SSA will adjudicate cases when there is reason to believe that fraud or similar fault was involved in an individual's application for monthly disability benefits. However, these non-redetermination cases are not yet administratively final or closed, unlike redetermination cases addressed in HALLEX HA 01130.025. Unless the adjudications apply only at the hearings or Appeals Council levels, these cases may be coordinated with other components.

Except in 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. 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 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 claimant.

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.

When there is reason to believe that fraud or similar fault was involved in the providing of evidence, OAO or OHO will send the claimant an appropriate notice. The notice will include information regarding the factual and legal basis for disregarding evidence. Additionally, the notice will explain how SSA will consider the claimant'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 provision of evidence in the individual's case, SSA will provide detailed information regarding relevant criminal, civil, congressional, or administrative investigative findings and how they relate to the suspect evidence. 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.

Pursuant to sections 205(u)(1)(B) and 1631(e)(7)(A)(ii) of the Act, SSA will set forth detailed case specific instructions regarding the evidence SSA must disregard if an adjudicator finds there is reason to believe that fraud or similar fault was involved in the providing of evidence based on any of the following:

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  OIG referrals of information pursuant to section 1129(l) of the Act; or

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  Information obtained during a criminal, civil, administrative, or other law enforcement investigation; or

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  A conviction (whether upon a verdict after trial or upon a plea of guilty or nolo contendere) of a Federal or State crime; or other sworn admissions, as in a pre-trial diversion agreement; or

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  An SSA investigation.

Under sections 205(u) and 1631(e)(7) of the Act, adjudicators must disregard evidence if there is reason to believe that fraud or similar fault was involved in the providing of evidence.

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, the ALJ will consider the individual's objection to the disregarding of that evidence and will decide whether there is reason to believe that fraud or similar fault was involved in the providing of evidence in the individual's case. If the ALJ determines that fraud or similar fault was not involved in providing the evidence, the ALJ will consider the evidence. However, if the ALJ disregards the evidence because a reason to believe shows that fraud or similar fault was involved in providing the evidence, the ALJ will address the claimant's objection in the decision. These procedures are outlined in SSR 22-2p: Titles II and XVI: Evaluation of Claims Involving Similar Fault in the Providing of Evidence.

Evidence that is disregarded will remain associated in the claim(s) file but will be clearly designated as disregarded evidence.

When considering other evidence in the claim(s) file, adjudicators will use the procedures in SSR 22-2p and applicable HALLEX provisions in HA 01295.000 and HA 01395.000 to determine whether to disregard other evidence.

In the decision, an adjudicator will clearly explain that a claimant may appeal both the issue of whether the ALJ should have disregarded evidence as well as the overall finding of whether the claimant was entitled to disability insurance benefits and/or eligible for supplemental security income.

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

Unique appeal processing issues will be set forth in a HALLEX TI, based on the particular circumstances involved.