SSR 16-1p: Rescinded

SSR-00-2p: Rescinded and replaced by SSR

22-1p effective May 17, 2022

Effective Date: March 14, 2016 Federal Register

Vol. 81, No. 49, page 13436

Policy Interpretation Ruling

Social Security Ruling

PURPOSE: This Social Security Ruling (SSR) explains the process

we use to redetermine an individual's entitlement to or eligibility for

benefits when there is reason to believe that fraud or similar fault

was involved in that individual's application for benefits. [1]

CITATIONS: Sections 205(u) and 1631(e)(7) of the Social Security Act, 42 U.S.C. 405(u), 1383(e)(7), as amended;

Regulations No. 4, sections 404.704 , 404.708 , 404.1512 , 404.1520 , and 404.1527 ;

Regulations No. 16, sections 416.912 , 416.920 , 416.924 , and 416.927 ;

and Regulations No. 22, section 422.130(b) .

INTRODUCTION: The Social Security Independence and Program

Improvements Act of 1994, Public Law

103-296, amended the Social Security Act (Act) to add provisions

addressing fraud or similar fault. These amendments to sections 205

and 1631 of the Act provide that we must immediately redetermine an

individual's entitlement to monthly insurance benefits under title II or

eligibility for benefits under title XVI if there is reason to believe

that fraud or similar fault was involved in the individual's application

for such benefits. This legislation requires us to redetermine an

individual's entitlement or eligibility unless a United States Attorney,

or equivalent State prosecutor, with jurisdiction over potential or

actual related criminal cases, certifies, in writing, that there is a

substantial risk that such action by SSA with regard to beneficiaries or

recipients in a particular investigation would jeopardize the criminal

prosecution of a person involved in a suspected fraud

entitlement or eligibility unless a United States Attorney,

or equivalent State prosecutor, with jurisdiction over potential or

actual related criminal cases, certifies, in writing, that there is a

substantial risk that such action by SSA with regard to beneficiaries or

recipients in a particular investigation would jeopardize the criminal

prosecution of a person involved in a suspected fraud. This statute

further provides that, when we redetermine entitlement or eligibility,

or when we make an initial determination of entitlement or eligibility,

we “shall disregard any evidence if there is reason to believe that

fraud or similar fault was involved in the providing of such evidence.”

If, after redetermining entitlement to or eligibility for benefits, we

determine that without the disregarded evidence, the evidence does not

support entitlement or eligibility, we may terminate such entitlement

or eligibility and may treat benefits paid based on such evidence as

overpayments.

This ruling describes the process we use when we redetermine

individual's entitlement or eligibility to receive benefits when there

is reason to believe that fraud or similar fault was involved in that

individual's application for benefits.

This ruling applies to all final determinations or decisions on

entitlement or eligibility to receive benefits under title II and title

XVI of the Act.

This ruling does not replace or limit other appropriate standards

and criteria for evaluation of claims.

POLICY INTERPRETATION:

A. General

- Sections 205(u) and 1631(e)(7) of the Act provide that we must immediately

redetermine an individual's entitlement to monthly insurance benefits

under title II or eligibility for benefits under title XVI if there

is reason to believe that fraud or similar fault was involved in the

individual's application for benefits.

d criteria for evaluation of claims.

POLICY INTERPRETATION:

A. General

- Sections 205(u) and 1631(e)(7) of the Act provide that we must immediately

redetermine an individual's entitlement to monthly insurance benefits

under title II or eligibility for benefits under title XVI if there

is reason to believe that fraud or similar fault was involved in the

individual's application for benefits.

- This legislation requires us to redetermine an individual's entitlement

or eligibility unless a United States Attorney, or equivalent State

prosecutor, with jurisdiction over potential or actual related criminal

cases, certifies, in writing, that there is a substantial risk that

our action with regard to beneficiaries or recipients in a particular

investigation would jeopardize the criminal prosecution of a person

involved in a suspected fraud.

- When we redetermine a case under sections 205(u) or 1631(e)(7) of

the Act, we must disregard evidence if there is reason to believe that

fraud or similar fault was involved in providing that evidence.

