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HA 01560.001A Puerto Rico (Non-Redetermination Cases; PRHD) (Redacted)

Table of Contents
IPurpose
IIBackground
IIIHearings Level Procedures
IVAppeals Council Procedures
VInquiries
Attachment 1Indictments and Plea Agreements
Attachment 2OIG Section 1129(l) Referral
Attachment 3Notice of Hearing

Issued: April 25, 2016

Revised: June 14, 2023

I. Purpose

This Temporary Instruction advises Office of Hearings Operations (OHO) and Office of Appellate Operations (OAO) in the Office of Analytics, Review, and Oversight (OARO) employees of the procedures for processing certain non-redetermination cases that do not have a final determination or decision (i.e., the case was not a closed case subject to readjudication under Hearings, Appeals and Litigation Law (HALLEX) manual HA 01560.001. See HALLEX HA 01130.026.

This instruction relates to plea agreements entered by a non-attorney representative and several medical providers in criminal actions in Puerto Rico, as noted in the background section below.

This instruction replaces any prior instruction and will be modified as additional information becomes available.

NOTE 1: 

Nothing in this instruction precludes OHO or OAO staff or adjudicators from referring suspected instances of fraud or similar fault to the Office of the Inspector General (OIG) using the procedures in HALLEX HA 01130.006 or HA 01130.009.

NOTE 2: 

This instruction was initially issued on July 2, 2014, and was formerly located in HALLEX HA 01560.001.

II. Background

In 2013, after an extensive investigation by the Social Security Administration's (SSA) OIG and the Department of Justice (DOJ), the United States Attorney for the District of Puerto Rico obtained indictments for a non-attorney representative and several medical professionals for creating and submitting fraudulent evidence in support of claimants' applications for Social Security benefits. The non-attorney representative, Samuel Torres Crespo, later pleaded guilty to making false statements to SSA, as did two of the medical providers, Drs. Jose R. Hernandez-Gonzalez and Wildo Vargas. A copy of the indictments and each of the plea agreements is located in Attachment 1.

NOTE: 

SSA disqualified Mr. Torres Crespo from representing claimants before SSA on November 4, 2014.

The United States Attorney for the District of Puerto Rico indicted additional medical providers and beneficiaries for making false statements to SSA, including Drs. Rafael Miguez Balseiro and Erica Rivera Castro. A copy of each of the plea agreements is located in Attachment 1. While these individuals were not ultimately convicted of fraud, OIG provided SSA with a section 1129(l) referral indicating its reason to believe that fraud was involved in certain evidence these individuals submitted to SSA (see the June 19, 2015 OIG section 1129(l) referral in Attachment 2).

Under section 205(u)(1)(B) of the Social Security Act (Act), SSA must disregard any evidence if there is reason to believe that the provision of evidence involved fraud or similar fault.

In cases processed under this instruction, OHO and OAO adjudicators will use the procedures in Social Security Ruling (SSR) 22-2p: Titles II and XVI: Evaluation of Claims Involving the Issue of Similar Fault in the Providing of Evidence when deciding whether to disregard evidence because of fraud or similar fault. Before SSA disregards evidence under section 205(u)(1)(B) of the Act at the hearings level of the administrative review process, it will consider the individual's objection to the disregarding of evidence.

III. Hearings Level Procedures

A. General

OHO received a list of non-redetermination cases that require SSA to disregard evidence from sources listed below in subsection III.B.1. if SSA finds there is reason to believe that fraud or similar fault was involved in the providing of that evidence. The Special Review Cadre (SRC) in OHO has been assigned to process the Puerto Rico cases described in this instruction.

The SRC will identify cases in the Case Processing and Management System (CPMS) and Hearing and Appeals Case Processing System (HACPS) with the case characteristics “PRHD” (Puerto Rico Hold) and “FRD3” (Suspected Fraud No Prior Award) and process the cases using the following instructions.

NOTE: 

If a case processed under this instruction involves facts and evidence requiring processing under a separate instruction in HALLEX HA 01560.000, SRC staff will add the case characteristic “FHYB” (Fraud Hybrid) in addition to the above and any other applicable case characteristics directed by the separate instruction.

