SSR 22-1p: Titles II and XVI: Fraud and Similar Fault Redeterminations Under Sections 205(u) and 1631(e)(7) of the Social Security Act

Effective Date: May 17, 2022 Federal Register

Vol. 87, No. 95, page 29998

Policy Interpretation Ruling

This Social Security Ruling (SSR) rescinds and replaces SSR 16-1p :

“Titles II and XVI: Fraud and Similar Fault

Redeterminations Under Sections 205(u) and 1631(e)(7) of the Social Security Act.”

Purpose: To explain the process we use to redetermine an

individual's entitlement to benefits or eligibility for

payments under titles II or XVI of the Social Security Act

(Act) when there is reason to believe that fraud or similar

fault was involved in that individual's original

application for benefits or payments. [1]

Citations (Authority): Sections 205(u) and 1631(e)(7) of

the Social Security Act, 42 U.S.C. 405(u) and 1383(e)(7),

as amended; 20 CFR 404.704 , 404.708 , 404.1512 , 404.1520 , 416.912 , 416.920 , 416.924 , and 422.130 .

Dates: We will apply this notice on May 17, 2022

Introduction:

The Social Security Independence and Program

Improvements Act of 1994, Public Law 103-296, amended the

Act to add provisions addressing fraud or similar fault.

These amendments to sections 205 and 1631 of the Act

require us to immediately redetermine an individual's

entitlement to monthly insurance benefits under title II or

eligibility for payments under title XVI if there is reason

to believe that fraud or similar fault was involved in the

individual's application for such benefits or payments.

provisions addressing fraud or similar fault.

These amendments to sections 205 and 1631 of the Act

require us to immediately redetermine an individual's

entitlement to monthly insurance benefits under title II or

eligibility for payments under title XVI if there is reason

to believe that fraud or similar fault was involved in the

individual's application for such benefits or payments.

The Act 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.” [2] If, after redetermining entitlement to

benefits or eligibility for payments, we determine that the

evidence does not support entitlement to benefits or

eligibility for payments, we may terminate such entitlement

or eligibility and may treat benefits or payments paid

based on such evidence as overpayments.

This ruling explains the standards we use when we

determine whether there is reason to believe that fraud or

similar fault was involved in providing evidence in

connection with an application for benefits or payments.

The ruling applies to all applications for benefits under

title II and payments under title XVI of the Act; e.g.,

claims for old-age and survivors benefits and disability

benefits under title II of the Act, and applications for

Supplemental Security Income payments for the aged, blind,

and disabled under title XVI of the Act.

This ruling also describes the process we use when we

redetermine an individual's entitlement to benefits or

eligibility for payments when there is reason to believe

that fraud or similar fault was involved in that

individual's original application for benefits or

payments.

ations for

Supplemental Security Income payments for the aged, blind,

and disabled under title XVI of the Act.

This ruling also describes the process we use when we

redetermine an individual's entitlement to benefits or

eligibility for payments when there is reason to believe

that fraud or similar fault was involved in that

individual's original application for benefits or

payments.

This ruling does not replace or limit other appropriate

standards and criteria for development and evaluation of

claims in accordance with our rules. There may be instances

in which we will not disregard evidence under the statutory

provisions discussed in this ruling, but nevertheless,

factors may exist that justify considering the evidence in

question less persuasive or probative than other

evidence.

Policy Interpretation:

A. General

1. Sections 205(u) and 1631(e)(7) of the Act require us to immediately redetermine an individual's

entitlement to monthly insurance benefits under title II or eligibility

for payments under title XVI if there is reason to believe that fraud or

similar fault was involved in the individual's application for benefits

or payments.

2. The Act requires us to redetermine an individual's

entitlement or eligibility immediately, unless a United

States Attorney or other Department of Justice prosecutor,

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.

States Attorney or other Department of Justice prosecutor,

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.

3. We may discover suspected fraud or similar fault

related to a claim for benefits or payments or in the

provision of the evidence in a variety of ways. Most often,

we learn about fraud from our Office of the Inspector

General (OIG). OIG is responsible for investigating fraud

within our programs and must notify us under section 1129(l) of the Act when it has reason to believe that fraud

was involved in an individual's claim for benefits or

payments. We refer to this notification as a section 1129(l) referral. We may also learn about fraud from a

Federal or State prosecutor during the course of a criminal

investigation or prosecution. With regard to similar fault,

as we administer our programs, we may uncover information

that provides a reason to believe similar fault was

involved in the provision of evidence in an individual's

claim for benefits or payments.

4. We may find there is reason to believe fraud or

similar fault was involved in a claim for benefits or

payments, or in providing evidence, based on the actions of

any individual whose actions affect an application for

benefits or payments, or the evidence provided in support

of it, even when such an individual has no direct

relationship to the affected claimant, beneficiary, or

recipient or acts without the affected claimant's,

beneficiary's, or recipient's knowledge or participation.

