TN 12 (09-16)

A. Purpose of the rebuttal process

The purpose of the OQR rebuttal process is to enable the adjudicating component and the reviewing component to resolve their differences regarding deficiencies quickly.

B. Procedure for the adjudicating component

The adjudicating component should:

• Submit 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);

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

• Take appropriate development actions on any issues not in dispute upon receipt of the deficiency.

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.

1. Consultation requirements when a medical issues is the basis for the rebuttal

   If a medical issue is the basis for the rebuttal, obtain a written analysis from the appropriate adjudicating component MC and PC and ensure that it addresses the issues described in the reviewing component return.

   EXCEPTION: 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.

2. Consultation requirements when a vocational issue is the basis for the rebuttal

   If a vocational issue is the basis for the rebuttal, obtain a written analysis from an adjudicating component VC (or an adjudicating component staff member experienced in vocational issues if there is no VC on staff) and ensure that it addresses the issues described in the reviewing component return.

3. Late submittal of the rebuttal

   To submit a rebuttal after the 30-calendar day timeframe, include a full explanation of any unusual circumstances that justify a late submittal in the rebuttal letter or memorandum.

   NOTE: The reviewing component will not accept a late rebuttal submitted without the required justification.

4. Routing of the rebuttal letter

   To route a rebuttal letter or memorandum:

   • Prepare the rebuttal letter or memorandum after completing any additional development actions not in dispute directed by the SSA-1774-U5 or SSA-847.

     Place any additional medical or vocational evidence and analysis statements in the file.

   • Send the rebuttal letter or memorandum and MDF via an overnight carrier to the reviewing component.

   • Send a copy of the rebuttal letter or memorandum to the CD or CDPS.

C. Procedures for the reviewing component

1. Summary of reviewing component procedures

   • The reviewing component will handle rebuttals as priority cases, and will review and respond to the rebuttal within 14 calendar days of receipt in the reviewing component.

   • Upon receipt of the rebuttal, a new team reviews the case, the rebuttal rationale, as well as all new and existing evidence and documentation provided by the adjudicating component. The new review team completes an independent quality review of the evidence available at the time of adjudication to determine if the determination originally proposed by the adjudicating component was policy compliant.

   • Upon completion of the review, the new review team prepares a concise resolution letter or memorandum that addresses the specific policy issues in dispute, and explains how the evidence supports the resolution.

   • When rescinding the deficiency, the reviewing component will document the folder, code the results in the OQR legacy system, send copies of the resolution to the appropriate components, and route the case for effectuation.

   • When proposing to affirm or correct the deficiency, the reviewing component will not take final case actions but will send the proposed resolution to DDQ. When DDQ determines the final resolution, a DDQ staff member will code and clear the case in the OQR legacy system and route it to the appropriate component.

2. 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 must:

   • 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, have not been completed and informal attempt with the adjudicating component to resolve the issue is unsuccessful, or the corrected determination is inaccurate. DDQ may advise the reviewing component to prepare a second return to assume jurisdiction;

   • Complete coding of the OQR legacy system and clear the folder according to usual procedures.

D. Procedures for DDQ

1. Receipt of the rebuttal

   The branch chief (BC) 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

   • 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 discussion of policy compliance and final resolution. See additional information regarding OQR, DDQ procedures in GN 04440.410E.

   • 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 the resolution and:

   • Ensure all related documents are placed in the appropriate sections of the MDF paper folder and the EF.

   • 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

   • 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 MDF paper folder and EF and place the signed OQR final resolution in the appropriate sections of the MDF paper folder and the EF;

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

   • Take any additional actions required.

5. Clearance actions

   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 CD or CDPS; and

   • Control the return.

   If the resolution does not require additional case development or action by the adjudicating component, DDQ will:

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

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

   • Release notices following usual procedures.

6. 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, DDQ will not effectuate the disability determination and will return the case to the adjudicating component.

7. Follow-up questions

   DDQ will only accept policy clarification questions after finalizing the resolution. DDQ will not accept case specific follow-up questions because the paper folder will no longer be available.

See Details

GN 04440.410, The Office of Quality Review (OQR) Rebuttal Process