B. Evidence

1. Screening

Designated adjudicators will review the file to determine whether it contains any of the following:

  • •

    Evidence dated August 1, 2008, through September 26, 2014, that was submitted, supplied, or sourced by Mr. Torres Crespo;

  • •

    Evidence from Dr. Hernandez-Gonzalez dated August 1, 2008, through October 28, 2013;

  • •

    Evidence from Dr. Vargas dated January 30, 2012, through September 16, 2014;

  • •

    Evidence submitted, supplied, or sourced from Dr. Miguez Balseiro; and

  • •

    Evidence submitted, supplied, or sourced from Dr. Rivera Castro.

NOTE 1: 

If it is unclear whether Mr. Torres Crespo supplied the evidence, or the claimant independently supplied the evidence from a non-suspect source, SSA will treat the evidence as evidence that the claimant submitted.

NOTE 2: 

If the file contains evidence from Luis Escabi-Perez, M.D. (Dr. Escabi-Perez) and the case has the case characteristic “ESNR” (Escabi Non-Referral) in CPMS or HACPS, adjudicators and SRC staff will follow the instructions in SSR 22-2p in determining whether to disregard evidence from Dr. Escabi-Perez. See HALLEX HA 01560.005B.

If the file contains any of the evidence as outlined above, or if the adjudicator suspects that fraud or similar fault was involved in the provision of any other evidence, the adjudicator will determine whether there is an issue of fraud or similar fault that requires adjudication in accordance with SSR 22-2p.

If an issue of fraud or similar fault requires adjudication, the adjudicator will offer the individual an opportunity for a hearing and continue processing the case. At the hearing, the individual will have the opportunity to object to the disregarding of evidence. The adjudicator will process the case using the instructions below.

2. Fraud or Similar Fault Identified as an Issue for Adjudication

If, after screening, the adjudicator determines there is an issue of fraud or similar fault requiring adjudication, SRC staff will add the Possible Fraud or Similar Fault (Special F) flag in eView for an electronic claim(s) file or attach the flag to the front of a paper claim(s) file.

Additionally, if not already part of the record, SRC staff will add a copy of the OIG section 1129(l) referral (see Attachment 2), the relevant indictment(s), and the relevant plea agreement(s) (see Attachment 1) to the claim(s) file. In paper cases, staff will add the OIG section 1129(l) referral and the plea agreement(s) to Part B- Jurisdictional Documents/Notices (red tab) of the claim(s) file. In electronic cases, staff will upload the OIG section 1129(l) referral and the plea agreement(s) using document type 7011-Misc. Jurisdictional Documents/Notices to Part B- Jurisdictional Documents/Notices (red tab) of the claim(s) file.

3. Reason to Believe Standard

Under section 205(u)(1)(B) of the Act, SSA must disregard evidence when there is reason to believe that fraud or similar fault was involved in the providing of such evidence. See HALLEX HA 01130.015 C.1. for the definition of “reason to believe.”

In determining if there is a reason to believe fraud or similar fault exists, the adjudicator may consider, among other evidence, the plea agreements and the OIG referral.

Before the administrative law judge (ALJ) disregards the evidence under section 205(u)(1)(B) of the Act at the hearings level of our administrative review process, the ALJ will consider the individual's objection to the disregarding of that evidence. See HALLEX HA 01130.026. After considering any objections, the ALJ will decide whether there is reason to believe that fraud or similar fault was involved in providing evidence in the individual's case.

If, after the hearing and considering any objections, the ALJ finds there is reason to believe that fraud or similar fault was involved in the provision of the evidence, the ALJ will disregard such evidence under section 205(u)(1)(B) of the Act.

If the ALJ does not find there is reason to believe that fraud or similar fault was involved in the provision of the evidence, the ALJ will not disregard the evidence under section 205(u)(1)(B) of the Act. Rather, the ALJ will evaluate it in accordance with SSA's existing policies regarding the evaluation of symptoms and medical evidence. The ALJ will consider any internal inconsistencies in the individual's statements, as well as inconsistencies with other evidence. See 20 CFR 404.1513a, 404.1527 and SSR 16-3p: Titles II and XVI: Evaluation of Symptoms in Disability Claims.

