receives a sample case that has been inadvertently effectuated, they will process the case as expeditiously as possible to avoid possible overpayment or nonpayment of benefits. On occasion, the entries on the paper SSA-831/832/833-C3/U3 in the case file differ from those on the electronic record (i.e., the data input by the DDS at the time they clear the case that are passed on to DQB electronically) transmitted to the review component. Unless the difference is due to an obvious keying error, the review component will base their review on the electronic record and cite any deficiency based on a disagreement with the electronic record. This is so even if the review component agrees with the entries on the disability determination that is in the case file.

2. No appeal filed

If the review component receives a sample case that has been inadvertently effectuated, they will review and process the case as usual. All group I and group II deficiencies will be applied to effectuated cases and deficiencies will be charged when appropriate.

3. Appeal filed while case undergoing QR

If the review component receives notice of a request for reconsideration or a hearing while a case is undergoing QR, they associate the appeals notice with the file and hand carry the folder through all review operations.

If the case contains a deficiency that requires adjudicating component corrective action, the review component will prepare an SSA-1774-U5 and request that the adjudicating component take the necessary corrective action.

If the case contains a deficiency that requires adjudicating component corrective action, and the appeal request was not filed in the FO, the review component:

• prepares an SSA-1774-U5;

• prepares a photocopied file;

• sends the original case file with a copy of the SSA-1774-U5 to the FO; and

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

Refer to GN 04440.250D. and GN 04440.250E. for a further explanation of review component action in this situation.

C. Procedure - DDS

1. General instruction

The following instruction applies to all deficient QR cases that have been inadvertently effectuated regardless of whether an appeal is filed. When the SSA-1774-U5 or SSA-847-U3 is received in the adjudicating component, take the following action:

• Process the corrective action request from the review component as expeditiously as possible to avoid possible overpayment or nonpayment of benefits.

• Refer to DI 30005.413C.5. if it is necessary to re-contact the claimant for additional evidence to correct a deficiency.

• Refer to DI 30005.413C.6. for notice action if the review evidence does not result in a formal reopening.

• Return the folder to the review component after all actions are completed.

If no appeal has been filed, follow DI 30005.413C.2. If a request for a reconsideration or a hearing is filed, follow DI 30005.413C.3. or DI 30005.413C.4.

2. No appeal filed - deficient case

a. Favorable determination - documentation deficiency

If the case is returned because there is a group I or group II documentation deficiency:

• Obtain the requested documentation.

• If the documentation you obtain would change the favorable determination to a less than fully favorable or an unfavorable determination, follow existing adverse reopening procedures, including applying the medical improvement review standard (MIRS), when appropriate, in determining whether revision is possible.

• If the documentation you obtain changes the onset date, follow existing reopening procedures. Note that the 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.

• Return the case to the review component upon completion of all actions.

b. Favorable determination - group I decisional deficiency

If the case is returned because there is a group I decisional deficiency, and a MIRS group I or group II exception to MI does not apply, the review component will return the case with the SSA-1774-U5 annotated as follows:

"We have charged a group I decisional deficiency in this case. However, we do not believe the determination can be reopened under the error or fraud exceptions to MIRS. Therefore, no further action is necessary at this time. Return the case to the review component for completion of the review." See DI 28020.375.

• If you agree with the deficiency and that the determination cannot be reopened, return the file to the review component without taking any action.

• If you do not agree with the deficiency, follow the usual procedures for rebuttals.

c. Favorable determination - group II decisional deficiency

If the case is returned because there is a group II decisional deficiency:

• Follow existing reopening procedures. Note that the 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.

• Return the case to the review component upon completion of all actions.

d. Unfavorable determination - documentation deficiency

If the case is returned because there is a group I or group II documentation deficiency:

• Obtain the requested documentation.

• If the documentation you obtain changes the determination or the cessation date, follow the existing reopening procedures. See DI 28005.205D.2. for cessation month and error exception cases.

