Identification Number:
DI 27505 TN 3
Intended Audience:See Transmittal Sheet
Originating Office:ORDP ODP
Title:Rules for Reopening
Type:POMS Transmittals
Program:All Programs
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM
Part DI – Disability Insurance
Chapter 275 – Reopenings, Adoptions and Refilings
Subchapter 05 – Rules for Reopening
Transmittal No. 3, 11/02/2021

Audience

PSC: CA, CS, DE, DEC, DTE, IES, RECONR, SCPS, TSA, TST;
OCO-OEIO: BET, CR, ERE, FCR, FDE, RECONE;
OCO-ODO: BET, CR, DE, DEC, DS, PAS, PETE, PETL, RCOVTA, RECONE;
ODD-DDS: ADJ, DHU;

Originating Component

ODP

Effective Date

Upon Receipt

Background

This Transmittal provides:

  • Updated instructions for the Disability Determination Services office to complete a referral for a potential fraud or similar fault allegation through the Allegation Referral Intake System;

  • New instructions for electronic and paper cases when it is required to reopen due to fraud or similar fault;

  • Examples when an adjudicator may reopen a prior claim due to the evidence in the initial allowance or in the prior continuing disability review is disregarded due to fraud or similar fault;

  • The offices responsible for reopening a case at the appropriate adjudicative levels.

Summary of Changes

DI 27505.015 Fraud or Similar Fault - Reopenings

Subsection A

  • We renamed the title in section A from "Fraud" to "When to use this section." and provided updated instructions.

  • We provided some examples of when an adjudicator may reopen a claim due to fraud or similar fault.

Subsection B

  • We renamed the title in section B to "Definitions of related terms to use in this section."

  • We removed duplicative language related to cross-referencing the definitions of fraud or similar fault.

  • We added the full definitions of fraud and similar fault.

Subsection C

  • We renamed the title to "When potential FSF is suspected in a prior favorable determination or decision."

  • We updated instructions to complete a referral for a potential fraud or similar fault allegation through the Allegation Referral Intake System to the Office of Inspector General.

  • We updated and reorganized instructions for electronic and paper cases.

  • We provided the offices which are responsible for reopening a claim due to fraud or similar fault at the appropriate adjudicative levels.

  • We removed the Office of Medical and Vocational Expertise (OMVE) and replaced it with the jurisdictional DDS, as OMVE no longer exists.

DI 27505.015 Fraud or Similar Fault (FSF) - Reopenings

A. When to use this section

Use the procedures in this section to reopen an allowance when the evidence in the prior determination or decision was obtained by fraud or similar fault.

Some examples of when we may follow these procedures are:

We may conduct an unscheduled medical continuing disability review (CDR) where the comparison point decision (CPD) shows the individual was disabled (or continued to be disabled) on that date, but we learn that the CPD was based on fraudulent medical evidence;

We may reopen a prior favorable CDR determination or decision when evidence in a prior CDR is now disregarded due to FSF; or

We may reopen a prior favorable initial allowance if we determine that the evidence the adjudicator relied upon in the initial allowance may be disregarded due to FSF, even if we conducted a CDR(s) since the initial allowance.

See also:

  • DI 23025.025 Disability Determination Services (DDS) - Disregarding Evidence

  • GN 04020.010 Unrestricted Reopening For Determinations or Decisions Obtained by Fraud or Similar Fault

  • SI 04070.005 Title XVI Administrative Finality Definitions

B. Definitions of related terms used in this section

  1. 1. 

    Fraud

Fraud exists when a person with the intent to defraud, either makes or causes to be made, a false statement or misrepresentation of a material fact for use in determining rights under the Social Security Act; or conceals or fails to disclose a material fact for use in determining rights under the Social Security Act.

2. Similar Fault

Similar Fault is involved with respect to a determination if:

(a) an incorrect or incomplete statement that is material to the determination is knowingly made; or

(b) information that is material to the determination is knowingly concealed.

See also

  • GN 04020.010 Unrestricted Reopening - Determinations or Decisions Obtained by Fraud or Similar Fault

  • GN 04105.005 Violations of the Social Security Act

  • SI 04070.005 Title XVI Administrative Finality Definitions

C. When potential FSF is suspected in a prior favorable determination or decision

1. The DDS suspects a case with evidence of FSF

If the DDS suspects that the prior determination was obtained by FSF:

  • Determine if another office (e.g., field office (FO)) documented its findings or observations in an SSA-5002 (Report of Contact);

  • After reviewing the documented findings or observations in the SSA-5002, complete a potential fraud referral through the Allegation Referral Intake System (ARIS) to the Office to Inspector General (OIG); to complete a potential fraud referral, see ARIS User Guide ;

  • After a potential fraud allegation is submitted through ARIS to the OIG, the following situations may occur:

If the OIG accepts the allegation for investigation and completes an investigation on the fraud allegation, the OIG will complete a report of investigation (ROI), outlining its findings and will forward the ROI to the requesting office for consideration. The requesting office will determine if the OIG's findings in the ROI indicate fraud and will reopen the case accordingly, or

If the OIG declines to investigate the allegation or does not find evidence of fraud during the investigation, the requesting office must evaluate whether the prior determination or decision was obtained by similar fault. Continue to develop the case by following guidance in DI 23025.010 Disability Determination Services (DDS) - Handling Potential Fraud or Similar Fault (FSF) Cases and GN 04020.010.B.2.