- We may find that any individual or entity whose actions affect an

individual's application for monthly benefits, has committed fraud or

similar fault. Examples of any individual or entity include a claimant,

beneficiary, auxiliary, recipient, spouse, representative, medical source,

translator, interpreter, and representative payee. Sections 205(u) or 1631(e)(7) of the Act do not require that the

individual or entity who committed fraud or similar fault, or the

individual or entity providing the evidence that involves fraud or similar

fault, have a direct relationship to or act on behalf of the claimant,

beneficiary, or recipient, or directly or indirectly benefit from the fraud

or similar fault.

presentative payee. Sections 205(u) or 1631(e)(7) of the Act do not require that the

individual or entity who committed fraud or similar fault, or the

individual or entity providing the evidence that involves fraud or similar

fault, have a direct relationship to or act on behalf of the claimant,

beneficiary, or recipient, or directly or indirectly benefit from the fraud

or similar fault.

- During the redetermination, we will consider evidence that was provided

absent fraud or similar fault, and that relates to the individual's

entitlement and eligibility from the time of the individual's original

allowance, even if that evidence was not presented previously.

- If, after redetermining an individual's entitlement to monthly insurance

benefits under title II or eligibility for benefits under title XVI,

we determine that the evidence does not support such entitlement or

eligibility, we may terminate such entitlement or eligibility and

may treat benefits paid or payments made based on such evidence as

overpayments.

- If an individual disagrees with our finding that the evidence does not

support his or her entitlement or eligibility at the time of the original

allowance, that individual may appeal our determination or decision.

- If the individual believes he or she is currently disabled, he or she

may file a new application while appealing our determination or

decision.

- If we assess an overpayment, we will apply the provisions of 20

C.F.R. Part 404, Subpart F (20 C.F.R. 404.501 et seq.), 20 C.F.R. Part

416, Subpart E (20 C.F.R. 416.501 et seq.). The individual assessed with

the overpayment may request that we waive that overpayment, and we will

consider such a request under our rules.

file a new application while appealing our determination or

decision.

- If we assess an overpayment, we will apply the provisions of 20

C.F.R. Part 404, Subpart F (20 C.F.R. 404.501 et seq.), 20 C.F.R. Part

416, Subpart E (20 C.F.R. 416.501 et seq.). The individual assessed with

the overpayment may request that we waive that overpayment, and we will

consider such a request under our rules.

- We will not waive an assessed overpayment if we find that the individual

is at fault in causing the overpayment. In determining whether an

individual is at fault, we will consider all pertinent circumstances,

including the individual's age and intelligence, and any physical,

mental, educational, or linguistic limitations (including any lack of

facility with the English language) the individual has.

Sections 205(u) and 1631(e)(7) of the Act provide that we must immediately

redetermine an individual's entitlement to monthly insurance benefits

under title II or eligibility for benefits under title XVI if there

is reason to believe that fraud or similar fault was involved in the

individual's application for benefits.

This legislation requires us to redetermine an individual's entitlement

or eligibility unless a United States Attorney, or equivalent State

prosecutor, with jurisdiction over potential or actual related criminal

cases, certifies, in writing, that there is a substantial risk that

our action with regard to beneficiaries or recipients in a particular

investigation would jeopardize the criminal prosecution of a person

involved in a suspected fraud.

When we redetermine a case under sections 205(u) or 1631(e)(7) of

the Act, we must disregard evidence if there is reason to believe that

fraud or similar fault was involved in providing that evidence.

substantial risk that

our action with regard to beneficiaries or recipients in a particular

investigation would jeopardize the criminal prosecution of a person

involved in a suspected fraud.

When we redetermine a case under sections 205(u) or 1631(e)(7) of

the Act, we must disregard evidence if there is reason to believe that

fraud or similar fault was involved in providing that evidence.

We may find that any individual or entity whose actions affect an

individual's application for monthly benefits, has committed fraud or

similar fault. Examples of any individual or entity include a claimant,

beneficiary, auxiliary, recipient, spouse, representative, medical source,

translator, interpreter, and representative payee. Sections 205(u) or 1631(e)(7) of the Act do not require that the

individual or entity who committed fraud or similar fault, or the

individual or entity providing the evidence that involves fraud or similar

fault, have a direct relationship to or act on behalf of the claimant,

beneficiary, or recipient, or directly or indirectly benefit from the fraud

or similar fault.

During the redetermination, we will consider evidence that was provided

absent fraud or similar fault, and that relates to the individual's

entitlement and eligibility from the time of the individual's original

allowance, even if that evidence was not presented previously.

If, after redetermining an individual's entitlement to monthly insurance

benefits under title II or eligibility for benefits under title XVI,

we determine that the evidence does not support such entitlement or

eligibility, we may terminate such entitlement or eligibility and

may treat benefits paid or payments made based on such evidence as

overpayments.

