I-2-9-65.Conditions Necessary for Reopening Due to Fraud or Similar Fault
Last Update: 5/13/14 (Transmittal I-2-107)
Under 20 CFR 404.988(c)(1) and 416.1488(c), a determination, revised determination, decision, or revised decision may be reopened at any time if it was obtained by fraud or similar fault. For the definitions of fraud and similar fault, see Hearings, Appeals and Litigation Law (HALLEX) manual I-1-3-15.
Fraud or similar fault may be perpetrated by a claimant or any other person (e.g., a representative, interpreter, medical provider, or a Social Security Administration (SSA) employee). For reopening purposes, it is not necessary that the other person have any direct relationship to the claimant or be acting on behalf of the claimant. However, under 20 CFR 404.988(c)(1) and 416.1488(c), SSA will consider any physical, mental, educational, or linguistic limitations (including any lack of facility with the English language) that a claimant may have had when the circumstances leading to fraud or similar fault occurred.
B. Additional Considerations for Reopening for Similar Fault in Title XVI Cases
To reopen based on similar fault in title XVI cases, the preponderance of the evidence must show:
The changed event is material (i.e., will change payments and create a new overpayment or enlarge an existing overpayment);
A wide discrepancy exists between the new data and the data reported;
The person (claimant, representative, medical provider, or any other individual) knowingly completed an incorrect or incomplete report, knowingly concealed events or changes, or knowingly neglected to report events or changes that affect payments;
The event can and will be verified; and
The event is clearly attributable to the person.