Subject: Fraud, Similar Fault, Criminal Violations, and Referrals from OIG
This transmittal amends section I-1-3 of the Hearings, Appeals, and Litigation Law (HALLEX) manual to update our policies and instructions based on the rescission of Social Security Ruling (SSR) 16-1p Titles II and XVI: Fraud and Similar Fault Redeterminations Under Sections 205(u) and 1631(e)(7) of the Social Security Act and SSR 16-2p, Titles II and XVI: Evaluation of Claims Involving the Issue of Similar Fault in the Providing of Evidence, and the publication of SSR 22-1p, Titles II and XVI: Fraud and Similar Fault Redeterminations Under Sections 205(u) and 1631(e)(7) of the Social Security Act and SSR 22-2p, Titles II and XVI: Evaluation of Claims Involving the Issue of Similar Fault in the Providing of Evidence.
I-1-3-15 – In subsection A, we added general information, with applicable cross references, regarding issues that may involve fraud or similar fault. We redesignated the NOTE in this subsection as NOTE 1 and moved guidance regarding referrals to the Office of Inspector General to a new NOTE 2. We added a cross reference in NOTE 1 to new HALLEX section I-1-3-26 regarding “non-redetermination” cases. In subsection B.1. we revised the definition of fraud for readability. We removed NOTE 1 in this subsection and updated the designation for NOTE 2. In subsection B.2., we updated the designation for NOTE 1, revised the contents of this note for readability, and removed NOTE 2. We added a new subsection, B.3., with the definition of “material,” that was previously contained in the notes removed in B.1. and B.2. In subsection C, we added new sections C.1. and C.2. to discuss the different standards of proof that may be at issue with cases involving fraud or similar fault. In new section C.1., we updated the standard of proof used when adjudicating fraud or similar fault issues under sections 205(u) and 1631(e)(7) from “preponderance of the evidence” to “reason to believe” based on the new SSRs. In new section C.2., we added that adjudicators will use “preponderance of the evidence” as the standard of proof when adjudicating issues involving reopening. We also added an example in this new section of when it is likely that a preponderance of the evidence supports finding a determination or decision was obtained by fraud or similar fault. We updated subsection D to state that before SSA disregards evidence at the hearing level an adjudicator will consider an individual's objection to the disregarding of the evidence. We also replaced and updated references to SSRs 16-1p and 16-2p with references to SSRs 22-1p and 22-1p, respectively, throughout. We made minor editorial changes for readability throughout the section.
I-1-3-25 – We updated subsection A based on guidance in the new SSRs. In subsection C.1. we added instructions for screening cases with potential fraud or similar fault. We renamed subsection C.2. for readability and added guidance regarding our notices when fraud or similar fault is an issue. In subsection C.4.a., we removed prior guidance based on the rescinded SSRs and added new instructions based on the new SSRs. In C.5., we simplified and updated our guidance on when a hearing is required. In subsection C.6., we revised our instructions regarding appeal rights involving fraud or similar fault issues. We also replaced and updated references to SSRs 16-1p and 16- 2p with references to SSRs 22-1p and 22-1p, respectively, throughout. We made minor editorial changes for readability throughout the section.
I-1-3-26 – We created a new section titled “Processing Non-Redetermination Fraud or Similar Fault Cases and Disregarding Evidence Under Sections 205(u)(1)(B) and 1631(e)(7)(A)(ii) of the Social Security Act (Fraud or Similar Fault “Non-Redetermination Cases”)” to address the procedures and special adjudication issues when processing “non-redetermination” cases, i.e., cases involving fraud or similar fault that have not had a final determination or decision. In subsection A, we provide general information about our policies regarding adjudication of fraud or similar fault, and about how these cases are uncovered. In subsection B, we describe our procedures for identifying and processing these cases. In subsection C, we identify several special adjudication issues related to non-redetermination cases.
Date: June 7, 2022