I-3-2-1.Overview

Last Update: 6/25/14 (Transmittal I-3-68)

A. Policy

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-3-2-11.

For general information relating to “redeterminations” based on fraud or similar fault, see HALLEX I-1-3-25.

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).

NOTE 1:

If fraud or criminal conduct is suspected and fraud or similar fault is not the issue before the adjudicator, see the applicable instructions in HALLEX I-1-3-0 and I-3-2-9 for making a referral to the Office of the Inspector General (OIG).

NOTE 2:

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

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.