NOTE 1: 

SSA generally does not develop evidence of a claimant's intent. Therefore, a finding of similar fault in accordance with SSR 22-2p is sufficient for the ALJ to disregard the evidence at issue. See HALLEX HA 01295.010 A.

NOTE 2: 

If the agency disregarded evidence at another level of the administrative process after finding fraud or similar fault, the ALJ will use the information in SSR 22-2p to determine whether there is a reason to believe that fraud or similar fault was involved in the provision of evidence, and will consider the individual's objection to the disregarding of that evidence. If there is not a reason to believe fraud or similar fault was involved in the provision of the evidence, the ALJ will add the information into the record and consider it when adjudicating the claim.

4. Other Evidence

In some cases, it may also be appropriate to disregard evidence provided by a source who was not involved in the fraud or similar fault scheme described in subsection II. For example, if a physician relies on medical evidence from one of the sources listed in subsection III.B.1. that the ALJ disregards, then the ALJ must also disregard the parts of the physician's report relying on the disregarded evidence, or, when based solely on the disregarded evidence, the entire document. When the degree of reliance on evidence from one of the sources listed in subsection III.B.1. is unclear, the ALJ will evaluate the evidence in accordance with SSA's existing policies regarding the evaluation of medical evidence.

C. Exhibiting and Marking Issues

Disregarded evidence must remain in the claim(s) file, and the ALJ must ensure that evidence from any of the sources listed in subsection III.B.1. (or other disregarded evidence) is clearly identified.

In electronic cases, SRC staff will clearly designate the information as “DISREGARDED-FSF” in the Note field in eView or the Electronic Non-Medical (ENM) application. In a paper claim(s) file, SRC staff will add “DISREGARDED-FSF” on the first page of the information with the number of pages, and each subsequent page. To illustrate, a 2-page submission that the ALJ disregards would be marked as follows: page 1 “DISREGARDED-FSF 1/2” and page 2 “DISREGARDED-FSF 2/2.”

NOTE 1: 

To ensure that claimants and any representative with access to the electronic file can identify and object to the disregarding of the evidence in question, SRC staff will exhibit the evidence, even if the ALJ determines that it should be disregarded.

NOTE 2: 

If the ALJ disregards only certain portions of evidence from a source, SRC staff will remove the information using the same procedures for removing personally identifiable information that is not properly associated with a claim(s) file. The ALJ will retain both versions of the evidence (the original and the redacted) in the claim(s) file, exhibiting both, but identifying the non-redacted version as above with the caption “PORTIONS DISREGARDED-FSF – See Ex. [**].”

NOTE 3: 

If another administrative level previously disregarded evidence, or the hearings level in a remanded case previously disregarded evidence, and the ALJ subsequently determines that the agency should not have disregarded the evidence, SRC staff will update eView, ENM, or the paper claim(s) file to reflect the evidence was not disregarded.

D. Notice of Hearing

Prior to an ALJ determining there is reason to believe fraud or similar fault was involved in the provision of evidence in support of the claimant's application, the ALJ will offer the claimant an opportunity for a hearing. The ALJ must give notice to the claimant and their representative, if any, regarding the issues related to disregarding evidence. To give notice regarding the statutory basis for disregarding evidence, the ALJ will use specific language in the “It Is Important That You Attend Your Hearing” and “Issues I Will Consider” sections of the notice of hearing. See Attachment 3 for a sample Notice of Hearing. If the claimant or their representative objects to the exclusion of evidence, the ALJ will evaluate the objection and arguments using the procedures in SSR 22-2p.

If the ALJ decides to disregard other evidence for fraud or similar fault that from a source other than those listed in subsection III.B.1., the ALJ will also provide notice in the notice of hearing.

