Subject: Fraud, Similar Fault, Criminal Violations and Referrals
This transmittal amends section I-1-3-25 of the Hearings, Appeals and Litigation Law (HALLEX) manual to provide more detailed information about how the Office of Disability Adjudication and Review handles redeterminations under sections 205(u) and 1631(e)(7) of the Social Security Act (Act).
HALLEX I-1-3-25 is amended as follows:
I-1-3-25 – We changed the title to “Processing Cases Under Sections 205(u) and 1631(e)(7) of the Social Security Act (Fraud or Similar Fault “Redeterminations”)” to more accurately reflect the purpose of the section.
I-1-3-25 A – We changed the title to “In General” to remove confusion about the term “redeterminations” as used in a non-fraud or similar fault situation. We updated and expanded the information describing the redetermination process under sections 205(u) and 1631(e)(7) of the Act. For example, we clarified that under the Act, the Social Security Administration is required to disregard any evidence if there is reason to believe fraud or similar fault was involved in providing the evidence.
I-1-3-25 B – We made editorial changes throughout this subsection and clarified that an individual will be provided information relevant to his or her case in notices and other communications from the agency.
I-1-3-25 C – We provided more detail regarding how we adjudicate redeterminations under sections 205(u) and 1631(e)(7) of the Act. For example, we explained that we first screen the cases to determine if a favorable decision is supported after disregarding the identified evidence, and, if the decision is supported, we end any further redetermination proceedings. Additionally, we expanded our explanation of the notice provided to the beneficiary. We clarified that when the agency has determined evidence must be disregarded under 205(u) and 1631(e)(7) of the Act, the adjudicator does not have discretion to reconsider the issue. We modified our instructions relating to developing evidence to clarify when this action may be appropriate. We also expanded our instructions about the submission of additional evidence to clarify what evidence will be considered and how to handle evidence of a new impairment with onset after the period of consideration. We removed the sub-subsection relating to suspension of benefits and moved the information to the NOTE in the sub-subsection regarding notice to the beneficiary. We explained when an additional hearing may be needed and clarified decision writing requirements and appeal rights. We added information relating to representative fee issues and handling cases that were redetermined at another adjudicative level.
Date: February 25, 2016