The focus of a Social Security quality review may affect a benefit decision, but it doesn't target you specifically. Instead, the focus is on the claims examiner in charge of evaluating your application for Social Security disability or supplemental security income benefits. The reason is that claims examiners are third-party contractors, not employees of the Social Security Administration. A quality assurance review conducted by an SSA employee helps to ensure that third-party examiners follow federal guidelines in processing applications.
About the Quality Review Board
Employees in the disability and supplemental security income branches of the SSA Office of Quality Review evaluate randomly selected benefits applications from each of the regional Disability Determination Services regional office. According to Disability Secrets, about one of every 100 applications accepted at each field office are chosen to undergo a review.
The random selection takes place after the claims examiner finishes verifying and approving or rejecting an application, but before the application is forwarded to the SSA for final processing. If your application received an initial approval, benefits won't begin until the quality review is complete. There is also no set time frame for an SSA examiner to complete a quality review and notify you of the board's decision. Depending on what the review uncovers, the process can take a few weeks or months.
Quality Review Procedures
Specific review procedures depend on whether you're applying for disability or supplemental security income benefits. According to the SSA, reviews generally consist of in-house document reviews and telephone or postal mail interviews. A reviewer has the option to contact you and any third-party source of information, such as your physician.
For a disability benefits application, the focus is on making sure that:
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- Your file contains the required documentation and medical evidence to support the examiner's final decision
- The claims examiner evaluated all medical evidence correctly
- The examiner applied medical-vocational grid rules properly for applicants whose disability doesn't match a medical impairment, also known as a "Blue Book" or listing of impairments exactly
- The examiner applied the correct residual functional capacity rating according to your remaining functional capacity (your ability to perform essential work activities) in spite of your disability
For a supplemental security income review, an SSA reviewer also verifies income and asset information to ensure that your application truly meets SSI eligibility requirements.
Outcomes and Consequences
A quality review can have one of three possible outcomes:
- The reviewer can agree with the claim examiner's decision and either approve or deny your application.
- The reviewer can overturn an examiner's decision to award or deny benefits.
- The reviewer can delay making a final decision and instead send your application back to the claims examiner. This is common in situations such as an application with missing paperwork or the correct. documentation. The reviewer finishes once you correct the errors.
Appealing a Quality Review Decision
You have the right to appeal a quality review decision. The notice of denial letter from the SSA outlines the steps and describes the appeal process.
The first step usually involves a review of your claim from start to finish. If this results in a second denial, you'll have 60 days to request a hearing before an attorney employed by the SSA Office of Disability Adjudication and Review, commonly known as an administrative law judge.
Even though approximately 67 percent of all applicants win their appeal case, according to Nolo, you can request an Appeals Council review if you lose. However, the Appeals Council only randomly selects cases for review. If yours is chosen, Nolo reports that only about 2 to 3 percent of applicants win their case.
If all else fails, as a last resort, you may hire an attorney and file a lawsuit in a federal court.