E. Decision Language

In all decisions, the ALJ will specifically explain in the decision that:

  • •

    [If file contains evidence from Mr. Torres Crespo or Drs. Hernandez-Gonzalez or Vargas] The United States Department of Justice and the Office of the Inspector General (OIG) of the Social Security Administration (SSA) conducted an extensive criminal investigation that resulted in a guilty plea from several individuals who admitted to making false statements or other misrepresentations to SSA.

  • •

    [If file contains evidence from Drs. Miguez Balseiro or Rivera Castro] The Office of the Inspector General (OIG) of the Social Security Administration (SSA) notified SSA as required by section 1129(l) of the Social Security Act (Act) that it had reason to believe that certain medical evidence submitted by Drs. Miguez Balseiro and Rivera Castro involved fraud.

  • •

    Under section 205(u) of the Act, SSA must disregard evidence when there is reason to believe fraud or similar fault was involved in the providing of evidence.

  • •

    [Mr. Torres Crespo/Dr. Hernandez-Gonzalez/Dr. Vargas/Dr. Miguez Balseiro/Dr. Rivera Castro] provided evidence in the case, and the ALJ was required to make a finding regarding whether there was a reason to believe that fraud or similar fault was involved in the providing of the evidence from [Mr. Torres Crespo/Dr. Hernandez-Gonzalez/Dr. Vargas/Dr. Miguez Balseiro/Dr. Rivera Castro] [and evidence in which a source relied on evidence from [Mr. Torres Crespo/Dr. Hernandez-Gonzalez/Dr. Vargas/Dr. Miguez Balseiro/Dr. Rivera Castro]].

  • •

    The ALJ allowed the claimant the opportunity to object to the disregarding of evidence from [Mr. Torres Crespo/Dr. Hernandez-Gonzalez/Dr. Vargas/Dr. Miguez Balseiro/Dr. Rivera Castro]. [If applicable] The ALJ considered the claimant's objections to the disregarding of evidence. [Explanation for the finding].

  • •

    [If evidence was disregarded] The ALJ found a reason to believe fraud or similar fault was involved in the providing of evidence from [Mr. Torres Crespo/Dr. Hernandez-Gonzalez/Dr. Vargas/Dr. Miguez Balseiro/Dr. Rivera Castro] and disregarded that evidence. [Explanation for the finding].

  • •

    [If some of the evidence was not disregarded] The ALJ found no reason to believe fraud or similar fault was involved in the providing of the following evidence from [Mr. Torres Crespo/Dr. Hernandez-Gonzalez/Dr. Vargas/Dr. Miguez Balseiro/Dr. Rivera Castro] and did not disregard those pieces of evidence. [Explanation for the finding].

  • •

    [If no evidence was disregarded] The ALJ found no reason to believe fraud or similar fault was involved in the providing of evidence from [Mr. Torres Crespo/Dr. Hernandez-Gonzalez/Dr. Vargas/Dr. Miguez Balseiro/Dr. Rivera Castro] and did not disregard any evidence. [Explanation for the finding].

  • •

    The ALJ considered all of the evidence of record, [if applicable] excluding any disregarded evidence, and decided the case on the remaining evidence.

  • •

    The claimant may appeal the ALJ's decision regarding the issue of disability and the disregarding of evidence.

For all evidence, other than evidence from the sources listed in subsection III.B.1., the ALJ will use the procedures in SSR 22-2p to determine whether to disregard evidence because of fraud or similar fault. See also HALLEX HA 01130.015 D. If the ALJ disregards other evidence based on a fraud or similar fault issue, the ALJ must clearly address the other evidence and explain why it was disregarded. See HALLEX HA 01295.014. The claimant may appeal the fraud or similar fault finding.

IV. Appeals Council Procedures

The instructions below apply to cases before the Appeals Council (AC) in which SSA has identified the applications as including evidence from the sources described in subsection III.B.1. and where the case was not redetermined (i.e., the case was not a closed case subject to a readjudication under HALLEX HA 01560.001).

