SSA will redetermine cases when there is reason to believe that fraud or similar fault was involved in an individual's application for monthly disability benefits. Unless the redeterminations apply only at the hearing or Appeals Council levels, redeterminations may be coordinated with other components.

Except in unusual circumstances where individual case instruction is more appropriate, Office of Appellate Operations (OAO) and Office of Hearings Operations (OHO) staff will draft specific processing instructions for any group of cases involving the same source(s) believed to have committed fraud or similar fault. To meet the “immediacy” requirement, OAO and OHO may initially release instructions in a temporary format, such as a memorandum or other established mechanism, but will usually finalize instructions in a HALLEX temporary instruction (TI). In cases where there is an ongoing criminal, civil, or administrative investigation, the case specific HALLEX TI may not be made publicly available. However, relevant information will be provided in notices and other SSA communications with the individual.

The HALLEX TI will describe the facts or case characteristics common to the patterns of known or suspected fraudulent activity. This information will permit the ALJ to decide based on the totality of the circumstances if there is a reason to believe fraud or similar fault was involved in the provision of evidence in an individual case.

OAO or OHO will then screen the identified cases to determine whether, after excluding the suspect evidence, the original favorable decision is supported by a preponderance of the remaining evidence. If the prior decision remains supported, OAO or OHO will document the record and end further redetermination proceedings.

If the prior decision is not supported, OAO or OHO will proceed with further redetermination proceedings (as explained in following procedures).

When the prior decision is not supported, OAO or OHO will send the individual an appropriate notice. The notice will include information regarding the factual and legal basis for the redetermination. The notice will also explain in clear terms the redetermination process, including where, when, and how the individual may submit new and material evidence that is related to the period at issue, and how SSA will consider requests for an extension of time. Additionally, the notice will explain how SSA will consider the individual's objections to the disregarding of evidence at the hearings level. If OIG has identified the individual pursuant to section 1129(l) of the Act, SSA will provide a summary of the OIG investigative findings, or a copy of the OIG 1129(l) referral, with the notice or in the claim(s) file. If a prosecuting authority identified the individual, SSA will provide a summary of the prosecutor's finding(s), as well as a copy of the indictment(s), plea agreement(s), or other court filing(s) relevant to the case.

If SSA determined that fraud or similar fault was involved in the individual's application, SSA will provide detailed information regarding relevant criminal, civil, congressional, or administrative investigative findings and how they relate to the individual's application for benefits. SSA will associate copies of any relevant material(s) with the notice and in the claim(s) file.

In most cases that are processed at the hearings level, OHO will also provide additional notice of the issue(s) by including special language in the acknowledgement of the hearing request and, if applicable, the notice of hearing.

When redetermining a claim(s), an adjudicator will be directed to consider the claim(s) only through the date of the final and binding determination or decision on the individual's application for benefits (i.e., the original allowance date).

A hearing is not required if the evidence of record, excluding any disregarded evidence, supports a favorable decision by a preponderance of the evidence.

Under SSR 22-1p, before SSA disregards evidence pursuant to sections 205(u)(1)(B) and 1631(e)(7)(A)(ii) of the Act at the hearings level of the administrative review process, an ALJ will consider the individual's objection to the disregarding of that evidence. An ALJ will decide whether there is reason to believe that fraud or similar fault was involved in providing evidence in the individual's case. Thus, the individual is entitled to raise any objections to the disregarding of the suspect evidence to an ALJ.

Additionally, when a recipient is receiving payments under title XVI, SSA will offer the opportunity for a hearing prior to taking an action that would result in a termination of benefits, pursuant to Goldberg v. Kelly, 397 U.S. 254 (1970).

When SSA initiates redetermination proceedings on an OAO or OHO level case and the case is not “screened out” under the procedures in HALLEX HA 01130.025 C.1. above, an adjudicator must issue a decision on the case. Under no circumstances can an adjudicator dismiss a request for hearing or a request for review, even if the usual criteria for a dismissal are present.

In the decision, an adjudicator will clearly explain that an individual may appeal the decision regarding whether they were entitled to disability benefits or eligible for supplemental security income as of the original allowance date. Additionally, the adjudicator will clearly explain in the decision that SSA's initiation of a redetermination under sections 205(u) and 1631(e)(7) of the Act is not subject to administrative or judicial review. However, in conjunction with an appeal of a redetermination determination or decision, an individual may object to SSA's finding to disregard evidence under the Act.

If SSA conducted or initiated a continuing disability review (CDR) before notice of the redetermination proceedings, the adjudicator will explain in the decision that the redetermination proceedings supersede any findings made during the CDR.

The applicable HALLEX TI will address any additional special language that is required in the decision due to the unique circumstances involved.

Newly appointed representative fee issues will be handled on a case-by-case basis. However, in situations where SSA does not suspend benefits, there will be no past due benefits if a favorable decision is issued because the individual is receiving ongoing benefits. When there are no past due benefits, OAO or OHO must disapprove any fee agreement. See HALLEX HA 01120.012.

Any appointed or previously appointed representative can submit a fee petition for the services they provided, and OAO or OHO will use the applicable procedures in HALLEX HA 01120.000 for evaluating these requests and determining a reasonable fee. However, if a representative submits a contingency fee contract, the representative is not entitled to request a fee unless a favorable decision is issued on the redetermination proceedings. See HALLEX HA 01120.051.

Unique appeal processing issues will be set forth in a HALLEX TI, based on the particular circumstances involved. Regardless of the unique processing instructions, when dismissal criteria are present on an appeal after a redetermination, and a dismissal would otherwise be appropriate, an adjudicator may dismiss the appeal request. For the criteria for dismissing a request for hearing, see HALLEX HA 01240.005. For the criteria for dismissing a request for review, see HALLEX HA 01340.001.

In fraud redeterminations, adjudicators will apply the rules in 20 CFR, 404 Subpart P (20 CFR 404.1501-1599), and 416 Subpart I (20 CFR 416.901-416.999d) used to determine whether an individual was disabled or blind that were in effect at the time of the original determination or decision. See the Code of Federal Regulations (Annual Edition) for prior rules.

In particular, adjudicators:

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  Will apply the listings in the Listing of Impairments (20 CFR, Part 404, Subpart P, Appendix 1) that were in effect at the time of the original favorable determination or decision. See POMS DI 34100.000.

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  Will consider an individual's residual functional capacity and vocational background using the rules that were in effect at the time the agency made the original favorable determination or decision. See 20 CFR 404.1560-404.1569a and 416.960-416.969a.

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  Will use the education categories and grid rules that were in effect at the time the agency made the original favorable determination or decision. See HALLEX HA 01560.015 for a copy of the prior education categories and grid rules.