TN 5 (08-18)

A. Introduction

The RPC resolution panel is composed of one member each from ODP, the Office of Disability Determinations (ODD), and the Office of Quality Review (OQR).

The RPC panel discussion is a collaborative decision-making process. Panel members work in partnership to:

• Collaboratively resolve policy and procedure disagreements between the DDSs and the DQBs regarding deficiencies;

• Ensure adjudicative actions and the decisional outcome are supported by policy and comply with required procedures;

• Ensure correct and consistent application of disability policy and procedures across components.

B. The RPC Panel responsibilities

Each member of the RPC panel reviews the case in its entirety (including all prior certified electronic files (CEF)) prior to the RPC panel discussion in order to have a clear understanding of the medical, functional, and vocational evidence, issues, and policies and procedures involved. During the RPC panel discussion, the RPC panel evaluates the case and takes the following steps to reach resolution:

1. Determine whether program instructions support the DDS’s determination. If program instructions support the determination, the panel rescinds the deficiency. If program instructions do not support the determination, the panel goes to step two.

2. Determine whether program instructions support DQB’s deficiency citation. If program instructions support the deficiency, the panel affirms the deficiency. If program instructions do not support the deficiency, the panel goes to step three.

3. Determine the appropriate adjudicative and decisional actions needed to resolve the case, based on the evidence in the file, in accordance with disability policy and program instructions.

C. RPC Panel discussion attendance

An RPC facilitator manages the RPC panel discussion.

NOTE: When RPC schedules an RPC panel discussion, the RPC tool automatically sends a notification email including place, time, and call-in information to the involved parties. The RPC panel discussion schedule is available on the RPC website.

The RPC panel discussion is open to anyone who wishes to attend. Voting is limited to the three panel members (one each from ODP, ODD, and OQR), who may participate in person or by telephone. During the RPC panel discussion, staff from the involved DDS, DQB, CD, or RO may raise policy issues not addressed in the panel discussion and clarify concerns. Observers present in the room may participate in the discussion. Telephone observers may not contribute to the call.

RPC’s Technical Expert (TE) regularly attends the panel discussion, either in person or on the phone. The TE is present as a resource for the panel members, providing input during the panel discussion, and does not vote.

Participating components should find coverage when a designated panel member cannot attend an RPC panel discussion. If a panel member is unavailable to attend the discussion and provides notice to RPC, the branch will consider re-scheduling the panel discussion. If an ODD or OQR panel member fails to attend the discussion without prior notice, the panel discussion will not proceed and will be rescheduled.

D. Description and expectations of the RPC panel discussion

The panel discussion process resolves case-specific policy and procedural questions.

The RPC process must be transparent and impartial. The panel may not refer to personally identifiable information (PII), including names of claimants, treating sources, DDSs or DQBs. The panel members must base the discussion on the applicable policy/procedure, rather than representing or advocating for a particular component.

E. Role of the facilitator

The role of the RPC facilitator is to:

• Ensure all panel members introduce themselves and have an opportunity to participate in the discussion;

• Ensure non-involved telephone listeners do not participate;

• Ensure the RPC panel discussion is mutually respectful, professional, and follows the decision-making steps;

• Ensure the RPC panel discussion remains focused on the applicable policy and procedure in relation to the case and is not influenced by bias;

• Facilitate the discussion to determine appropriate actions when program instructions support neither the DDS’s nor the DQB’s position;

• Ensure policy/procedure disagreements among the panel members are addressed and resolved by the appropriate ODP office responsible for the policy;

• Ensure the panel discussion moves at an appropriate pace to allow full participation of all panel members, while meeting the allotted timeframe; and

• Ensure that after the panel discussion, the panel follows each step in the decision making process to reach the appropriate resolution (see DI 30007.145G. in this section).

F. RPC Panel discussion

The ODP panel member identifies the RPC case number and presents the case facts, central issues, actions taken by the DDS, the DQB, and basis of the RPC submission, and opens the discussion. Subsequently the panel discusses all actions taken during adjudication and review, findings, and concerns about applying program instructions.

During the discussion and prior to the vote, if any of the panel members or DDS, DQB, CD, or RO participants have a policy question that is unresolved by the discussion, participants for the case in question may request a suspension of the discussion for more formal policy/medical guidance. Once guidance is received, the ODP panel member will share it with the original panel (or a representative, if an original panel member is not available), including the original DDS and DQB. Jointly, the members will determine whether the panel needs to reconvene for further discussion or if a vote can be taken.

NOTE: The panel will not discuss any post-adjudicative evidence until after RPC resolution. For discussion of post-adjudicative evidence, see DI 30007.145J.2. in this section.

After the RPC panel discussion and prior to the vote, the DDS, DQB, CD, and RO involved will have an opportunity to raise policy issues not addressed in the panel discussion and clarify concerns.

G. Decision making process and voting procedures

After the RPC panel discussion is finished, the facilitator asks the following questions sequentially to facilitate the decision-making process:

1. Do program instructions support the DDS’s determination?

If the panel agrees that instructions support the proposed determination, the resolution will rescind the deficiency and explain how policy and procedure support the determination.