A. Handling Requests for Review When the Disregarding of Evidence Is an Issue

If the AC receives a request for review in a case in which a prior adjudicator disregarded evidence at another administrative level under subsection III. above, the AC will assess whether the evidence was properly disregarded and follow its usual request for review procedures. In processing requests for review in these cases, the AC will keep in mind that under SSR 22-2p, before an adjudicator disregards evidence at the hearings level, they will consider the individual's objection to the disregarding of that evidence. The AC will generally grant review and remand cases where the claimant has not yet been afforded that opportunity.

1. Documenting the System and the Record

OAO staff will ensure any non-redetermination cases involving evidence from a source identified in subsection III.B.1. above include the case characteristic “PRHD” (Puerto Rico Hold) in the Appeals Review Processing System (ARPS).

NOTE 1: 

If OAO staff encounter a case that does not have the case characteristic “PRHD” and which contains evidence from one of the sources listed in subsection III.B.1. that was not identified at another administrative level, they will consult with the Executive Director's Office (EDO) by sending an email to ^DCARO OAO Fraud Redetermination to verify whether the case requires processing under this instruction.

NOTE 2: 

If a case processed under this instruction involves facts and evidence requiring processing under a separate instruction in HALLEX HA 01560.000, OAO staff will ensure that the case characteristic “FHYB” (Fraud Hybrid) has been added to the case in addition to the above and any other applicable case characteristics directed by the separate instruction.

If it is not already part of the record, OAO staff will add a Possible Fraud or Similar Fault (Special F) flag in eView or attach the flag to the front of a paper claim(s) file.

Additionally, if not already part of the record, OAO staff will add a copy of the OIG section 1129(l) referral (see Attachment 2), the relevant indictment(s), and the relevant plea agreement(s) (see Attachment 1) to the claim(s) file. In paper cases, staff will add the OIG section 1129(l) referral and the plea agreement(s) to Part B- Jurisdictional Documents/Notices (red tab) of the claim(s) file. In electronic cases, staff will upload the OIG section 1129(l) referral and the plea agreement(s) using document type 7011-Misc. Jurisdictional Documents/Notices to Part B- Jurisdictional Documents/Notices (red tab) of the claim(s) file.

2. Evidence

Under section 205(u)(1)(B) of the Act, SSA must disregard evidence if there is reason to believe that fraud or similar fault was involved in providing such evidence. Before SSA disregards evidence under section 205(u)(1)(B) of the Act at the hearings level of the administrative review process, it will consider the individual's objection to the disregarding of the evidence.

NOTE 1: 

If it is unclear whether Mr. Torres Crespo supplied the evidence, or the claimant independently supplied the evidence from a non-suspect source, SSA will treat the evidence as evidence that the claimant submitted.

NOTE 2: 

In some cases, it may also be appropriate to disregard evidence provided by a source who was not involved in the fraud or similar fault scheme described in subsection II. For example, if a physician relies on medical evidence from one of the sources listed in subsection III.B.1. that the AC disregards, then the AC must also disregard the parts of the physician's report relying on the disregarded evidence, or, when based solely on the disregarded evidence, the entire document. When the degree of reliance on evidence from one of the sources listed in subsection III.B.1. is unclear, the AC will evaluate the evidence in accordance with SSA's existing policies regarding the evaluation of medical evidence. However, before the AC disregards any evidence, the AC must ensure the claimant had previously been provided the opportunity to object to the disregarding of that evidence at the hearings level.

3. Exhibiting and Marking Issues

Disregarded evidence must remain in the claim(s) file, and the AC must ensure that evidence from the sources listed in subsection III.B.1. (or other disregarded evidence) is clearly identified. Generally, the ALJ should have exhibited disregarded evidence, and the AC must ensure that disregarded evidence is clearly designated as such. In electronic cases, the AC will ensure that staff noted the information as “DISREGARDED-FSF” in the Notes in eView or ENM. In a paper claim(s) file, the AC will ensure staff added “DISREGARDED-FSF” on the first page of the information with the number of pages, and on each subsequent page. To illustrate, a 2-page submission that the AC disregards would be marked as follows: page 1 “DISREGARDED-FSF 1/2” and page 2 “DISREGARDED-FSF 2/2.”