These individuals may include, but are not limited to,

claimants, beneficiaries, auxiliaries, recipients, spouses,

representatives, medical sources, translators,

interpreters, and representative payees

vidual has no direct

relationship to the affected claimant, beneficiary, or

recipient or acts without the affected claimant's,

beneficiary's, or recipient's knowledge or participation.

These individuals may include, but are not limited to,

claimants, beneficiaries, auxiliaries, recipients, spouses,

representatives, medical sources, translators,

interpreters, and representative payees. For example, we

may have reason to believe a medical source or a

representative provided false information to support a

claim without the knowledge or participation of the

beneficiary or the recipient.

5. When we redetermine an individual's entitlement to

benefits or eligibility for payments 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.

6. Except for evidence we are required to disregard

under the Act, we will consider all other evidence that

relates to the individual's entitlement or eligibility

during the period at issue in the redetermination, in

accordance with our rules. Even if we disregard evidence,

we will evaluate the remaining evidence of record and

determine whether that evidence supports a finding of

entitlement to benefits or eligibility for payments. This

includes evidence included in the record at the time of the

original favorable determination or decision, along with

evidence provided during the redetermination process. When

requested, we will help individuals obtain evidence

relevant to the redetermination.

7. If, after redetermining an individual's entitlement

to monthly insurance benefits under title II or eligibility

for payments under title XVI, we determine that the

evidence does not support such entitlement to benefits or

eligibility for payments, we may terminate such entitlement

or eligibility and may treat benefits paid or payments made

based on such evidence as overpayments.

n.

7. If, after redetermining an individual's entitlement

to monthly insurance benefits under title II or eligibility

for payments under title XVI, we determine that the

evidence does not support such entitlement to benefits or

eligibility for payments, we may terminate such entitlement

or eligibility and may treat benefits paid or payments made

based on such evidence as overpayments.

8. 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 favorable

determination or decision, that individual may appeal our

determination or decision. Together with such an appeal, an

individual may object to our finding to disregard evidence

under the Act. We will consider any appeal in accordance

with our rules for administrative review.

9. If the individual believes he or she was disabled at

any point after the period at issue in the redetermination,

he or she may file a new application while appealing our

determination or decision. [3]

10. If we assess an overpayment, we will apply the

provisions of 20 CFR Part 404, Subpart F ( 20 CFR 404.501 et

seq.) and 20 CFR Part 416, Subpart E ( 20 CFR 416.501 et

seq.). We will consider a request to waive the overpayment

in accordance with our rules.

B. Definitions

1. 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 Act; or conceals or

fails to disclose a material fact for use in determining

rights under the Act.

2. Similar Fault. Similar fault is involved with

respect to a determination if: “an incorrect or incomplete

statement that is material to the determination is

knowingly made, or information that is material to the

determination is knowingly concealed.” [4]

in determining rights under the Act; or conceals or

fails to disclose a material fact for use in determining

rights under the Act.

2. Similar Fault. Similar fault is involved with

respect to a determination if: “an incorrect or incomplete

statement that is material to the determination is

knowingly made, or information that is material to the

determination is knowingly concealed.” [4]

3. Material. Material 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 payments under

title XVI of the Act.

4. Knowingly. Knowingly 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.

5. Reason to Believe. Reason to believe means

reasonable grounds to suspect that fraud or similar fault

was involved in the application or in the provision of

evidence. The reason to believe standard requires more than

mere suspicion, speculation, or a hunch, but it does not

require a preponderance of evidence.

C. How We Redetermine an Individual's

Entitlement to Benefits or Eligibility for Payments under

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

1. Under sections 205(u) and 1631(e)(7) of the Act, we will immediately redetermine an individual's entitlement

to benefits or eligibility for payments when there is

reason to believe that fraud or similar fault was involved

in an individual's application for benefits or payments,

including the providing of evidence.

igibility for Payments under

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

1. Under sections 205(u) and 1631(e)(7) of the Act, we will immediately redetermine an individual's entitlement

to benefits or eligibility for payments when there is

reason to believe that fraud or similar fault was involved

in an individual's application for benefits or payments,

including the providing of evidence.

2. We will disregard any evidence if we find there is

reason to believe that fraud or similar fault was involved

in the providing of such evidence. We will consider all

evidence in the case record before determining whether

specific evidence must be disregarded. In determining if

there is reason to believe fraud or similar fault was

involved, adjudicators may make reasonable inferences based

on the totality of the circumstances such as facts or case

characteristics common to patterns of known or suspected

fraudulent activity. For us to disregard evidence it is not

necessary that the affected beneficiary or recipient had

knowledge of or participated in the fraud or similar fault.

