I-3-2-3.Referrals From Other Components for Own Motion Review Based on Fraud or Similar Fault

Last Update: 5/13/14 (Transmittal I-3-65)

A. Receipt of Referral

1. Referral from Another Component

Under limited circumstances, the Appeals Council (AC) may receive a referral for own motion review from another component. Under 20 CFR 404.969 and 416.1469, a case will be referred only if:

  • The case is identified through random and selective sampling techniques, which may be used in association with examination of the cases identified by sampling; or

  • The case is identified during the evaluation of cases conducted in order to effectuate a decision.

NOTE 1:

An effectuating component will refer a case to the AC only if the perceived error appears to prevent effectuation of the decision, such as when an error is clearly inconsistent with the Social Security Act, the regulations, or a published ruling.

NOTE 2:

A referral to the AC by another component must be in writing.

2. Referrals or Requests from the Office of the Inspector General (OIG)

The AC will not consider referrals or requests from OIG to review an administrative law judge (ALJ) decision for the following reasons:

  • OIG does not have the authority to refer a case to the AC for possible own motion review.

  • OIG is not a party to the decision and therefore cannot request review of an ALJ decision.

  • OIG units are statutorily precluded from participating in program operating functions, and may not express opinions about whether benefits should be awarded or denied.

B. Special Considerations in Processing Own Motion Referrals

If the AC decides to review a case on its own motion after referral for possible fraud or similar fault, the AC will attach a copy of the referral to the Notice of Review. See Hearings, Appeals and Litigation Law (HALLEX) manual I-3-6-51 for instructions on notifying a claimant of own motion review. The AC will also copy the referring component on the notice.

If the folder contains OIG evidence that the claimant has not previously had the opportunity to review, the AC will also notify the claimant in the Notice of Review that the file contains OIG evidence. If the OIG evidence is associated after the Notice of Review is sent, and the AC anticipates granting review, the AC will send an interim notice to the claimant with a copy of the evidence, providing the claimant the opportunity to comment before the AC takes action. See HALLEX I-3-6-1 C.