Attachment A Medical Contractor Review Questions for 72 Disability Cases Final Copy 3-4-24.docx

ATTACHMENT A

Physician Questions for Initial Disability Decision Quality Assurance Review (72 Cases)

Identifying Case Information (in the data entry form header)

1. Type of Disability Entitlement - Prefilled By RRB

· Occupational

· Total Disability

· Widow(er)

· Child

2. What was the initial disability determination- Prefilled By RRB

· Grant

· Denial

3. What was the basis for the grant/denial? Prefilled By RRB Note: Based on the basis, the physician is directed to complete either the Limitations, Listing Level or Denial tabs in the database. The questions for the Limitations, Listing Level and Denial tabs are shown below.

The prefilled drop-down menu options are:

· Met Listing Level Severity

· Met Listing- Adopting SSA

· Equaled Listing

· Equaled Listing- Adopting SSA

· Limitations from RFC

· Limitations - Adopting SSA

· RFC and Listing

· No limitations from an RFC cited

Limitations

4. Does the medical evidence that the limitations were based upon come from an accepted medical source and have objective findings from exam results or clinical/laboratory tests??

The physician selects one of the following drop-down menu options:

•Yes •No – if answered no, the physician provides additional comments

5. If the most recent medical evidence in the case was more than a year old, do you feel it was sufficient to proceed with rating the case?

The physician selects one of the following drop-down menu options:

•Yes •No – if answered no, the physician provides additional comments

6. Identify RFC(s) in the decision and whether the RFC was supported. Note: There is space to document up to four RFCs.

· Source of the RFC? (drop down: Consultative Exam, Consultative Opinion, Chief Medical Officer (CMO), SSA RFC)

· RFC Supported? (Drop down: Fully, Partially, Not)

· Does the physician concur with the disability examiner’s assessment of RFC support? (Yes or No)

· Comment Field:

· Enter RFC physician’s name:

7. Limitations Used in the Initial Disability Decision The physician provides description of the actual type(s) of Limitations the Disability Examiner cited in the decision

· Physical Limitations

· Environmental Limitations

· Mental Limitations

8. Were the limitations identified by the examiner and used in the initial disability determination supported by the medical evidence of record at the time of the determination?

[Physical? Environmental? Mental?] The physician selects one of the following drop-down menu options:

· Yes

· No

9. Were there limitations from an RFC that the disability examiner said were supported that could have been used, however they were not used.

The physician selects one of the following drop-down menu options:

10. After review of the medical evidence, do you believe that Listing Level severity could have been met or equaled rather than the disability examiner proceeding using limitations?

The physician provides explanation

11. Did the medical evidence support the onset date established by the disability examiner?

The physician selects one of the following drop-down menu options:

· Yes

· No – if answered no, the physician provides additional comments in a separate database field.

12. During your review, did you notice any unusual patterns or inconsistencies in the objective findings in the medical evidence submitted in support of the disability application?

The physician selects one of the following drop-down menu options:

•Yes– if answered yes, the physician provides additional comments •No

Listing Level Severity

13. Indicate whether the disability examiner specified that the applicant met or equaled the Listings?

The physician selects one of the following drop-down menu options:

•Met Listing Level Severity •Equaled Listing Level Severity

14. Does the medical evidence used in support of Listing Level severity come from an accepted medical source and have objective findings from exam results or clinical/laboratory tests??

The physician selects one of the following drop-down menu options:

•Yes •No – if answered no, the physician provides additional comments

15. If the most recent medical evidence in the case was more than a year old, do you feel it was sufficient to proceed with rating the case?

The physician selects one of the following drop-down menu options:

· Yes

· No – if answered no, the physician provides additional comments in a separate database field.

· Not Applicable

16. If the applicant was found to Meet Listing Level Severity:

The physician completes the following:

· Listing Used:

· Drop down: Did the medical evidence support all the criteria specified in the Listing (Yes or No)

· Provide additional comments as needed:

17. If the applicant was found to Equal Listing Level Severity:

The physician completes the following:

· Listing Used:

· Was a severity assessment secured by the examiner (Yes or No)

· Drop down: Did the medical evidence support equaling the criteria specified in the Listing (Yes or No)

· Provide additional comments as needed:

18. Did the medical evidence support the onset date established by the disability examiner?

The physician selects one of the following drop-down menu options:

· Yes

· No – if answered no, the physician provides additional comments in a separate database field.

19. Complete only if a Child decision -- did the medical evidence establish limitations/Listing level severity before age 22?

The physician selects one of the following drop-down menu options:

· Yes

· No – if answered no, the physician provides additional comments in a separate database field.

20. During your review, did you notice any unusual patterns or inconsistencies in the objective findings in the medical evidence submitted in support of the disability application?

The physician selects one of the following drop-down menu options:

•Yes– if answered yes, the physician provides additional comments •No

Denial Decisions

21. If the applicant was denied and the decision was based on Listing Level Severity, The physician answers the following:

· Did the medical evidence fail to establish Listing Level Severity (Yes or No)

· Provide additional comments as necessary

22. If the applicant was denied and Limitations were used in the decision, The physician answers the following:

· Did the medical evidence support the limitations the examiner used in the decision (Yes or No)

· Provide additional comments as necessary

23. If the denial was for a child, The physician answers the following:

· Did the medical evidence support Limitations and/or Listing Level Severity before age 22 (Yes or No)

· Provide additional comments as necessary

24. During your review, did you notice any unusual patterns or inconsistencies in the objective findings in the medical evidence submitted in support of the disability application?

The physician selects one of the following drop-down menu options:

•Yes– if answered yes, the physician provides additional comments •No

Prepared by PEMS 3/4/24 2