Last Update: 6/7/22 (Transmittal I-3-186)
For definitions of fraud and similar fault, see Hearings, Appeals, and Litigation Law (HALLEX) manual I-1-3-15 B.
For definitions and instructions associated with administrative sanction cases, see HALLEX I-2-10-16 and I-3-10-11.
For general information relating to “redeterminations” based on fraud or similar fault, see HALLEX I-1-3-25.
For general information relating to “non-redetermination cases” based on fraud or similar fault, see HALLEX I-1-3-26.
B. Appeals Council (AC) Adjudicative Responsibilities
When a case involves an issue of fraud or similar fault, or in an administrative sanction action, the AC will consider issues such as the following:
Whether the notice and hearing decision requirements were followed (see HALLEX I-2-10-6 and I-2-10-14);
Whether certain evidence was properly disregarded (see HALLEX I-2-10-10);
Whether the appropriate administrative sanctions were imposed (see HALLEX I-2-10-16); and
Whether reopening issues were handled in accordance with agency policy (see HALLEX I-2-9-65).
In a redetermination, a claimant may appeal a determination or decision regarding whether they were entitled to disability benefits or eligible for supplemental security income as of the date of the original allowance. In conjunction with an appeal, an individual may object to an administrative law judge's (ALJ) finding to disregard evidence under the Act.
C. Ex Parte Communications
Due to possible litigation concerns, and to avoid the appearance of impropriety, the AC will not attempt to contact or question an OIG agent or witness.
However, there is no prohibition on the AC consulting with appropriate non-OIG personnel about technical issues or questions of law or policy regarding information from OIG (through the appropriate management chain). 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.