If an individual disagrees with our finding that the evidence does not

support his or her entitlement or eligibility at the time of the original

allowance, that individual may appeal our determination or decision.

s not support such entitlement or

eligibility, we may terminate such entitlement or eligibility and

may treat benefits paid or payments made based on such evidence as

overpayments.

If an individual disagrees with our finding that the evidence does not

support his or her entitlement or eligibility at the time of the original

allowance, that individual may appeal our determination or decision.

If the individual believes he or she is currently disabled, he or she

may file a new application while appealing our determination or

decision.

If we assess an overpayment, we will apply the provisions of 20

C.F.R. Part 404, Subpart F (20 C.F.R. 404.501 et seq.), 20 C.F.R. Part

416, Subpart E (20 C.F.R. 416.501 et seq.). The individual assessed with

the overpayment may request that we waive that overpayment, and we will

consider such a request under our rules.

We will not waive an assessed overpayment if we find that the individual

is at fault in causing the overpayment. In determining whether an

individual is at fault, we will consider all pertinent circumstances,

including the individual's age and intelligence, and any physical,

mental, educational, or linguistic limitations (including any lack of

facility with the English language) the individual has.

B. Definitions

- 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.

- Similar Fault. As defined in sections 205(u)(2) and 1631(e)(7)(B) of the Act, similar fault is involved with respect to a determination

if: “(A) an incorrect or incomplete statement that is material to the

determination is knowingly made; or (B) information that is material to

the determination is knowingly concealed.”

terial fact for use in determining

rights under the Social Security Act.

- Similar Fault. As defined in sections 205(u)(2) and 1631(e)(7)(B) of the Act, similar fault is involved with respect to a determination

if: “(A) an incorrect or incomplete statement that is material to the

determination is knowingly made; or (B) information that is material to

the determination is knowingly concealed.”

- Material. This term describes a statement or information, or an

omission from a statement or information, that could influence us in

determining entitlement to benefits under title II or eligibility for

benefits under title XVI of the Act.

- Knowingly. This term describes a person's awareness or

understanding regarding the correctness or completeness of the information

he or she provides us, or the materiality of the information he or she

conceals from us.

- Preponderance of Evidence. This term means such relevant evidence

that as a whole shows that the existence of a 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.

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.

g that it

outweighs more than one piece of evidence in opposition.

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.

Similar Fault. As defined in sections 205(u)(2) and 1631(e)(7)(B) of the Act, similar fault is involved with respect to a determination

if: “(A) an incorrect or incomplete statement that is material to the

determination is knowingly made; or (B) information that is material to

the determination is knowingly concealed.”

Material. This term describes a statement or information, or an

omission from a statement or information, that could influence us in

determining entitlement to benefits under title II or eligibility for

benefits under title XVI of the Act.

Knowingly. This term describes a person's awareness or

understanding regarding the correctness or completeness of the information

he or she provides us, or the materiality of the information he or she

conceals from us.

Preponderance of Evidence. This term means such relevant evidence

that as a whole shows that the existence of a 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.

C. How We Redetermine An Individual's Entitlement or

Eligibility under Sections 205(u) and 1631(e)(7) of the Act

The following steps outline how we redetermine

entitlement or eligibility in this SSR.

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.

C. How We Redetermine An Individual's Entitlement or

Eligibility under Sections 205(u) and 1631(e)(7) of the Act

The following steps outline how we redetermine

entitlement or eligibility in this SSR.

- Under sections 205(u) or 1631(e)(7) of the Act, we must immediately

redetermine an individual's entitlement to or eligibility for benefits

when there is reason to believe that fraud or similar fault was involved

in an individual's application for benefits.

- We will disregard any evidence if there is reason to believe that fraud

or similar fault was involved in the providing of such evidence. We will disregard any evidence supplied, prepared, or signed by a source

when there is a reason to believe that the source provided the evidence

knowing it was incorrect or incomplete or concealed information knowing it

was material to the determination, even if it includes a report prepared

or signed by another source, such as lab findings and x-rays. We will not develop evidence from a source when there is a reason to

believe that the source provided evidence knowing it was fraudulent,

incorrect, or incomplete. In certain circumstances, we may disregard evidence provided by someone

