I-1-3-25.Processing Multiple Cases When Fraud or Similar Fault Involved (“Redeterminations”)

Last Update: 6/25/14 (Transmittal I-1-75)

A. Redeterminations- In General

Under sections 205(u) and 1631(e)(7) of the Social Security Act (Act), the Social Security Administration (SSA) must immediately redetermine the entitlement of individuals to monthly disability benefits if there is reason to believe that fraud or similar fault was involved in the individual's application for such benefits. A redetermination is a re-adjudication of the individual's application for benefits, based on the agency's finding that fraud or similar fault was involved in an individual's application for monthly disability benefits. The agency may be required to initiate a redetermination based on an Office of the Inspector General (OIG) referral of information pursuant to section 1129(l) of the Act or information from a criminal prosecutor with jurisdiction over potential or actual related criminal cases.

NOTE 1:

SSA will redetermine cases immediately unless a United States attorney or other State prosecutor handling potential or actual related criminal cases certifies in writing that there is a substantial risk that conducting redeterminations will jeopardize prosecution of the criminal case.

NOTE 2:

As the Act states that a redetermination can only be performed when an individual is receiving monthly benefits, SSA will use redetermination procedures when a favorable decision was issued and the claim(s) now needs to be reevaluated due to a new issue of fraud or similar fault. However, under sections 205(u)(1)(B) and 1631(e)(7)(A)(ii) of the Act, the agency may also disregard tainted evidence on pending cases that have proceeded beyond the initial determination level.

B. Procedures

1. Identification of Cases

The agency determines when to redetermine cases based on a finding that fraud or similar fault was involved in an individual's application for monthly disability benefits. The agency may also receive an OIG referral of information pursuant to section 1129(l) of the Act or information from a criminal prosecutor with jurisdiction over potential or actual related criminal cases. Unless the redeterminations apply only at the Office of Disability Adjudication and Review (ODAR) levels, redeterminations may be coordinated with other components.

2. Assignment of Cases

The Deputy Commissioner of ODAR will determine which ODAR component is designated to redetermine the affected case(s).

3. Instructions for Processing Cases

Except in unusual circumstances where individual case instruction is more appropriate, ODAR will draft specific processing instructions for any particular batch of cases. To meet the “immediacy” requirement, ODAR may initially release instructions in a temporary format such as a memorandum or other established mechanism, but will usually finalize instructions in a Hearings, Appeals and Litigation Law (HALLEX) manual temporary instruction (TI).

C. Special Adjudication Issues in Redeterminations

For each batch of cases, the HALLEX TI will usually address issues unique to redeterminations based on fraud or similar fault. Common examples of these unique issues include the following:

1. Notice to Claimant

When an adverse redetermination is necessary, ODAR will send the claimant an appropriate notice based on the circumstances. The notice may include issues relating to benefit continuation or the opportunity for a supplemental hearing. Additionally, the notice may include the opportunity and time-frame for submitting arguments or rebuttal evidence.

In some cases, special language in an acknowledgement of hearing or notice of hearing may be required.

2. Period of Adjudication

When redetermining a claim(s), an adjudicator will be directed to consider the claim(s) only through the date of the final and binding determination or decision on the beneficiary's application for benefits (i.e., the original allowance date).

NOTE:

An ODAR adjudicator will give special attention to specific processing instructions for handling allegations of a disabling impairment(s) with onset after the date of the adjudication. See HALLEX I-1-3-25 C.3.c. below.

3. Evidence

a. Disregarding Evidence

Based on OIG referrals of information pursuant to section 1129(l) of the Act or information obtained through other criminal, congressional, or administrative investigation, the agency may direct an ODAR adjudicator to disregard certain evidence.

When considering other evidence that the adjudicator has not been previously instructed to disregard, ODAR adjudicators will use the procedures in Social Security Ruling (SSR) 00-2p: Titles II and XVI: Evaluation of Claims Involving the Issue of “Similar Fault” in the Providing of Evidence and applicable HALLEX provisions in I-2-10-0 and I-3-2-0 to determine whether to disregard that evidence.

b. Developing Evidence

During redeterminations based on fraud or similar fault, SSA will not generally develop evidence beyond the original allowance date. However, an adjudicator may consider evidence submitted by the beneficiary that post-dates the original allowance date if that evidence relates to the period at issue in the redetermination. For example, if a beneficiary submits evidence of an IQ test dated after her original allowance, and that evidence, with the remaining evidence of record, supports her claim that she met Listing 12.05C as of the date of her original allowance, SSA will consider that evidence during a redetermination.

c. Evidence of New Impairment Submitted

If the beneficiary submits evidence of an impairment that existed at the time of his or her original allowance, but was not alleged on his or her application, the agency will consider that evidence.

If the beneficiary submits evidence of a new impairment unrelated to those alleged in the application being redetermined, and the onset date is after the original allowance date, the adjudicator will usually not consider or develop the evidence of the new impairment during the redetermination, unless objective evidence shows a new critical or disabling condition. In that instance, the ODAR adjudicator will consult with ODAR management to determine the appropriate course of action.

4. Suspension of Benefits

When a claim is being redetermined, the agency may decide to suspend current benefits (after proper notice).

5. Appeal Rights and Special Decision Language

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 Act or information from a criminal prosecutor with jurisdiction over potential or actual related criminal cases.

The HALLEX TI for each batch of cases will address any special language required in a redetermination decision.