GN 04440.110: Defining the Probability of Reversal (POR) Rule and Classifying Documentation Deficiencies
- Effective Dates: 02/26/2014 - Present
- TN 16 (04-11)
- GN 04440.110 Defining the Probability of Reversal (POR) Rule and Classifying Documentation Deficiencies
- A. Introduction to the POR rule
- When a case does not contain complete medical or vocational documentation as required by SSA disability program policy, the quality reviewer must decide whether to return the case to the adjudicating component to obtain the missing documentation and whether to classify the determination as a deficiency or technical corrective action. With certain exceptions as described in GN 04440.112, the Federal quality reviewer employs the POR rule to make this determination.
- B. Definition of the POR rule
- The POR rule is an administrative criterion used by the Federal quality reviewer to decide whether to return medical or vocational documentation deficiencies to the adjudicating component for correction. The purpose is to minimize unnecessary use of resources for development of medical or vocational evidence.
- Under the POR rule,
- * if a disability determination is not fully documented as required by SSA disability program policy,
- * but the evidence in file is sufficient for the Federal quality reviewer to judge that the missing evidence is unlikely to change the disability determination
- * or the length of the period of disability,
- the Federal quality reviewer classifies the discrepancy as a non-returnable “technical corrective action.” Classify any other medical or vocational documentation deficiency as either a group I or group II documentation deficiency and return it for correction.
- C. Who makes POR determinations
- Federal quality reviewers make POR determinations in deciding whether a case has sufficient medical or vocational documentation to support the disability determination.
- Federal review physicians may offer opinions on the potential effect of missing documentation on impairment severity or residual functional capacity, but these opinions are not binding on the Federal quality reviewer.
- Federal quality reviewers are responsible for the final POR determination, subject to discretionary review by review component management.
- See Details:
- * For an explanation of who is a Federal quality reviewer, see GN 04440.003.
- * For a further explanation of the reviewing physician's role in POR determinations, see GN 04440.135B.3.
- NOTE: The adjudicating component may not use POR to determine whether to make an initial request for required medical or vocational documentation or as the basis for rebuttal. However, adjudicators may process a fully favorable allowance determination without awaiting receipt of, or continuing to follow up on development of, required evidence that should not, in the judgment of the adjudicative team, affect the allowance determination.
For a complete explanation of expedients for evaluating evidence, refer to DI 24515.001 and DI 24515.020.
- D. When to apply POR
- Apply the POR rule, subject to the exceptions listed in GN 04440.112, whenever the medical or vocational documentation does not conform to a specific requirement of disability program policy.
- NOTE: Include a statement in the file regarding whether you considered POR only when the medical staff states the file contains "insufficient evidence," and the review component does not return the case because, after applying POR, they determined the missing documentation is unlikely to reverse the determination. In that situation, the review component documents the file (e.g., SSA-5002) with an explanation that they applied POR and the conclusion reached was that it was not necessary to return the case for additional documentation.
x← This means that the line was removed and was added – in other words, the "Effective Dates" line at the top of the document has been updated to reflect that the new version is effective as of the date the change was made.