We will fully document the record with the description of

the disregarded evidence and the reasons for disregarding

the evidence.

a. We will disregard evidence supplied, prepared, or

signed by a medical source or nonmedical source when there

is reason to believe that the source knowingly (1) provided

incorrect or incomplete evidence material to the

determination or decision or (2) concealed or failed to

disclose evidence material to the determination or

decision, even if it includes a report prepared or signed

by another source.

rd evidence supplied, prepared, or

signed by a medical source or nonmedical source when there

is reason to believe that the source knowingly (1) provided

incorrect or incomplete evidence material to the

determination or decision or (2) concealed or failed to

disclose evidence material to the determination or

decision, even if it includes a report prepared or signed

by another source.

b. 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 medical source's opinion, which relies

on evidence that we disregarded from another medical

source. Depending on the extent to which the medical source

relied on the disregarded evidence, we may disregard some

or all of the medical source's opinion.

c. Before we disregard evidence pursuant to sections 205(u)(1)(B) and 1631(e)(7) (A)(ii)

of the Act at the hearings level of our administrative review process, we

will consider the individual's objection to the

disregarding of that evidence. After considering any

objections, our adjudicators will decide whether there is

reason to believe that fraud or similar fault was involved

in providing evidence in the individual's case.

d. If we do not find there is reason to believe evidence

provided by a source involved fraud or similar fault, we

will consider the evidence in accordance with our rules,

such as our rules regarding evaluating symptoms and medical

evidence. We will adhere to existing due process and

confidentiality requirements during the process of

resolving fraud or similar fault issues.

3. We will consider the claim only through the date of

the final determination or decision on the beneficiary's or

recipient's application for benefits or payments (i.e., the

date of the original favorable determination or decision).

medical

evidence. We will adhere to existing due process and

confidentiality requirements during the process of

resolving fraud or similar fault issues.

3. We will consider the claim only through the date of

the final determination or decision on the beneficiary's or

recipient's application for benefits or payments (i.e., the

date of the original favorable determination or decision).

4. We will consider evidence relevant to the issues we

decide during a redetermination. For example, we will

consider evidence that postdates the original date of the

favorable determination or decision if that evidence

relates to the period at issue in the redetermination. We

will not develop evidence about new medical conditions or

impairments arising after the date of the original

favorable determination or decision.

5. Generally, a finding that there is reason to believe

fraud or similar fault was involved in providing evidence

does not constitute complete adjudicative action on the

redetermination. Even if we disregard evidence, we will

evaluate the remaining evidence of record and determine

whether that evidence supports a finding of entitlement to

benefits or eligibility for payments.

D. Appeal Rights

1. Our regulations contain examples of

administrative actions that are not initial

determinations. [5] Our initiation of a redetermination under sections 205(u) and 1631(e)(7) of the Act is not listed as an example in

those regulations. However, the initiation of a

redetermination is similar to the administrative action of

starting or discontinuing a continuing disability review,

which is listed as an example in the regulations of an

administrative action that is not an initial

determination. [6] Therefore, we interpret our regulations to mean that our

initiation of a redetermination under sections 205(u) and 1631(e)(7) of the Act is not an initial determination that

is subject to administrative or judicial review.

or discontinuing a continuing disability review,

which is listed as an example in the regulations of an

administrative action that is not an initial

determination. [6] Therefore, we interpret our regulations to mean that our

initiation of a redetermination under sections 205(u) and 1631(e)(7) of the Act is not an initial determination that

is subject to administrative or judicial review.

2. After a redetermination, an individual who is

dissatisfied with our determination or decision may request

an appeal of our determination or decision. In conjunction

with such an appeal, an individual may object to our

finding to disregard evidence under the Act. We will

consider any appeal in accordance with our rules for

administrative review.

3. An individual may appeal any overpayments we assess,

or request waiver of the overpayment. We will consider any

appeal of the assessment of an overpayment or a request for

waiver of our overpayment in accordance with our rules. [7]

Cross-References: SSR

85-23 : Title XVI: Reopening Supplemental Security Income Determinations at Any Time for

“Similar Fault”; SSR 22-2p : 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 and 416.987 .

[2] See 42 U.S.C. §§ 405(u)(1)(B), 1383(e)(7)(A)(ii)

[3] SSR 11-1p :

Titles II and XVI: Procedures for Handling Requests to File

Subsequent Applications for Disability Benefits does not apply in the

context of fraud or similar fault redeterminations.

[4] See 42 U.S.C. §§ 405(u)(2), 1383(e)(7)(B).

[5] 20 CFR 404.903 and 416.1403 .

[6] 20 CFR 404.903(z) and 416.1403(a)(24) .

4 and 416.987 .

[2] See 42 U.S.C. §§ 405(u)(1)(B), 1383(e)(7)(A)(ii)

[3] SSR 11-1p :

Titles II and XVI: Procedures for Handling Requests to File

Subsequent Applications for Disability Benefits does not apply in the

context of fraud or similar fault redeterminations.

[4] See 42 U.S.C. §§ 405(u)(2), 1383(e)(7)(B).

[5] 20 CFR 404.903 and 416.1403 .

[6] 20 CFR 404.903(z) and 416.1403(a)(24) .

[7] 20 CFR Part 404.501 – 404.545 and 20 CFR 416.501 – 416.590 .

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