Last Update: 6/25/14 (Transmittal I-2-112)
For definitions of fraud and similar fault in regard to evidence in a claim(s), see Hearings, Appeals and Litigation Law (HALLEX) manual I-1-3-15 B.
For definitions associated with administrative sanction cases, see HALLEX I-2-10-16.
For general information relating to redeterminations based on fraud or similar fault, see HALLEX I-1-3-25.
In a redetermination, a claimant may appeal a determination or decision regarding whether he or she was entitled to disability benefits or supplemental security income as of the date of his or her original allowance. The claimant may also appeal the agency's finding of fraud or similar fault that is unrelated to the basis for the redetermination. However, the claimant may not appeal the agency's statutory mandate to disregard evidence based on OIG referrals of information pursuant to section 1129(l) of the Social Security Act or information from a criminal prosecutor with jurisdiction over potential or actual related criminal cases.
B. Administrative Law Judge (ALJ) Responsibilities
When a case involves an issue of fraud or similar fault, the issues before an ALJ may include one or more of the following:
Whether certain evidence must be disregarded (HALLEX I-2-10-10);
Whether to impose administrative sanctions in the form of nonpayment of benefits (HALLEX I-2-10-16); and
Whether a prior final determination or decision should be reopened under the rules of administrative finality because it was obtained by fraud or similar fault (HALLEX I-2-9-65).
If an ALJ suspects fraud or criminal conduct that is not material to the issue(s) before the ALJ, the applicable instructions in HALLEX I-1-3-0 apply.
The disregarding of evidence based on a fraud or similar fault finding does not complete the adjudication of any claim for benefits. Unless a dismissal is appropriate, the ALJ must issue a favorable, partially favorable, or unfavorable decision on the claim by evaluating the remaining evidence. See HALLEX I-2-10-10.
In the circumstances outlined in HALLEX I-1-3-25, an ALJ may be directed to disregard certain evidence based on fraud or similar fault.
C. Ex Parte Communications
ALJs will not attempt to contact or question an Office of the Inspector General (OIG) agent or witness unless HALLEX I-2-10-8 A applies.
However, there is no prohibition on ALJs consulting with other appropriate agency personnel about technical issues or questions of law or policy regarding information from OIG. Additionally, this instruction does not preclude a person or party from inquiring about the status of a case or asking routine questions about administrative functions or procedures.