[Federal Register Volume 87, Number 95 (Tuesday, May 17, 2022)]
[Notices]
[Pages 29995-29998]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2022-10558]


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SOCIAL SECURITY ADMINISTRATION

[Docket No. SSA-2020-0017]


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

AGENCY: Social Security Administration.

ACTION: Notice of Social Security Ruling (SSR).

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SUMMARY: We are providing notice of SSR 22-1p. This ruling rescinds and 
replaces SSR 16-1p and explains the revised process we will 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. We are 
revising the evidentiary standard for fraud and similar fault from a 
``preponderance of the evidence'' to ``reason to believe'' to align 
more closely with the standard provided in the Act. We are also 
providing a new procedure at the hearings level of our administrative 
review process. The procedure provides that, before we disregard 
evidence under the Act at the hearings level of our administrative 
review process, we will consider the individual's objection to the 
disregarding of that evidence. We expect that these revised procedures 
will allow us to implement relevant sections of the Act in a manner 
consistent with the decisions of the Courts of Appeals that have 
considered legal challenges to the procedures outlined in SSR 16-1p.

DATES: We will apply this notice on May 17, 2022.

FOR FURTHER INFORMATION CONTACT: Mary Quatroche, Office of Disability 
Policy, Social Security Administration, 6401 Security Boulevard, 
Baltimore, MD 21235-6401, 410-966-4794. For information on eligibility 
or filing for benefits, call our national toll-free number 1-800-772-
1213 or visit our internet site, Social Security online, at http://www.socialsecurity.gov.

SUPPLEMENTARY INFORMATION: Although 5 U.S.C. 552(a)(1) and (a)(2) do 
not require us to publish this SSR, we are publishing it in accordance 
with 20 CFR

[[Page 29996]]

402.35(b)(1). SSRs do not have the same force and effect as statutes or 
regulations, but they are binding on all components of the Social 
Security Administration. 20 CFR 402.35(b)(1).
    We use SSRs to make available to the public precedential decisions 
relating to the Federal old-age, survivors, disability, supplemental 
security income, and special veterans benefits programs. We may base 
SSRs on determinations or decisions made in our administrative review 
process, Federal court decisions, decisions of our Commissioner, 
opinions from our Office of the General Counsel, or other 
interpretations of law and regulations.
    This SSR will remain in effect until we publish a notice in the 
Federal Register that rescinds it, or we publish a new SSR that 
replaces or modifies it.

(Catalog of Federal Domestic Assistance, Programs Nos. 96.001, 
Social Security--Disability Insurance; 96.002, Social Security--
Retirement Insurance; 96.004, Social Security--Survivors Insurance; 
96.006--Supplementary Security Income.)

    The Acting Commissioner of Social Security, Kilolo Kijakazi, having 
reviewed and approved this document, is delegating the authority to 
electronically sign this document to Faye I. Lipsky, who is the primary 
Federal Register Liaison for the Social Security Administration, for 
purposes of publication in the Federal Register.

Faye I. Lipsky,
Federal Register Liaison, Office of Legislation and Congressional 
Affairs, Social Security Administration.

Policy Interpretation Ruling

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

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

[[Page 29997]]

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

[[Page 29998]]

    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.
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    \5\ 20 CFR 404.903 and 416.1403.
    \6\ 20 CFR 404.903(z) and 416.1403(a)(24).
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    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\
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    \7\ 20 CFR part 404.501-404.545 and 20 CFR 416.501-416.590.
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    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.

[FR Doc. 2022-10558 Filed 5-16-22; 8:45 am]
BILLING CODE 4191-02-P