BASIC (01-08)

A. Overview – Federal QR

The Office of Quality Review (OQR) performs Federal QRs:

• In the OQR reviewing offices located in the ten regions; and

• In the OQR’s reviewing office in Baltimore (previously known as DDQO).

OQR selects cases for Federal QR during the Disability Determination Services (DDS) case closure process and prior to effectuation of the DDS’s determinations. Certified Electronic Folder (CEF) cases selected for Federal QR are transferred to the appropriate OQR review component for quality review (e.g., QA, PER, special studies).

Results of Federal QRs include:

• Non-Deficient (Correct) Cases – the OQR review component completes the QR, closes out the case, and clears the CEF case to the Field Office (FO) for effectuation of the determination.

• Deficient Cases – The OQR review component returns jurisdiction of the CEF to the DDS for corrective action or takes the corrective action and clears the CEF to the FO for effectuation of the determination.

• FO Action Needed – the OQR returns case to the FO for additional development prior to taking a corrective action

B. Two-Step Rebuttal Process – General Guidelines

OQR’s rebuttal process is a two-step process. The general rebuttal procedures are described in DI 30005.501 through DI 30005.550. Refer to these sections for resolution of DDS/OQR disagreements involving deficiencies cited by the OQR review component and returned to the DDS. NOTE: If the DDS is participating in the Request for Program Consultation (RPC) process and the case is a CEF and no paper folder is involved in the review, the two-step rebuttal process is not applicable. For more information about RPC, see Federal Quality Review (QR) - DI 81020.135F.

1. First-Level Rebuttals

When a DDS disagrees with the OQR review component’s deficiency return, the DDS decides to prepare a first-level rebuttal letter/memorandum to the OQR review component that returned the deficient case.

• If OQR agrees with the DDS’s first-level rebuttal, OQR rescinds the deficiency.

• If OQR disagrees with the DDS’s first-level rebuttal, OQR affirms their original deficiency.

For more information about the first-level rebuttal process, see Federal Quality Review (QR) - DI 81020.135H.

2. Second-Level Rebuttals

• The DDS (through concurrence with the Regional Offices’ Center for Disability [CD]) decides to elevate the rebuttal to the second-level for resolution if OQR affirms the original deficiency.

• OQR is the final arbiter in rebuttal cases.

For more information about the second-level rebuttal process, see Federal Quality Review (QR) - DI 81020.135I.

C. Automated Selection of Cases for Quality Review

1. NDDSS Alert

During the case closure process, the DDS receives an alert via NDDSS when selecting a CEF case for Federal QR (e.g., quality assurance review, Pre-Effectuation Review (PER), special studies).

Follow current policies and procedures to release the case to the reviewing office.

NOTE: If associating a paper folder with the CEF, the DDS mails the folder to the reviewing OQR office. For Quick Disability Determination cases, use overnight mail.

2. NDDSS and eView Indicators

Both NDDSS and eView display an indicator that the case has been selected for Federal QR. eView also displays the message “Determination not final; {Claim Type(s)} under quality review”.

D. OQR Quality Review Office Selection

The OQR review office is no longer limited to the regional OQR office when the current case is a CEF and no prior paper folders are attached. It is very important that the DDS verifies the current Paper Folder Indicator (PFI) and the prior PFI are accurate before they close a case so the appropriate OQR review office is selected. For more information about PFIs, see Paper Folder Indicators (PFI) - DI 81020.010.

1. CEF – Prior PFI is Blank

• The OQR review office is not limited to the regional OQR office. In some situations, OQR transfers these CEF cases from one office to another. When this occurs, NDDSS may not display the final OQR review office code.

• After OQR transfers the case, eView displays the current office with jurisdiction.

NOTE: When returning a QR case to the DDS, the Electronic Folder Interface (EFI) download contains the correct OQR review office code. If the DDS needs to return the case to the OQR review office, they must return it to the OQR office that is in the EFI download.