If the panel finds instructions do not support the proposed determination, the facilitator asks the second question.

2. Do program instructions support the DQB’s deficiency citation?

If the panel agrees that instructions support the deficiency citation, the resolution will affirm the deficiency. The resolution will explain why program instructions did not support the determination, how policy and procedure support the deficiency, and direct the DDS to take the appropriate action(s).

If the panel does not reach agreement at questions #1 and #2, the facilitator asks the third question.

3. What are the appropriate program-supported actions to resolve this case and what program references support these actions?

The panel identifies what actions, based on disability program instructions, are appropriate to resolve the issues. If all panel members agree on the actions, those actions become the basis for the resolution. The resolution will explain why program instructions supported neither DDS’s determination nor DQB’s deficiency citation, and will detail the actions DDS and DQB must take.

Generally, the panel will reach consensus in making the resolution, and resolve any policy issues prior to reaching a decision. However, if the panel does not reach consensus, the action(s) supported by a majority vote of the three panel members becomes the basis for the resolution, unless program instructions do not support the outcome of the vote.

H. Suspending the panel discussion to obtain policy guidance

Prior to the vote, if the panel members are unable to agree on a policy-supported outcome, any panel member may request additional policy guidance.

Prior to the vote, if the panel members agree on a policy-supported outcome, the involved DDS, DQB, CD, or RO is not clear on how policy should be applied, and the panel members can explain their application of the policy, no further additional policy guidance will be requested.

Prior to the vote, if the panel members agree on a policy-supported outcome, the involved DDS, DQB, CD, or RO is not clear on how policy should be applied, and the panel members cannot explain their application of the policy, DDS, DQB, CD, or RO may request additional policy guidance.

NOTE: Any DDS, DQB, CD, and RO may seek policy clarification from the division in ODP responsible for the policy by sending policy questions to ^ODP Controls.

I. Process after receiving policy guidance

Once the ODP panel member receives the requested guidance, the panel member will share it with the original panel (or a representative if an original panel member is unavailable). ODP, ODD, and OQR will decide whether the guidance results in a resolution or merits reconvening the panel for discussion.

J. Special issues related to the RPC panel discussion

1. New issue(s) identified

The panel members’ review is generally limited to the issue(s) cited as a deficiency by DQB and contested by the DDS in the RPC submission. The primary goal of the RPC process is resolving case disagreements by following program instructions, not case re-adjudication (de novo review). The panel will identify and address issues not cited by the DDS or the DQB only when such issues affect the accuracy of a decisional outcome.

The DDS must take corrective action when the new issue is relevant to program compliance and decisional accuracy.

EXAMPLE: If, in a case that is going to result in an allowance, there is clear evidence the claimant worked after the alleged onset date and neither the DDS nor the DQB addressed the work, the panel will identify this issue in the resolution and direct a substantial gainful activity investigation.

The DDS is not required to undertake suggested corrective action when the panel determines the new issue(s) does not affect program compliance and decisional accuracy.

NOTE: Neither the panel nor the DQB issues a new deficiency citation when new issues are identified during the panel’s evaluation of a case.

2. Post-adjudicative evidence

The RPC panel bases the resolution on the evidence in the file at the time of the DDS’s determination. The RPC panel will not consider evidence received after the date of the determination when evaluating the case and reaching a resolution (see DI 30007.145F. in this section). If the RPC panel determines the post-adjudicative evidence is material to the decision, or affects the corrective actions required of the DDS, the disposition of the case may change. The ODP panel member will discuss this in the RPC resolution narrative.

EXAMPLE: The DDS’s determination is a medical-vocational allowance. The DQB issues a documentation deficiency for insufficient vocational evidence. The RPC panel agrees the evidence at the time of adjudication did not support the DDS’s determination and additional vocational evidence is necessary. Post-adjudicative medical evidence indicates the claimant’s condition meets a listing. The RPC panel affirms the documentation deficiency and directs the DDS to allow the claim, finding the condition meets a listing without further development.

3. Wrong Deficiency Cited

See DI 30007.146 for a complete discussion.

The RPC panel may find that program instructions do not support the DDS’s determination and the DQB has identified the wrong category of deficiency on the Form SSA-1774 (Request for Corrective Action). When the panel decides DQB cited a wrong deficiency, RPC will:

• Return the case to the DDS with instructions to complete the corrective actions in accordance with disability program instructions;

• Instruct the DQB to correct the deficiency category; and

• Document the resolution to indicate the correct deficiency citation and close the RPC submission.

NOTE: A wrong deficiency situation will not result in two deficiencies.

4. Probability of reversal (POR)

A DDS adjudicator cannot use probability of reversal (POR) policy in making a determination (per the “NOTE” in GN 04440.110C.). Likewise, the RPC panel cannot consider POR.

When evaluating a fully favorable allowance, the panel will consider disability policy contained in DI 24515.020A.

5. Substitution of judgment (SOJ)

The RPC panel handles the issue of substitution of judgment (SOJ) by the order of the questions asked during the discussion (see DI 30007.145G. in this section). The RPC panel will only consider the DQB’s position after they find the DDS’s determination inconsistent with disability program instructions. At that point, SOJ is no longer an issue.