I-1-3-21.Submitting a Referral For Investigation of Possible Fraud or Similar Fault Discovered During Disability Claim Adjudication- Appeals Council

Last Update: 5/13/14 (Transmittal I-1-74)

A. Referral During Case Adjudication or Own Motion Review

1. When the Appeals Council (AC) Will Submit a Request For an Investigation of Fraud or Similar Fault

When adjudicating a disability case or performing own motion review, the AC will request that a Cooperative Disability Investigations Unit (CDIU) investigate an issue of fraud or similar fault when the AC is unable to determine whether an administrative law judge's (ALJ) decision to disregard evidence was appropriate.

NOTE:

The AC will not notify the claimant of a request for the CDIU to investigate an issue of fraud or similar fault. However, the AC will retain a copy for inclusion in the record and give the claimant an opportunity to examine the response, if any, when it is received.

If the case presents a new issue of fraud or similar fault that requires formal consideration and resolution, the AC will generally remand the case. See Hearings, Appeals and Litigation Law (HALLEX) manual I-3-10-5. However, formal consideration and resolution of a new fraud or similar fault issue is generally not required when the claimant appeals an unfavorable ALJ decision and the AC intends to deny review. Rather, the AC may refer the new issue to the Office of the Inspector General using the procedures in HALLEX I-3-10-9 and I-1-3-0.

2. How the AC Will Submit a Request For an Investigation

a. Submit to CDIU

The AC may send a referral to the CDIU by completing and submitting the electronic version of Form SSA-8551 (e8551) (Reporting Form for Programmatic Fraud). Step-by-step instructions for completing this form are found in Program Operations Manual System GN 04111.065.

Alternatively, the AC may submit a referral by calling the CDIU using the contact information referenced in HALLEX I-1-3-90.

b. Submit to Field Office or Disability Determination Services

When appropriate, the AC will request, in writing, that the local Social Security field office (FO) or the Disability Determination Services (DDS) initiate or reopen a CDIU investigation. The AC will send the request to the FO when the issue relates to work activity or a non-disability issue. The AC will send the request to the DDS when the matter involves medical issues.

A copy of the request must also be sent to the Executive Director's Office (EDO) via email to ¦¦¦ODAR OAO.

3. CDIU Response

The CDIU makes an independent determination concerning whether to initiate or continue an investigation. Therefore, the AC may proceed with case adjudication when CDIU either:

  • Notifies the AC in writing of its decision to decline investigation, or

  • Returns its report when an investigation is undertaken.

B. Referral After Final Action

AC referrals for fraud or similar fault after a final action are not part of the administrative proceedings in the case. Therefore, it is unnecessary to associate the referral with the claim(s) file. In referrals after a final AC action, the AC will use the procedures in HALLEX I-1-3-6 B or I-1-3-9 B rather than the procedures outlined in this section.