2. Current or Prior Paper Folder Processed Electronically

• The OQR review office is limited to the regional OQR review office.

• The DDS forwards the paper folder to the appropriate office using the following destination codes:

NOTE: For Quick Disability Determination (QDD) cases use overnight mail.

3. Prior Paper File Received in DDS While OQR is Reviewing Case

If the DDS receives a prior paper folder and OQR currently has jurisdiction of the CEF, the DDS:

• Adds a message to the CEF indicating that a prior paper folder was received during the OQR Review process and is being mailed to OQR. The OQR office is responsible for updating the Prior PFI; and

• Mails the paper folder to the OQR reviewing component that has jurisdiction of the CEF. For Quick Disability Determination cases, use overnight mail.

E. Disposition of Paper SSA-827s in QR Cases

If an SSA-827 (Authorization to Disclose Information to the Social Security Administration [SSA]) is available, be sure to store the image of the SSA-827 in the CEF when selecting the case for Federal QR. Destroy extra paper copies of the SSA-827 once the image is saved to the CEF.

F. OQR Returns Deficient CEF to DDS for Correction

1. OQR Action

If the case requires correction by the DDS, the OQR review component:

• Adds the request for corrective action form (e.g., SSA-1774, SSA-847) to the CEF; and

• Electronically returns jurisdiction of the CEF to the DDS.

2. DDS Action

a. DDS Accepts Jurisdiction and Processes OQR’s Return

• Accept jurisdiction of the CEF. NOTE: If the CEF was sent to an incorrect site, reject jurisdiction only to the OQR office that sent the return or to a Field Office (FO) or another DDS that is in the same state. Do not reject jurisdiction to an out of state DDS.

• Receipt the CEF as a return per Returned Cases - SM 06001.208. NOTE: Do not receipt the QR return as a new claim;

• Assign the QR return;

• Take the corrective action (refer to Federal Quality Review (QR) - DI 81020.135F.2.b., if the DDS Determination requires correction);

• Prepare an Assistance Request to the FO for any FO development. Do not transfer the CEF to another component during the review process;

• Add any additional evidence and documentation to the CEF;

• If necessary prepare a corrected PRTF and/or RFC assessment form. The original PRTF and/or RFC should remain in file as part of the audit trail. The original should be annotated "Do Not Process" For more information see Correcting Incorrect PRTF and RFC Assessment Forms - DI 30005.236; and

• Return jurisdiction of the CEF to the OQR review component that performed the review when OQR requests return of the CEF. If a CEF needs to be referred to another component for final action, such as the FO, return the CEF to the OQR review component first.

NOTE: The OQR office that actually reviewed the case may be different than the regional OQR or office shown in NDDSS. The DDS must return the case to the OQR office that is in the EFI download.

b. DDS Corrects the SSA-831 (Disability Determination and Transmittal) and/or the Personal Disability Notice (PDN)

When the OQR review component cites a deficiency which requires the DDS to correct the SSA-831, document the CEF appropriately to show that the original SSA-831 has been superseded. The DDS must:

• Prepare a corrected SSA-831.

• Notate the corrected SSA-831 in the “Remarks” (Item #34): “Corrected SSA-831 replaces the original SSA-831 dated (mm/dd/yy).”

• Upload the corrected SSA-831 to the CEF.

• Upload any additional evidence and documentation (e.g., new evidence, eForms, decision notices) to the CEF.

• If applicable, move the incorrect PDN to Section C, Current Development/Temporary (Green Section) and upload the corrected PDN notice to the CEF.

• Retain the original unprocessed SSA-831 image in the Yellow Front Section of the folder. Add the following note in eView: “DO NOT PROCESS the original SSA-831 dated mm/dd/yy.”

• Verify that the image(s) of the revised document(s), such as the new SSA-831 and PDN, have been updated and added to the CEF.