who has not committed fraud or similar fault, but whose evidence relies

on other evidence involving fraud or similar fault. For example, we may

disregard parts of a physician's report that rely on another source's

evidence that we disregarded. Depending on the extent to which the

physician relied on the disregarded evidence, we may disregard the

physician's entire report. We may consider evidence we relied on to find fraud or similar fault

in one claim in deciding whether there is fraud or similar fault in

another claim. We may also consider that evidence in deciding the weight

we give to evidence in another claim

t we disregarded. Depending on the extent to which the

physician relied on the disregarded evidence, we may disregard the

physician's entire report. We may consider evidence we relied on to find fraud or similar fault

in one claim in deciding whether there is fraud or similar fault in

another claim. We may also consider that evidence in deciding the weight

we give to evidence in another claim. If we cannot determine whether evidence provided by a source involved

fraud or similar fault, we will consider the evidence in accordance

with our policies regarding evaluating symptoms and weighing medical

source opinions. We will also consider its consistency with the

remaining evidence. We will document the claim file with a description of the disregarded

evidence and the reasons for disregarding the evidence.

- We will consider the claim only through the date of the final

determination or decision on the beneficiary's application for benefits

(i.e., the original date of the allowance). We will not develop evidence

about new medical conditions or impairments with an onset date after the

original date of the allowance. We will not develop information about

the recipient's or beneficiary's current state of health.

- We will accept evidence relevant to the issues we decide during a

redetermination. For instance, we will accept evidence that relates to

the issue of whether the individual was disabled as defined under the

Act at the time of the individual's original allowance.

- We will consider evidence that postdates the original date of the

allowance if that evidence relates to the period at issue.

- A finding of fraud or similar fault and disregarding evidence based on

that finding does not constitute complete adjudicative action on a claim.

We will evaluate the remaining evidence in file and determine whether that

evidence supports a finding of entitlement to or eligibility for

benefits.

at postdates the original date of the

allowance if that evidence relates to the period at issue.

- A finding of fraud or similar fault and disregarding evidence based on

that finding does not constitute complete adjudicative action on a claim.

We will evaluate the remaining evidence in file and determine whether that

evidence supports a finding of entitlement to or eligibility for

benefits.

Under sections 205(u) or 1631(e)(7) of the Act, we must immediately

redetermine an individual's entitlement to or eligibility for benefits

when there is reason to believe that fraud or similar fault was involved

in an individual's application for benefits.

We will disregard any evidence if there is reason to believe that fraud

or similar fault was involved in the providing of such evidence.

- We will disregard any evidence supplied, prepared, or signed by a source

when there is a reason to believe that the source provided the evidence

knowing it was incorrect or incomplete or concealed information knowing it

was material to the determination, even if it includes a report prepared

or signed by another source, such as lab findings and x-rays.

- We will not develop evidence from a source when there is a reason to

believe that the source provided evidence knowing it was fraudulent,

incorrect, or incomplete.

- In certain circumstances, we may disregard evidence provided by someone

who has not committed fraud or similar fault, but whose evidence relies

on other evidence involving fraud or similar fault. For example, we may

disregard parts of a physician's report that rely on another source's

evidence that we disregarded. Depending on the extent to which the

physician relied on the disregarded evidence, we may disregard the

physician's entire report.

- We may consider evidence we relied on to find fraud or similar fault

in one claim in deciding whether there is fraud or similar fault in

another claim. We may also consider that evidence in deciding the weight

we give to evidence in another claim.

disregarded. Depending on the extent to which the

physician relied on the disregarded evidence, we may disregard the

physician's entire report.

- We may consider evidence we relied on to find fraud or similar fault

in one claim in deciding whether there is fraud or similar fault in

another claim. We may also consider that evidence in deciding the weight

we give to evidence in another claim.

- If we cannot determine whether evidence provided by a source involved

fraud or similar fault, we will consider the evidence in accordance

with our policies regarding evaluating symptoms and weighing medical

source opinions. We will also consider its consistency with the

remaining evidence.

- We will document the claim file with a description of the disregarded

evidence and the reasons for disregarding the evidence.

We will disregard any evidence supplied, prepared, or signed by a source

when there is a reason to believe that the source provided the evidence

knowing it was incorrect or incomplete or concealed information knowing it

was material to the determination, even if it includes a report prepared

or signed by another source, such as lab findings and x-rays.

We will not develop evidence from a source when there is a reason to

believe that the source provided evidence knowing it was fraudulent,

incorrect, or incomplete.