• Return the case to the review component upon completion of all actions.

e. Unfavorable determination - decisional deficiency

If the case is returned because there is a group I or group II decisional deficiency:

• Follow the existing procedures for reopening and revision. See DI 28005.205D.2. for cessation month and error exception cases.

• Return the case to the review component upon completion of all actions.

3. Reconsideration request - deficient case

If a request for reconsideration is filed while the case is in the review component, and the case requires corrective action, the review component will send you:

• an SSA-1774-U5 and the original folder, if the request for reconsideration was filed in the FO; or

• an SSA-1774-U5 and a photocopied file, if the request for reconsideration was not filed in the FO.

See DI 30005.413B.3. for description of review component action. Upon receipt of the SSA-1774-U5, follow DI 30005.413C.1. take all reconsideration actions and return the case to the review component.

If, as a result of the corrective action request, the determination must be reopened and revised and you have a photocopied file:

• Obtain the original file and reconsideration request and associate it with the photocopied folder before undertaking any reversal action.

• Prepare the revised SSA-831-C3/U3, SSA-832-C3/U3 or SSA-833-C3/U3 and the reconsideration notice.

• Return the case file to the review component with the unreleased reconsideration notice in file.

• Do not effectuate the revised determination.

Refer to GN 04440.250D. for an explanation of review component procedure in these cases.

4. Hearing request - deficient case

The following instructions apply only to QR cases that have been effectuated. Informal remand cases that are selected for PER review are handled in the same manner as other PER sample cases.

a. Folder in DDS

If a request for a hearing before an ALJ is filed while a deficient case is in the adjudicating component, process the case as an informal remand per DI 27010.015 and DI 27520.005.

• Determination Can Be Reopened and Revised to Fully Favorable or Partially Favorable

  If the determination can be reopened and revised to a fully favorable or partially favorable determination:

  • Prepare a revised determination and notice per the procedure outlined in DI 27520.005.

  • Do not effectuate the revised determination or release the notice.

  • Annotate the deficiency transmittal form or route slip "Informal Remand Case."

  • Return the folder to the review component.

• Determination Cannot Be Reopened and Revised to Fully Favorable or Partially Favorable

  If the determination cannot be reopened and revised to a fully favorable or partially favorable determination:

  • Notify the review component by sending them a copy of the deficiency transmittal annotated to show that an ALJ hearing request was filed.

  • Forward the folder to Office of Disability Adjudication Review (ODAR) in accordance with DI 27520.005.

b. Folder in review component

If a request for a hearing before an ALJ is filed while a case is in the review component, the review component will send the folder to the FO for processing of the hearing request. If the case is deficient and the informal remand criteria are met, the review component will first photocopy the file and send the photocopied file and SSA-1774-U5 to the adjudicating component for necessary action.

Upon receipt of the photocopied file and SSA-1774-U5 in the adjudicating component, query the system to obtain the folder location.

• If the folder is not in the ODAR, obtain the folder and process the case as an informal remand in accordance with DI 27010.015, DI 27520.005 and DI 30005.413C.4.a.

• If the folder is in ODAR, return the SSA-1774-U5 and photocopied folder to the review component and advise them that the folder is in ODAR and is unavailable.

Refer to GN 04440.250E. for an explanation of review component procedure in these cases.

5. Claimant contact

If it is necessary to re-contact the claimant for additional evidence to correct a deficiency, do not tell the claimant that the additional development could result in a revised determination and do not mention possible overpayments. The first paragraph of the letter to the claimant should be worded as follows:

"The Social Security Administration has selected your case for review. We need the following additional information to complete the review."

The final paragraph should be worded as follows:

"Thank you for your cooperation. We will notify you of the results of this review."

6. Notice action

Whenever a claimant or beneficiary is aware of additional development and the review evidence does not result in a formal reopening, prepare, but do not release, a notice to advise the individual. The notice will be released by the review component.