Effective Dates: 03/12/2024 - Present Previous | Next

TN 11 (01-25)

DI 27505.015 Fraud or Similar Fault - Reopenings

A. When to use this section

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

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

Refer also to:

  • •

    DI 23025.025 Disability Determination Services - 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 an incorrect or incomplete statement that is material to the determination is knowingly made or information that is material to the determination is knowingly concealed.

3. Preponderance of the Evidence Standard

Preponderance of the evidence means such relevant evidence that as a whole shows that the existence of the fact to be proven is more likely than not.

Preponderance is established by that piece or body of evidence that, when considered, produces the stronger impression and is more convincing as to its truth when weighed against the evidence in opposition. Thus, preponderance does not require that a certain number of pieces of evidence (e.g. five or six) must be present. It is possible that just one piece of evidence may be so convincing that it outweighs more than one piece of evidence in opposition.

We may reopen a determination or decision when a preponderance of the evidence shows that a determination or decision was obtained by FSF. For CDRs, the Group II exception to the medical improvement review standard (MIRS) applies when a favorable determination or decision was obtained by FSF. Refer DI 28020.900 Group II Exceptions.

Refer also to:

  • •

    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 or unfavorable determination or decision

1. The Disability Determination Services (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 on an SSA-5002 (Report of Contact);

  • •

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

  • •

    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 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 - Handling Potential Fraud or Similar Fault Cases and GN 04020.010B.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 - Identifying Potential Fraud or Similar Fault 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.

Refer also to:

  • •

    DI 23025.010 Disability Determination Services - Handling Potential Fraud or Similar Fault Cases

  • •

    DI 23025.015 Disability Determination Services - Referring Potential Fraud or Similar Fault Cases for Possible Investigation

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 or payments 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, refer to 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) and the Evidence Portal (EP), if there is no electronic folder. The DDS must look for the FO's update in the PFI notation regarding an electronic case to a paper folder conversion.

Refer also to:

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

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

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

  • •

    Document the reason for reopening the prior determination and provide details that list the critical facts and analysis on the SSA-553 (Special Determination), the Findings of Facts and Analysis of Evidence (FOFAE) screen in the Disability Determination Explanation (DDE), or the case notes section or the case development worksheet in the Disability Case Processing System (DCPS);

  • •

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

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    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 and advise the individual by a due process notice that the they have within 30 days to provide additional evidence the individual believes may have a bearing on the determination. Refer to DI 27501.005B.7.;

  • •

    Follow instructions in DI 27501.005 when reopening and revising a determination;

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    Add the remark "FSF in the determination - see related documents in file" in the SSA-831, item #34 (Disability Determination and Transmittal), the SSA-832, item #24 (Cessation or Continuance of Disability or Blindness Determination and Transmittal – Title XVI), or in the SSA-833, item #24 (Cessation or Continuance of Disability or Blindness Determination and Transmittal –Title II); 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, refer to the following instructions:

  • •

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

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

b. If a federal disability hearing officer (DHO) made the prior determination

Transfer or send the case to the disability hearing unit (DHU) within the regional office.

c. If the state DHO made the prior determination

Transfer or send the case to the jurisdictional DHU.

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 27505.010B.2.;

  • •

    Prior to transfer to the appropriate office (jurisdictional Office of Hearings Operations (OHO) or the AC), the DDS adjudicator must complete the following actions:

    1. 1. 

      If a potential FSF referral has not been completed in ARIS, the adjudicator must follow the development and referral procedures in DI 27505.015C.1.

    2. 2. 

      After completing the appropriate referral and evaluation procedures in DI 27505.015C.1., the adjudicator may apply the Group II FSF exception and process a cessation, if the findings support FSF in the prior determination or decision – refer to DI 28020.900.

    3. 3. 

      The adjudicator would then follow the procedures in DI 27505.015C.4.d., since the DDS does not have jurisdiction over reopening the prior favorable decision, if the ALJ or the AC made the decision in question; refer also to DI 27505.010B.2.

  • •

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

  • •

    If the AC issued the prior favorable or unfavorable 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).

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0427505015
DI 27505.015 - Fraud or Similar Fault - Reopenings - 03/12/2024
Batch run: 04/28/2025
Rev:03/12/2024