Payment Validation Reviews
The Social Security Administration (SSA) Vocational Rehabilitation (VR) regulations
allow the Commissioner to pay claims based on a minimum of documentation. The Code
of Federal Regulations (CFR), 404.2121 and 416.2221, requires that SSA conduct a
validation review of a sample of reimbursement claims for payment filed by each State
Vocational Rehabilitation (VR) agency for program integrity purposes. SSA will use the
following types of reviews to validate claims submitted by State VR agencies.
The purposes of validation reviews are to ensure that the VR services and costs meet the
requirements for payment; to assess the validity of our documentation requirements; and,
to assess the need for additional validation reviews or additional documentation
requirements. Each claim will be reviewed to verify that there is sufficient documentation
to support the direct costs claimed. The direct cost items submitted must be consistent with
the Individualized Plan for Employment (IPE).
Claims for payment validation review (PVR) will be randomly selected by the system after
they are processed for approval and prior to payment. Post payment validation reviews will
be perform manually by Quality Assurance Team (QAT). All claims with overlapping
periods of VR services will be selected for validation review at the point that the
overlapping periods are detected. Payment for VR services or costs may be made under
more than one of the VR periods. However, payment will not be made more than once for
the same VR service or cost. Claims Unit Technicians will perform required reviews and
control the flow of the entire process.
Program analysts will provide technical guidance on validation review claims as deemed
appropriate by the supervisor of the Claims Unit.
The claims to be reviewed will be ready for release of payment when the validation is
completed. As soon as the VR provider substantiates the full amount of the direct cost
services provided, payment will be released immediately.
NOTE: Post validation reviews may occur immediately or many years after payment. If
documents for direct cost services cannot be produced in overlapping PVR’s, there will be
adjustments made to monies previously paid.
During each fiscal year, a random sample of claims will be selected for PVR from all VR
providers based on a percentage of the total allowed claims processed in the previous fiscal
year. Our fiscal year begins on October 1st and extends twelve months into the following
year ending on September 30th. Due to the great variance in the amount of claims
submitted by VR providers, we cannot apply a pre-determined percentage value to
calculate how many claims will be selected for the PVR process.
When a claim is selected for validation review, notification will be sent to the VR agency.
All validation review claims will be reviewed to validate the direct costs listed in items
17a, 17b and 17c on the Vocational Rehabilitation Claim Form, SSA-199. The technicians
must verify that each direct cost amount is equal to the amount SSA will pay on the claim
and that the purchase of the direct cost occurred within the payment period. The technician