G. Request for Program Consultation (RPC) - General Guidelines

DDS and OQR use the RPC process to resolve disagreements with deficiencies cited by OQR. RPC is:

• Administered by the Office of Disability Programs (ODP) in the Central Office;

• Available only for CEFs in states participating in the RPC process; and

• Replaces the two-step rebuttal process.

The general RPC procedures are described in Request for Program Consultation (RPC) - Table of Contents - DI 30007.000. NOTE: For states not participating in the RPC process or for cases involving current or prior paper folders, the two step rebuttal process applies (see Federal Quality Review (QR) - DI 81020.135A.).

1. Jurisdiction of RPC Cases

DDS maintains jurisdiction of the CEF when submitting an RPC. ODP processes the RPC and issues an RPC Resolution within 7 calendar days of receipt of the RPC per Timeframes for Submitting and Resolving RPCs.

2. Routing of the CEF after the RPC Resolution

After ODP issues the RPC Resolution, the DDS routes the CEF depending on whether:

• OQR requests the CEF to be returned after the DDS completes the corrective action (i.e., controlled return is “Y”);

• OQR does not request the CEF to be returned after the DDS completes the corrective action (i.e., controlled return is “N”); and

• The RPC Resolution affirms or rescinds the OQR cited deficiency.

a. Controlled Return is “Y”

DDS must route all CEFs to the OQR review component if the controlled return is “Y” regardless of the outcome of the RPC.

b. Controlled Return is “N”

If the RPC Resolution rescinds the OQR cited deficiency, the DDS may route the CEF to the OQR review component to ensure OQR updates DICARS and removes the deficiency.

If the RPC Resolution affirms the OQR cited deficiency, the DDS:

• Completes the corrective action(s);

• Adds the corrective action documentation to the CEF; and

• Routes the CEF to the appropriate Field Office (FO).

H. DDS Deficiency First-Level Rebuttal Process

1. DDS Action

• Refer to First-Level Rebuttals - DI 30005.510, for the general procedures of the first-level rebuttal process.

• When preparing a first-level rebuttal letter/memorandum, use document type 0165 (REBUT) for indexing QR rebuttal documents in the CEF.

• Electronically return the updated CEF case to the appropriate OQR review component.

2. OQR Action

The OQR reviewing office assigns the first-level rebuttal CEF to a new quality review team for an independent review. OQR completes a first-level rebuttal response letter/memorandum and addresses it to the DDS Administrator.

a. OQR Agrees With the Rebuttal

OQR:

• Rescinds the original deficiency;

• Faxes the appropriate documents into the CEF using document type 2070 (REBRESP);

• Prepares an email notification to the DDS Administrator (with cc’s to the appropriate components); and

• Clears the CEF case to the next appropriate component (usually the FO for effectuation of the determination).

b. OQR Does Not Agree With the Rebuttal

OQR:

• Affirms the original deficiency;

• Faxes the appropriate documents into the CEF using document type 2070 (REBRESP);

• Prepares an email notification to the DDS Administrator (with cc’s to the appropriate components); and

• Returns jurisdiction to the DDS for any necessary corrective action.

I. DDS Deficiency Second-Level Rebuttal Process

NOTE: Currently, due to functionality limitations, the Regional CDs; the OQR, Office of Quality Control (OQC), Division, DIB Initial Central Office (CO); and the Office of Disability and Income Security Programs (ODISP), Office of Disability Programs (ODP) are not able to electronically receipt and upload data to the CEF. However, when notified, these offices access and review CEFs using eView. Additionally, these offices fax pertinent documents into the CEF.

1. DDS Initiates Second-Level Rebuttal

• Prepare the second-level rebuttal letter/memorandum;

• Include in the letter/memorandum that the case is an CEF;

• Store a copy of the letter/memorandum in the CEF using document type 0170 (REBUT2), Level 2 Rebuttal.