In certain circumstances, we may disregard evidence provided by someone

who has not committed fraud or similar fault, but whose evidence relies

on other evidence involving fraud or similar fault. For example, we may

disregard parts of a physician's report that rely on another source's

evidence that we disregarded. Depending on the extent to which the

physician relied on the disregarded evidence, we may disregard the

physician's entire report.

provided by someone

who has not committed fraud or similar fault, but whose evidence relies

on other evidence involving fraud or similar fault. For example, we may

disregard parts of a physician's report that rely on another source's

evidence that we disregarded. Depending on the extent to which the

physician relied on the disregarded evidence, we may disregard the

physician's entire report.

We may consider evidence we relied on to find fraud or similar fault

in one claim in deciding whether there is fraud or similar fault in

another claim. We may also consider that evidence in deciding the weight

we give to evidence in another claim.

If we cannot determine whether evidence provided by a source involved

fraud or similar fault, we will consider the evidence in accordance

with our policies regarding evaluating symptoms and weighing medical

source opinions. We will also consider its consistency with the

remaining evidence.

We will document the claim file with a description of the disregarded

evidence and the reasons for disregarding the evidence.

We will consider the claim only through the date of the final

determination or decision on the beneficiary's application for benefits

(i.e., the original date of the allowance). We will not develop evidence

about new medical conditions or impairments with an onset date after the

original date of the allowance. We will not develop information about

the recipient's or beneficiary's current state of health.

We will accept evidence relevant to the issues we decide during a

redetermination. For instance, we will accept evidence that relates to

the issue of whether the individual was disabled as defined under the

Act at the time of the individual's original allowance.

We will consider evidence that postdates the original date of the

allowance if that evidence relates to the period at issue.

ealth.

We will accept evidence relevant to the issues we decide during a

redetermination. For instance, we will accept evidence that relates to

the issue of whether the individual was disabled as defined under the

Act at the time of the individual's original allowance.

We will consider evidence that postdates the original date of the

allowance if that evidence relates to the period at issue.

A finding of fraud or similar fault and disregarding evidence based on

that finding does not constitute complete adjudicative action on a claim.

We will evaluate the remaining evidence in file and determine whether that

evidence supports a finding of entitlement to or eligibility for

benefits.

D. Appeal Rights

- Initiating a redetermination under sections 205(u) or 1631(e)(7) of the

Act is not subject to administrative or judicial review.

- After a redetermination, an individual may appeal our determination that

after disregarding evidence, the remaining evidence does not support

that individual's entitlement to or eligibility for benefits and results

in termination of such entitlement or eligibility. The individual may

appeal any overpayments we assess based on such evidence.

- An individual may appeal our finding of fraud or similar fault.

However, we will not administratively review information provided by SSA's

Office of the Inspector General under section 1129(l) of the Act regarding its

reason to believe that fraud was involved in the individual's application

for benefits.

Initiating a redetermination under sections 205(u) or 1631(e)(7) of the

Act is not subject to administrative or judicial review.

After a redetermination, an individual may appeal our determination that

after disregarding evidence, the remaining evidence does not support

that individual's entitlement to or eligibility for benefits and results

in termination of such entitlement or eligibility. The individual may

appeal any overpayments we assess based on such evidence.

is not subject to administrative or judicial review.

After a redetermination, an individual may appeal our determination that

after disregarding evidence, the remaining evidence does not support

that individual's entitlement to or eligibility for benefits and results

in termination of such entitlement or eligibility. The individual may

appeal any overpayments we assess based on such evidence.

An individual may appeal our finding of fraud or similar fault.

However, we will not administratively review information provided by SSA's

Office of the Inspector General under section 1129(l) of the Act regarding its

reason to believe that fraud was involved in the individual's application

for benefits.

DATES: Effective Date: This SSR is effective on

March 14, 2016.

CROSS-REFERENCES: SSR 85-23 ,

“Title XVI: Reopening Supplemental Security

Income Determinations at Any Time for ‘Similar Fault.’ ” SSR 16-2p ,

“Titles II and XVI: Evaluation of Claims Involving the

Issue of “Similar Fault” in the Providing of Evidence.”

[1] Fraud and similar fault redeterminations under sections 205(u) and 1631(e)(7) of the Act are distinct from reopenings

as described in 20 CFR 404.987 – 404.996 and 20 CFR 416.1487 – 416.1494 .

Fraud and similar fault redeterminations are also distinct

from redeterminations of Supplemental Security Income eligibility under

Title XVI of the Act as described in 20 CFR 416.204 .