The information in this section applies when an adjudicator is resolving an issue of fraud or similar fault.

Several issues involving fraud or similar fault, based on different statutory or regulatory authority, may come before an administrative law judge (ALJ) or the Appeals Council (AC). These may include, but are not limited to:

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  When an ALJ or the AC considers reopening a prior determination or decision at any time on the basis that a preponderance of the evidence shows it was obtained by fraud or similar fault. See Hearings, Appeals, and Litigation Law (HALLEX) manual HA 01290.065, HA 01390.060, and HA 01395.007;

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  When the Social Security Administration (SSA) receives an Office of the Inspector General (OIG) referral of information pursuant to section 1129(l) of the Social Security Act (Act) or information from a criminal prosecutor with jurisdiction over potential or actual related criminal cases. See HALLEX HA 01130.025 and HA 01130.026;

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  When SSA initiates an unscheduled continuing disability review to consider whether a prior determination or decision was fraudulently obtained per 20 CFR 404.1590(b)(9), 404.1594(e)(1), 416.990(b)(9), and 416.994(b)(4)(i); or

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  When a field office imposes administrative sanctions on an individual after determining the individual made false or misleading statements, or withheld information per 20 CFR 404.459 and 416.1340. See HALLEX HA 01295.016 and HA 01395.011.

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  When a claimant or representative alleges that a third party engaged in fraud or similar fault in providing evidence related to the claim. For example, such allegations could include that a consultative examination (CE) provider engaged in fraud or similar fault or that a CE report was based on evidence that involved fraud or similar fault. See HALLEX HA 01295.012 and HA 01395.012.

One or more of the above corrective actions may be appropriate depending on the circumstances of the case.

For hearings level procedures regarding adjudicating cases involving fraud or similar fault, see HALLEX Chapter HA 01295.000. For AC procedures, see HALLEX Chapter HA 01395.000. Adjudicators at all levels should ensure that any applicable standards and procedures are followed as warranted by the issues before them.

The information in the below section does not apply to administrative sanction actions (HALLEX HA 01295.016 and HA 01395.011), or, unless otherwise instructed, to cases involving OIG referrals of information pursuant to section 1129(l) of the Act or information from a criminal prosecutor with jurisdiction over potential or actual related criminal cases (HALLEX HA 01130.025 and HA 01130.026).

The main difference between “fraud” and “similar fault” is that fraud requires an intent to defraud, whereas similar fault does not.

Under sections 205(u) and 1631(e)(7) of the Act, evidence must be disregarded if there is reason to believe that fraud or similar fault was involved in the providing of the evidence. Before SSA disregards evidence at the hearings level of the administrative process, an adjudicator will consider an individual's objection to the disregarding of evidence. See SSR 22-2p.

An adjudicator will use the similar fault standard when deciding whether to disregard evidence. This is because the issue of fraud involves the complex subordinate issue of intent to defraud, and that issue generally does not need to be evaluated to determine whether to disregard evidence. Detailed procedures regarding considering evidence within OHO and OAO are set forth in HALLEX HA 01295.000 and HA 01395.000.