• Prepare a rebuttal request email message to the regional CD. In the email message, identify the case as an CEF, include the SSN, indicate if any paper folders are being sent, and attach a copy of the rebuttal letter/memorandum;

• Retain electronic jurisdiction of the case. Do not close the case on the DDS system, attempt to transfer the case on NDDSS, or change the jurisdiction electronically.

• If the DDS has a paper folder, mail the paper folder to the CD.

• Email the rebuttal request to the Regional Office, CD, for their decision to support or not support the second-level rebuttal request. Use the following email addresses when sending the rebuttal request to the CD:

2. Rebuttal Request Requires Policy Issue Resolution

When a rebuttal request requires resolution of a policy issue, the policy issue takes precedence over the rebuttal. The CD refers the CEF case by an email message to the SSA component responsible for making the final policy ruling (i.e., ODP or OQR CO). In the email message, the CD includes the DDS and the appropriate OQR review components as cc’s.

3. CD Affirms Deficiency

a. CD Actions

• Prepares a letter/memorandum stating their position to not support the DDS’s second-level rebuttal request;

• Prepares a barcoded cover sheet using document type 2070 (REBRESP), Response to Rebuttal, and faxes the letter/memorandum into the CEF using fax number 866-722-2297. The DDS receives an alert when the CD adds the letter/memorandum to the CEF; and

• Emails the letter/memorandum to the DDS (with cc’s to the OQR review component).

b. DDS Actions

Upon receipt of the letter/memorandum from the CD, the DDS:

• Completes the corrective action(s) requested by the OQR review component;

• Adds all corrective action documentation to the CEF; and

• Returns the CEF to the OQR review office to code the rebuttal results.

4. CD Supports DDS Rebuttal

a. The CD Prepares:

• A cover letter/memorandum indicating their support of the DDS’s second-level rebuttal request, and emails it to the DDS with cc’s to the appropriate OQR review component that reviews and prepares a response to the rebuttal. OQR email addresses are on the OQR website.

• A barcoded cover sheet, using document type 0170 (REBUT2), Level 2 Rebuttal, and faxes the cover letter/memorandum and the DDS’s second-level letter/memorandum to the CEF using fax number 866-722-2297.

b. DDS Transfers Jurisdiction of the CEF to the CD

When the DDS is notified of the CD’s support of the rebuttal request, the DDS transfers jurisdiction of the CEF to the CD. Refer to the following chart for the appropriate Regional Office CD destination codes.

NOTE: The CEF status is “Transferred.”

c. OQR Review Office Receives Rebuttal from CD

• The OQR review component reviews the CEF in eView;

• Prepares a memorandum resolving the rebuttal and addresses the memorandum to regional CD Director; and

• Notifies OQR CO via email that the response is ready for review.

d. OQR CO Makes Final Rebuttal Decision

The Division Director, DIB Initial, reviews the CEF via eView, makes the final decision to affirm or rescind the deficiency, and signs the final memorandum. The Division Director, DIB Initial is the final arbiter. OQR CO ensures:

• The final memorandum (using document type 2070 (REBRESP), Response to Rebuttal) and any related documentation (e.g., medical review notes, ODP policy input, etc.) received during the rebuttal resolution process are faxed into the CEF using fax number 866-722-2297; and

• The appropriate components are notified of the final resolution of the second-level rebuttal.

5. OQR CO Rescinds Deficiency

If the OQR CO rescinds the deficiency, the OQR review component:

• Obtains jurisdiction of the CEF;

• Updates the CEF;

• Codes the final rebuttal in DICARS; and

• Completes processing of the case.

6. OQR CO Affirms Deficiency

a. OQR Review Component Actions

• Obtains jurisdiction of the CEF;

• Updates the CEF;

• Codes the final rebuttal in DICARS; and

• Sends the CEF to the appropriate component for action. The CEF is returned to the DDS if corrective action is needed.

b. DDS Actions

• Takes the corrective action(s) requested by the OQR review component;

• Adds all corrective action documentation to the CEF; and

• Returns the CEF to the OQR review office.