NOTE: 

To ensure that claimants and any representative with access to the electronic file can identify and object to the disregarding of the evidence in question, SRC staff will exhibit the evidence, even if the ALJ determines that it should be disregarded. The AC will not identify evidence as “disregarded” unless the claimant had previously been provided the opportunity to object to the disregarding of the evidence at the hearings level. If the AC subsequently determines that the agency should not have disregarded the evidence, OAO staff will update eView, ENM, or the paper claim(s) file to reflect the evidence was not disregarded.

4. Fraud or Similar Fault – Finding at Another Administrative Level

a. Evidence Automatically Disregarded

If the AC receives a request for review in a non-redetermination case processed under this instruction in which an ALJ, under now rescinded SSR 16-2p: Titles II and XVI: Evaluation of Claims Involving the Issue of Similar Fault in the Providing of Evidence, automatically disregarded the evidence without a fraud or similar fault finding, the AC will generally grant review. The automatic disregarding of evidence is an error of law that requires the AC to grant review to issue a fully favorable decision or remand.

b. Cases with Fraud or Similar Fault Findings

If the AC receives a request for review in a non-redetermination case processed under this instruction, and the ALJ made a finding regarding whether there was reason to believe that fraud or similar fault was involved in the providing of evidence under now rescinded SSR 16-2p or under SSR 22-2p, then the AC will assess whether the ALJ properly followed the instructions in subsection III. and follow its usual request for review procedures. If a grant review action is appropriate after reviewing the remaining evidence, the AC will follow the instructions in subsection IV.A.5. below.

c. Cases without Fraud or Similar Fault Findings

If the ALJ did not address an issue of fraud or similar fault, but the AC identifies that issue on review, the AC will generally grant review and either remand the case to an ALJ or issue a decision using the language in subsection IV.A.5.c. below.

5. AC Actions

In all cases, the AC will use the standard notice from the Document Generation System (DGS) with modifications as noted below, using Spanish notices and special notice options when appropriate.

a. Dismissal of Request for Review

The AC may dismiss requests for review for cases involving fraud or similar fault identified at a prior level of adjudication under the circumstances set forth in HALLEX HA 01340.001. When appropriate, no change to the standard notice is required. However, if the dismissal criteria are present but would result in the payment of benefits, the AC will consult with the EDO before taking any action.

b. Denial of Request for Review

As provided in subsection IV.A.4., the AC will not deny requests for review in cases in which a prior adjudicator automatically disregarded evidence without determining whether there is a reason to believe fraud or similar fault was involved in the provision of the evidence, or the adjudicator did not provide the claimant the opportunity to object to the disregarding of the evidence. The AC may otherwise deny a request for review provided there is no basis under the regulations for granting or dismissing the request (see HALLEX HA 01330.001).

c. Grant Review Action

A grant review action is appropriate if any basis for granting review is present.

The AC may issue a decision to resolve an issue of fraud or similar fault when the file contains sufficient evidence to determine whether there is reason to believe that fraud or similar fault was involved in the provision of evidence, the claimant was provided the opportunity to object to the disregarding of the evidence at the hearings level, and a remand is not necessary to decide all adjudication issues involved in the claim.

The AC will evaluate whether it can issue a fully favorable decision in the absence of the suspect evidence. If the record supports a fully favorable decision, the AC will issue the decision following its usual procedures in HALLEX HA 01380.000 and the instructions below on evaluating fraud or similar fault in the decision, as appropriate.

If the AC is unable to issue a decision, the AC will remand the case for a new hearing and decision.

For example, if the hearing decision did not address whether evidence was being disregarded, but the evidence is identified as “disregarded” in the claim file, and the individual has had the opportunity to object to the disregarding of evidence at the hearings level, the AC may issue a corrective unfavorable decision that disregards evidence from the source(s) identified in subsection III.B.1. The AC may also issue a favorable decision when an ALJ erred in disregarding evidence and consideration of that evidence warrants a favorable decision (see HALLEX HA 01395.005). When reopening issues are involved, see HALLEX HA 01395.007).

