Background

This transmittal introduces new chapter I-3-2 in the Hearings, Appeals and Litigation Law (HALLEX) manual, titled “Fraud, Similar Fault, and Administrative Sanctions.” The chapter includes instructions for the Appeals Council when adjudicating cases involving an issue of fraud or similar fault, and instructions on processing an administrative sanction case. All sections in chapter I-3-2 are new.

Explanation of Content and Changes

I-3-2-1 – The new section titled “Overview” includes basic references to definitions and outlines the Appeals Council's responsibility in fraud, similar fault, and administrative sanction cases. The section also explains that the Appeals Council must avoid ex parte communication with an Office of the Inspector General (OIG) agent or witness.

I-3-2-3 – In the new section titled “Referrals From Other Components for Own Motion Review Based on Fraud or Similar Fault” we explain how another component may submit a referral to the Appeals Council, and that the Appeals Council may not consider referrals from OIG. We also explain other required actions when the Appeals Council reviews a case under its own motion authority.

I-3-2-5 – We added a new section titled “Appeals Council (AC) Final Actions When a Fraud or Similar Fault Issue Is Raised” to explain when it is appropriate for the Appeals Council to deny or grant review when a case involves an issue of fraud or similar fault.

I-3-2-7 – We added a new section titled “Reopening When Fraud or Similar Fault Is Involved” to explain that the Appeals Council applies the same general procedures regarding reopening in all cases, even when the case involves an issue of fraud or similar fault.

I-3-2-9 – In a new section titled “Appeals Council (AC) Referrals to the Office of the Inspector General” we provide references to HALLEX provisions that may apply when the Appeals Council suspects possible fraud or criminal violations, and to those that apply when the Appeals Council encounters an issue of fraud or similar fault during case adjudication.

I-3-2-11 – We added a new section titled “Administrative Sanction Cases.” We explain that the Appeals Council uses its usual procedures in these cases in determining whether there is a basis for granting review.

Date: May 13, 2014