If there is a Special-F (Possible Fraud or Similar Fault) flag within the case file, and there is no explanation why the case was flagged for possible FSF:

  • Contact the FO staff who flagged the case through an assistance request (AR) for a brief explanation; see related instructions DI 11006.005 Field Office (FO) - Identifying Potential Fraud or Similar Fault (FSF) Cases, and

  • If the FO staff does not respond to the request for clarification, transfer the case back to the FO.

2. Office other than the DDS suspects evidence potentially involving FSF

If an office other than the DDS suspects a prior determination or decision was obtained by FSF involving non-medical issues (e.g., questionable earnings to the level of substantial gainful activity (SGA) or unreported work), it must refer to the jurisdictional FO for further development.

See also:

  • DI 23025.010 Disability Determination Services (DDS) - Handling Potential Fraud or Similar Fault (FSF) Cases

  • DI 23025.015 Disability Determination Services (DDS) - Referring Potential Fraud or Similar Fault (FSF) Cases for Possible Persecution

3. Folder procedures and documentation

Due to systems limitations, some electronic cases may be converted into paper cases. This situation occurs when an individual applied for benefits under multiple titles or multiple Social Security numbers (SSNs) and one or more of the claims is an electronic disability collect system exclusion (EDCS). The FO must create a paper modular disability folder (MDF), and this folder becomes the official folder; for additional information, see DI 81010.030 Certified Electronic Folder (CEF) Exclusions and Limitations. The FO may reactivate some electronic cases and send them back to the DDS for further development.

The FO must update the Paper Folder Indicator (PFI) in electronic view (eView). The DDS must look for the FO's update in the PFI notation regarding an electronic case to a paper folder conversion.

See also:

4. If the prior favorable determination or decision warrants reopening due to FSF

a. DDS has the authority to reopen the prior favorable determination

If the DDS discovers the prior favorable determination was obtained by FSF and has the authority to reopen the prior favorable determination:

  • Document the reason for reopening the prior determination and provide details that list the critical facts and analysis on an SSA-533 (Special Determination);

  • Reopen the prior determination per DI 27501.005B.3;

  • Complete the disability determination, including reopening and revising the prior determination:

    • If the case is a CEF, follow procedures in DI 81010.085 Transferring Cases in the Electronic Disability Collect System (ECDS) and DI 81020.230 Documenting the Comparison Point Decision (CPD) Evidence and Preparing the Electronic Continuing Disability Review (eCDR) Rationale; or

    • If the case is converted from a CEF to a paper modular disability folder (MDF), print out the pertinent information from the CEF and place it in the appropriate area(s) of the folder per DI 81010.030 Certified Electronic Folder (CEF) Exclusions and Limitations.

  • Notify the claimant by a due process notice and afford the claimant an opportunity to provide additional evidence the claimant believes may have a bearing on the determination, see DI 27501.005.D.1;

  • Follow instructions in DI 27505.005D.2 when reopening and revising a determination; and

  • Transfer the case to the jurisdictional FO after the revised determination has been made. For an adverse reopening of a title II claim, advise the FO to contact the Processing Service Center (PSC) of the adverse action.

For case routing see instructions:

  • DI 32005.001 General Principles Affecting Disability Determination Services Case Routing - Paper Case Only

  • DI 32010.001 Routing Case Instructions for Continuing Disability Review Electronic (eCDR) Cases

b. If a Disability Hearing Unit (DHU) made the prior determination

Transfer or send the case to the DHU within the regional office.

c. If the Disability Hearing Office (DHO) made the prior determination

Transfer or send the case to the jurisdictional DDS.

d. If an Administrative Law Judge (ALJ) or the Appeals Council (AC) made the prior decision

  • Transfer or send the case to the Office of Disability Operations (ODO) or the processing center for post-effectuation review, if appropriate refer to DI 27505.010.B.2;

  • If an ALJ issued the prior favorable decision, transfer the case through the Case Processing Management System (CPMS) or mail the case to the jurisdictional Office of Hearings Operations (OHO); or

  • If the AC issued the prior favorable decision, transfer the case through the Appeals Council Reviewing Processing System (ARPS) or mail the case to the appropriate AC branch office within the Office of Appellate Operations (OAO).

 


DI 27505 TN 3 - Rules for Reopening - 11/02/2021