  1. 1. 

    Remand

    If the AC remands the case, the remand order will identify the suspect evidence and instruct the ALJ to make a finding as to whether there is a reason to believe that fraud or similar fault was involved in the provision of evidence.

  2. 2. 

    Decision

    When issuing a decision on a case with a record that contains any of the evidence as outlined in subsection III.B.1. above, the AC will use the procedures in SSR 22-2p to determine if there is a reason to believe that fraud or similar fault was involved in the provision of the evidence.

    In determining if there is a reason to believe fraud or similar fault was involved in the provision of the evidence, the AC may consider, among other evidence, the plea agreements, and the OIG referral.

NOTE: 

SSA generally does not develop evidence of a claimant's intent. Therefore, a finding of similar fault in accordance with SSR 22-2p is sufficient for the AC to disregard the evidence at issue.

The AC will also use the procedures in SSR 22-2p and HALLEX HA 01395.005 to determine whether to disregard, based on fraud or similar fault, any other evidence individuals or entities other than those identified in subsection III.B.1. above submitted, supplied, or sourced. If the AC disregards other evidence based on a fraud or similar fault issue, the AC must ensure the claimant was previously provided the opportunity to object to the disregard of this other evidence, and in the AC decision, clearly address the other evidence, and explain why it disregarded that evidence.

In all decisions, the AC will specifically explain in the decision that:

  • •

    [If file contains evidence from Mr. Torres Crespo or Drs. Hernandez-Gonzalez or Vargas] The United States Department of Justice and the Office of the Inspector General (OIG) of the Social Security Administration (SSA) conducted an extensive criminal investigation that resulted in a guilty plea from several individuals who admitted to making false statements or other misrepresentations to SSA.

  • •

    [If file contains evidence from Drs. Miguez Balseiro or Rivera Castro] The Office of the Inspector General (OIG) of the Social Security Administration (SSA) notified SSA, as required by section 1129(l) of the Social Security Act (Act), that it had reason to believe that certain medical evidence submitted by Drs. Miguez Balseiro and Rivera Castro involved fraud.

  • •

    Under section 205(u) of the Act, SSA must disregard evidence when there is reason to believe fraud or similar fault was involved in the providing of evidence.

  • •

    [Mr. Torres Crespo/Dr. Hernandez-Gonzalez/Dr. Vargas/Dr. Miguez Balseiro/Dr. Rivera Castro] provided evidence in the case, and the ALJ was required to make a finding regarding whether there was a reason to believe that fraud or similar fault was involved in the providing of the evidence from [Mr. Torres Crespo/Dr. Hernandez-Gonzalez/Dr. Vargas/Dr. Miguez Balseiro/Dr. Rivera Castro] [and/or evidence in which a source relied on evidence from [Mr. Torres Crespo/Dr. Hernandez-Gonzalez/Dr. Vargas/Dr. Miguez Balseiro/Dr. Rivera Castro]].

  • •

    [If applicable] The ALJ allowed the claimant the opportunity to object to the disregarding of evidence from [Mr. Torres Crespo/Dr. Hernandez-Gonzalez/Dr. Vargas/Dr. Miguez Balseiro/Dr. Rivera Castro]. [If applicable] The [ALJ/AC] considered the claimant's objections to the disregarding of evidence. [Explanation for the finding].

  • •

    [If evidence was disregarded] The Appeals Council found a reason to believe that fraud or similar fault was involved in the providing of evidence from [Mr. Torres Crespo/Dr. Hernandez-Gonzalez/Dr. Vargas/Dr. Miguez Balseiro/Dr. Rivera Castro] (identifying the specific evidence that was disregarded by date) and disregarded that evidence. [Explanation for the finding].[If some of the evidence was not disregarded] The Appeals Council found no reason to believe fraud or similar fault was involved in the providing of the following evidence from [Mr. Torres Crespo/Dr. Hernandez-Gonzalez/Dr. Vargas/Dr. Miguez Balseiro/Dr. Rivera Castro] and did not disregard those pieces of evidence. [Explanation for the finding].

  • •

    [If no evidence was disregarded] The Appeals Council found no reason to believe that fraud or similar fault was involved in the providing of evidence from [Mr. Torres Crespo/Dr. Hernandez-Gonzalez/Dr. Vargas/Dr. Miguez Balseiro/Dr. Rivera Castro] (identifying the specific evidence that was disregarded by date) and did not disregard any evidence. [Explanation for the finding.]

  • •

    The Appeals Council considered all of the evidence of record, [if applicable] excluding any disregarded evidence, and decided the case on the remaining evidence.

  • •

    The claimant may appeal the Appeals Council's decision regarding the issue of disability and the disregarding of evidence.

6. Routing

The SRC will handle all AC remand orders for the non-redetermination Puerto Rico cases processed under this instruction. When closing out a case in ARPS, OAO staff will ensure that the remand is routed to the SRC and not the originating hearing office.

OAO staff will update the hearing office code under “Final Routing Information” to 5ZU for “Title 2 Routing,” when closing the case in ARPS and send an email to the SRC at |||DA SRC to alert the SRC of the remand. For paper cases, OAO staff will mail the claims file to the following address:

Special Review Cadre
1718 Woodlawn Drive
Woodlawn, MD 21207

B. Court Remands

1. General

In 2019 and 2020, the United States District Court for the District of Puerto Rico remanded several Puerto Rico redeterminations and non-redetermination cases subject to this instruction to the agency for further proceedings related to the disregarding of evidence in plaintiffs' cases.

Unless otherwise specified in these instructions, OAO staff in the Division of Civil Action (DCA) will generally follow the guidance in HALLEX HA 01460.000 for processing court remands.

The AC must remand all cases subject to this instruction in accordance with the court orders. Therefore, the AC cannot issue decisions in cases remanded for further administrative actions.

The AC must review all cases remanded to SSA for further administrative actions. The AC cannot process those cases under HALLEX HA 01460.025 (i.e., the Accommodations Signature process).

2. Notification of Court Remand

The Office of General Counsel (OGC) will provide a list of court remands to process once DCA effectuates the cases in the Legal Automated Workflow System (LAWS).

3. Adding and Checking ARPS Case Characteristics

On receipt of the court remand, DCA will add the case characteristic “PREX” (Puerto Rico 1 Exclusion Case) to the case in ARPS.

All court remands must contain the case characteristic “PRHD” for the non-redetermination Puerto Rico cases processed under this instruction. DCA staff will check and confirm the case has the “PRHD” case characteristic. If not, DCA staff will add the “PRHD” case characteristic.

4. AC Remand Order

Upon receipt of a court remand, the AC will issue a remand order instructing an ALJ to issue a new decision.

The AC remand order will specifically explain that:

  • •

    The ALJ will determine whether there is reason to believe that fraud or similar fault was involved in the provision of evidence in support of the claimant's application.

5. Routing of AC Remand Orders

The SRC will handle all AC remand orders for the Puerto Rico court cases requiring additional administrative actions. When closing out a case in ARPS, DCA staff must ensure that it routes the remand to the SRC and not the originating hearing office.

DCA staff will update the hearing office code under “Final Routing Information” to 5ZU for “Title 2 Routing,” when closing the case in ARPS and send an email to the SRC at |||DA SRC to alert the SRC of the remand. For paper cases, DCA staff will mail the claims file to the following address:

Special Review Cadre
1718 Woodlawn Drive
Woodlawn, MD 21207

Designated SRC staff will receive daily caster reports informing them of remanded cases.

V. Inquiries

OHO staff will direct all program-related and technical questions through appropriate management channels.

In OAO, staff and adjudicators will direct any program-related or technical questions to the EDO at ^DCARO Fraud Redetermination.

Attachment 2. OIG Section 1129(l) Referral

6-19-15 OIG Section 1129(l)

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/2501560001AR
HA 01560.001AR - Puerto Rico (Non-Redetermination Cases; PRHD) (Redacted) -
Batch run: 06/16/2026
Rev: