81_FR_13485 81 FR 13436 - Titles II and XVI: Fraud and Similar Fault Redeterminations Under Sections 205(U) and 1631(E)(7) of the Social Security Act

81 FR 13436 - Titles II and XVI: Fraud and Similar Fault Redeterminations Under Sections 205(U) and 1631(E)(7) of the Social Security Act

SOCIAL SECURITY ADMINISTRATION

Federal Register Volume 81, Issue 49 (March 14, 2016)

Page Range13436-13438
FR Document2016-05661

In accordance with 20 CFR 402.35(b)(1), the Commissioner of Social Security gives notice of SSR 16-1p. This Ruling provides guidance on how we redetermine entitlement to and eligibility for benefits when there is a reason to believe fraud or similar fault is involved with an individual's application for benefits.

Federal Register, Volume 81 Issue 49 (Monday, March 14, 2016)
[Federal Register Volume 81, Number 49 (Monday, March 14, 2016)]
[Notices]
[Pages 13436-13438]
From the Federal Register Online  [www.thefederalregister.org]
[FR Doc No: 2016-05661]



[[Page 13436]]

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SOCIAL SECURITY ADMINISTRATION

[Docket No. SSA-2015-0037; Social Security Ruling, 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

AGENCY: Social Security Administration (SSA).

ACTION: Notice of Social Security Ruling (SSR).

-----------------------------------------------------------------------

SUMMARY: In accordance with 20 CFR 402.35(b)(1), the Commissioner of 
Social Security gives notice of SSR 16-1p. This Ruling provides 
guidance on how we redetermine entitlement to and eligibility for 
benefits when there is a reason to believe fraud or similar fault is 
involved with an individual's application for benefits.

DATES: Effective Date: March 14, 2016.

FOR FURTHER INFORMATION CONTACT: Dan O'Brien, Director of Office of 
Vocational Evaluation and Process Policy in the Office of Disability 
Policy, Social Security Administration, 6401 Security Boulevard, 
Baltimore, MD 21235-6401, (410) 597-1632 or TTY 410-966-5609, for 
information about this notice. For information on eligibility or filing 
for benefits, call our national toll-free number, 1-800-772-1213 or TTY 
1-800-325-0778, 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 doing so in accordance with 
20 CFR 402.35(b)(1).
    Through SSRs, we convey to the public SSA 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 at all levels of 
administrative adjudication, Federal court decisions, Commissioner's 
decisions, opinions of the Office of the General Counsel, or other 
interpretations of the law and regulations.
    Although SSRs do not have the same force and effect as statutes or 
regulations, they are binding on all components of the Social Security 
Administration. 20 CFR 402.35(b)(1).
    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--Supplemental Security Income.)

    Dated: March 7, 2016.
Carolyn W. Colvin,
Acting Commissioner of Social Security.

Policy Interpretation Ruling

    Social Security Ruling, 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: 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\
---------------------------------------------------------------------------

    \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.

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. 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 an 
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

    1. 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.
    2. 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.
    3. 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.
    4. 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

[[Page 13437]]

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.
    5. 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.
    6. 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.
    7. 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.
    8. If the individual believes he or she is currently disabled, he 
or she may file a new application while appealing our determination or 
decision.
    9. If we assess an overpayment, we will apply the provisions of 20 
CFR part 404, subpart F (20 CFR 404.501 et seq.), 20 CFR part 416, 
subpart E (20 CFR 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.
    10. 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

    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 Social Security Act; or conceals or fails to disclose a 
material fact for use in determining rights under the Social Security 
Act.
    2. 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.''
    3. 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.
    4. 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.
    5. 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.
    1. 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.
    2. We will disregard any evidence if there is reason to believe 
that fraud or similar fault was involved in the providing of such 
evidence.
    a. 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.
    b. 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.
    c. 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.
    d. 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.
    e. 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.
    f. We will document the claim file with a description of the 
disregarded evidence and the reasons for disregarding the evidence.
    3. 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.
    4. 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.
    5. We will consider evidence that postdates the original date of 
the allowance if that evidence relates to the period at issue.
    6. 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

    1. Initiating a redetermination under sections 205(u) or 1631(e)(7) 
of the Act is not subject to administrative or judicial review.

[[Page 13438]]

    2. 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.
    3. 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.''

[FR Doc. 2016-05661 Filed 3-11-16; 8:45 am]
BILLING CODE 4191-02-P



                                                  13436                         Federal Register / Vol. 81, No. 49 / Monday, March 14, 2016 / Notices

                                                  SOCIAL SECURITY ADMINISTRATION                          Security—Retirement Insurance; 96.004,                disregard any evidence if there is reason
                                                                                                          Social Security—Survivors Insurance;                  to believe that fraud or similar fault was
                                                  [Docket No. SSA–2015–0037; Social                       96.006—Supplemental Security Income.)                 involved in the providing of such
                                                  Security Ruling, SSR 16–1p]
                                                                                                            Dated: March 7, 2016.                               evidence.’’ If, after redetermining
                                                  Titles II and XVI: Fraud and Similar                    Carolyn W. Colvin,                                    entitlement to or eligibility for benefits,
                                                  Fault Redeterminations Under                            Acting Commissioner of Social Security.               we determine that without the
                                                  Sections 205(U) and 1631(E)(7) of the                                                                         disregarded evidence, the evidence does
                                                                                                          Policy Interpretation Ruling                          not support entitlement or eligibility,
                                                  Social Security Act
                                                                                                            Social Security Ruling, SSR 16–1p:                  we may terminate such entitlement or
                                                  AGENCY:    Social Security Administration                                                                     eligibility and may treat benefits paid
                                                  (SSA).                                                  Titles II And XVI: Fraud and Similar
                                                                                                                                                                based on such evidence as
                                                                                                          Fault Redeterminations Under Sections
                                                  ACTION:   Notice of Social Security Ruling                                                                    overpayments.
                                                                                                          205(u) And 1631(e)(7) of the Social                      This ruling describes the process we
                                                  (SSR).                                                  Security Act                                          use when we redetermine an
                                                  SUMMARY:    In accordance with 20 CFR                   PURPOSE:   This Social Security Ruling                individual’s entitlement or eligibility to
                                                  402.35(b)(1), the Commissioner of Social                (SSR) explains the process we use to                  receive benefits when there is reason to
                                                  Security gives notice of SSR 16–1p. This                redetermine an individual’s entitlement               believe that fraud or similar fault was
                                                  Ruling provides guidance on how we                      to or eligibility for benefits when there             involved in that individual’s application
                                                  redetermine entitlement to and                          is reason to believe that fraud or similar            for benefits.
                                                  eligibility for benefits when there is a                fault was involved in that individual’s                  This ruling applies to all final
                                                  reason to believe fraud or similar fault                application for benefits.1                            determinations or decisions on
                                                  is involved with an individual’s                        CITATIONS: Sections 205(u) and                        entitlement or eligibility to receive
                                                  application for benefits.                               1631(e)(7) of the Social Security Act, 42             benefits under title II and title XVI of
                                                  DATES: Effective Date: March 14, 2016.                  U.S.C. 405(u), 1383(e)(7), as amended;                the Act.
                                                  FOR FURTHER INFORMATION CONTACT: Dan                    Regulations No. 4, sections 404.704,                     This ruling does not replace or limit
                                                  O’Brien, Director of Office of Vocational               404.708, 404.1512, 404.1520, and                      other appropriate standards and criteria
                                                  Evaluation and Process Policy in the                    404.1527; Regulations No. 16, sections                for evaluation of claims.
                                                  Office of Disability Policy, Social                     416.912, 416.920, 416.924, and 416.927;               POLICY INTERPRETATION:
                                                  Security Administration, 6401 Security                  and Regulations No. 22, section                       A. General
                                                  Boulevard, Baltimore, MD 21235–6401,                    422.130(b).
                                                  (410) 597–1632 or TTY 410–966–5609,                                                                              1. Sections 205(u) and 1631(e)(7) of
                                                                                                          INTRODUCTION: The Social Security
                                                                                                                                                                the Act provide that we must
                                                  for information about this notice. For                  Independence and Program
                                                                                                                                                                immediately redetermine an
                                                  information on eligibility or filing for                Improvements Act of 1994, Public Law
                                                                                                                                                                individual’s entitlement to monthly
                                                  benefits, call our national toll-free                   103–296, amended the Social Security
                                                                                                                                                                insurance benefits under title II or
                                                  number, 1–800–772–1213 or TTY 1–                        Act (Act) to add provisions addressing
                                                                                                                                                                eligibility for benefits under title XVI if
                                                  800–325–0778, or visit our Internet site,               fraud or similar fault. These
                                                                                                                                                                there is reason to believe that fraud or
                                                  Social Security Online, at http://                      amendments to sections 205 and 1631 of
                                                                                                                                                                similar fault was involved in the
                                                  www.socialsecurity.gov.                                 the Act provide that we must
                                                                                                                                                                individual’s application for benefits.
                                                  SUPPLEMENTARY INFORMATION:      Although                immediately redetermine an
                                                                                                                                                                   2. This legislation requires us to
                                                  5 U.S.C. 552(a)(1) and (a)(2) do not                    individual’s entitlement to monthly
                                                                                                                                                                redetermine an individual’s entitlement
                                                  require us to publish this SSR, we are                  insurance benefits under title II or
                                                                                                                                                                or eligibility unless a United States
                                                  doing so in accordance with 20 CFR                      eligibility for benefits under title XVI if
                                                                                                                                                                Attorney, or equivalent State prosecutor,
                                                  402.35(b)(1).                                           there is reason to believe that fraud or
                                                                                                                                                                with jurisdiction over potential or actual
                                                     Through SSRs, we convey to the                       similar fault was involved in the
                                                                                                                                                                related criminal cases, certifies, in
                                                  public SSA precedential decisions                       individual’s application for such
                                                                                                                                                                writing, that there is a substantial risk
                                                  relating to the Federal old-age,                        benefits. This legislation requires us to
                                                                                                                                                                that our action with regard to
                                                  survivors, disability, supplemental                     redetermine an individual’s entitlement
                                                                                                          or eligibility unless a United States                 beneficiaries or recipients in a particular
                                                  security income, and special veterans                                                                         investigation would jeopardize the
                                                  benefits programs. We may base SSRs                     Attorney, or equivalent State prosecutor,
                                                                                                          with jurisdiction over potential or actual            criminal prosecution of a person
                                                  on determinations or decisions made at                                                                        involved in a suspected fraud.
                                                  all levels of administrative adjudication,              related criminal cases, certifies, in
                                                                                                                                                                   3. When we redetermine a case under
                                                  Federal court decisions, Commissioner’s                 writing, that there is a substantial risk
                                                                                                                                                                sections 205(u) or 1631(e)(7) of the Act,
                                                  decisions, opinions of the Office of the                that such action by SSA with regard to
                                                                                                                                                                we must disregard evidence if there is
                                                                                                          beneficiaries or recipients in a particular
                                                  General Counsel, or other                                                                                     reason to believe that fraud or similar
                                                                                                          investigation would jeopardize the
                                                  interpretations of the law and                                                                                fault was involved in providing that
                                                                                                          criminal prosecution of a person
                                                  regulations.                                                                                                  evidence.
                                                     Although SSRs do not have the same                   involved in a suspected fraud. This
                                                                                                                                                                   4. We may find that any individual or
                                                  force and effect as statutes or                         statute further provides that, when we
                                                                                                                                                                entity whose actions affect an
                                                                                                          redetermine entitlement or eligibility, or
                                                  regulations, they are binding on all                                                                          individual’s application for monthly
                                                                                                          when we make an initial determination
                                                  components of the Social Security                                                                             benefits, has committed fraud or similar
                                                                                                          of entitlement or eligibility, we ‘‘shall
                                                  Administration. 20 CFR 402.35(b)(1).                                                                          fault. Examples of any individual or
jstallworth on DSK7TPTVN1PROD with NOTICES




                                                     This SSR will remain in effect until                   1 Fraud and similar fault redeterminations under
                                                                                                                                                                entity include a claimant, beneficiary,
                                                  we publish a notice in the Federal                      sections 205(u) and 1631(e)(7) of the Act are         auxiliary, recipient, spouse,
                                                  Register that rescinds it, or we publish                distinct from reopenings as described in 20 CFR       representative, medical source,
                                                  a new SSR that replaces or modifies it.                 404.987–404.996 and 20 CFR 416.1487–416.1494.         translator, interpreter, and
                                                                                                          Fraud and similar fault redeterminations are also
                                                  (Catalog of Federal Domestic Assistance,                distinct from redeterminations of Supplemental
                                                                                                                                                                representative payee. Sections 205(u) or
                                                  Programs Nos. 96.001, Social Security—                  Security Income eligibility under Title XVI of the    1631(e)(7) of the Act do not require that
                                                  Disability Insurance; 96.002, Social                    Act as described in 20 CFR 416.204.                   the individual or entity who committed


                                             VerDate Sep<11>2014   14:27 Mar 11, 2016   Jkt 238001   PO 00000   Frm 00127   Fmt 4703   Sfmt 4703   E:\FR\FM\14MRN1.SGM   14MRN1


                                                                                Federal Register / Vol. 81, No. 49 / Monday, March 14, 2016 / Notices                                              13437

                                                  fraud or similar fault, or the individual               respect to a determination if: ‘‘(A) an               evidence knowing it was fraudulent,
                                                  or entity providing the evidence that                   incorrect or incomplete statement that is             incorrect, or incomplete.
                                                  involves fraud or similar fault, have a                 material to the determination is                         c. In certain circumstances, we may
                                                  direct relationship to or act on behalf of              knowingly made; or (B) information that               disregard evidence provided by
                                                  the claimant, beneficiary, or recipient,                is material to the determination is                   someone who has not committed fraud
                                                  or directly or indirectly benefit from the              knowingly concealed.’’                                or similar fault, but whose evidence
                                                  fraud or similar fault.                                    3. Material. This term describes a                 relies on other evidence involving fraud
                                                     5. During the redetermination, we will               statement or information, or an                       or similar fault. For example, we may
                                                  consider evidence that was provided                     omission from a statement or                          disregard parts of a physician’s report
                                                  absent fraud or similar fault, and that                 information, that could influence us in               that rely on another source’s evidence
                                                  relates to the individual’s entitlement                 determining entitlement to benefits                   that we disregarded. Depending on the
                                                  and eligibility from the time of the                    under title II or eligibility for benefits            extent to which the physician relied on
                                                  individual’s original allowance, even if                under title XVI of the Act.                           the disregarded evidence, we may
                                                  that evidence was not presented                            4. Knowingly. This term describes a                disregard the physician’s entire report.
                                                  previously.                                             person’s awareness or understanding                      d. We may consider evidence we
                                                     6. If, after redetermining an                        regarding the correctness or                          relied on to find fraud or similar fault
                                                  individual’s entitlement to monthly                     completeness of the information he or                 in one claim in deciding whether there
                                                  insurance benefits under title II or                    she provides us, or the materiality of the            is fraud or similar fault in another
                                                  eligibility for benefits under title XVI,               information he or she conceals from us.               claim. We may also consider that
                                                  we determine that the evidence does not                    5. Preponderance of Evidence. This                 evidence in deciding the weight we give
                                                  support such entitlement or eligibility,                term means such relevant evidence that                to evidence in another claim.
                                                  we may terminate such entitlement or                    as a whole shows that the existence of                   e. If we cannot determine whether
                                                  eligibility and may treat benefits paid or              a fact to be proven is more likely than               evidence provided by a source involved
                                                  payments made based on such evidence                    not. Preponderance is established by                  fraud or similar fault, we will consider
                                                  as overpayments.                                        that piece or body of evidence that,                  the evidence in accordance with our
                                                     7. If an individual disagrees with our               when considered, produces the stronger                policies regarding evaluating symptoms
                                                  finding that the evidence does not                      impression and is more convincing as to               and weighing medical source opinions.
                                                  support his or her entitlement or                       its truth when weighed against the                    We will also consider its consistency
                                                  eligibility at the time of the original                 evidence in opposition. Thus,                         with the remaining evidence.
                                                  allowance, that individual may appeal                   preponderance does not require that a                    f. We will document the claim file
                                                  our determination or decision.                          certain number of pieces of evidence                  with a description of the disregarded
                                                     8. If the individual believes he or she                                                                    evidence and the reasons for
                                                                                                          (e.g., five or six) must be present. It is
                                                  is currently disabled, he or she may file                                                                     disregarding the evidence.
                                                                                                          possible that just one piece of evidence
                                                  a new application while appealing our                                                                            3. We will consider the claim only
                                                                                                          may be so convincing that it outweighs
                                                  determination or decision.                                                                                    through the date of the final
                                                     9. If we assess an overpayment, we                   more than one piece of evidence in
                                                                                                                                                                determination or decision on the
                                                  will apply the provisions of 20 CFR part                opposition.
                                                                                                                                                                beneficiary’s application for benefits
                                                  404, subpart F (20 CFR 404.501 et seq.),                C. How We Redetermine an                              (i.e., the original date of the allowance).
                                                  20 CFR part 416, subpart E (20 CFR                      Individual’s Entitlement or Eligibility               We will not develop evidence about
                                                  416.501 et seq.). The individual                        Under Sections 205(u) and 1631(e)(7) of               new medical conditions or impairments
                                                  assessed with the overpayment may                       the Act                                               with an onset date after the original date
                                                  request that we waive that overpayment,                                                                       of the allowance. We will not develop
                                                                                                             The following steps outline how we
                                                  and we will consider such a request                                                                           information about the recipient’s or
                                                                                                          redetermine entitlement or eligibility in
                                                  under our rules.                                                                                              beneficiary’s current state of health.
                                                     10. We will not waive an assessed                    this SSR.
                                                                                                                                                                   4. We will accept evidence relevant to
                                                  overpayment if we find that the                            1. Under sections 205(u) or 1631(e)(7)             the issues we decide during a
                                                  individual is at fault in causing the                   of the Act, we must immediately                       redetermination. For instance, we will
                                                  overpayment. In determining whether                     redetermine an individual’s entitlement               accept evidence that relates to the issue
                                                  an individual is at fault, we will                      to or eligibility for benefits when there             of whether the individual was disabled
                                                  consider all pertinent circumstances,                   is reason to believe that fraud or similar            as defined under the Act at the time of
                                                  including the individual’s age and                      fault was involved in an individual’s                 the individual’s original allowance.
                                                  intelligence, and any physical, mental,                 application for benefits.                                5. We will consider evidence that
                                                  educational, or linguistic limitations                     2. We will disregard any evidence if               postdates the original date of the
                                                  (including any lack of facility with the                there is reason to believe that fraud or              allowance if that evidence relates to the
                                                  English language) the individual has.                   similar fault was involved in the                     period at issue.
                                                                                                          providing of such evidence.                              6. A finding of fraud or similar fault
                                                  B. Definitions                                             a. We will disregard any evidence                  and disregarding evidence based on that
                                                    1. Fraud. Fraud exists when a person,                 supplied, prepared, or signed by a                    finding does not constitute complete
                                                  with the intent to defraud, either makes                source when there is a reason to believe              adjudicative action on a claim. We will
                                                  or causes to be made, a false statement                 that the source provided the evidence                 evaluate the remaining evidence in file
                                                  or misrepresentation of a material fact                 knowing it was incorrect or incomplete                and determine whether that evidence
                                                                                                          or concealed information knowing it
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                                                  for use in determining rights under the                                                                       supports a finding of entitlement to or
                                                  Social Security Act; or conceals or fails               was material to the determination, even               eligibility for benefits.
                                                  to disclose a material fact for use in                  if it includes a report prepared or signed
                                                  determining rights under the Social                     by another source, such as lab findings               D. Appeal Rights
                                                  Security Act.                                           and x-rays.                                              1. Initiating a redetermination under
                                                    2. Similar Fault. As defined in                          b. We will not develop evidence from               sections 205(u) or 1631(e)(7) of the Act
                                                  sections 205(u)(2) and 1631(e)(7)(B) of                 a source when there is a reason to                    is not subject to administrative or
                                                  the Act, similar fault is involved with                 believe that the source provided                      judicial review.


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                                                  13438                         Federal Register / Vol. 81, No. 49 / Monday, March 14, 2016 / Notices

                                                     2. After a redetermination, an                       benefits, call our national toll-free                 this AR, as provided by 20 CFR
                                                  individual may appeal our                               number, 1–800–772–1213 or TTY                         404.985(c) and 416.1485(c), we will
                                                  determination that after disregarding                   1–800–325–0778, or visit our Internet                 publish a notice in the Federal Register
                                                  evidence, the remaining evidence does                   site, Social Security Online, at http://              stating that we will apply our
                                                  not support that individual’s                           www.socialsecurity.gov.                               interpretation of the Act or regulations
                                                  entitlement to or eligibility for benefits              SUPPLEMENTARY INFORMATION:      We are                involved and explaining why we have
                                                  and results in termination of such                      publishing this Social Security AR in                 decided to relitigate the issue.
                                                  entitlement or eligibility. The individual              accordance with 20 CFR 402.35(b)(2),                  (Catalog of Federal Domestic Assistance,
                                                  may appeal any overpayments we assess                   404.985(a), (b), and 416.1485(a), (b) to              Program Nos. 96.001 Social Security—
                                                  based on such evidence.                                 explain how we will apply a holding in                Disability Insurance; 96.002 Social
                                                     3. An individual may appeal our                      Boley v. Colvin, 761 F.3d 803 (7th Cir.               Security—Retirement Insurance; 96.004
                                                  finding of fraud or similar fault.                      2014), regarding judicial review of an
                                                                                                                                                                Social Security—Survivors Insurance)
                                                  However, we will not administratively                   ALJ’s order finding no good cause for a                 Dated: March 3, 2016.
                                                  review information provided by SSA’s                    late hearing request and dismissing the               Carolyn W. Colvin,
                                                  Office of the Inspector General under                   request as untimely.                                  Acting Commissioner of Social Security.
                                                  section 1129(l) of the Act regarding its                   An AR explains how we will apply a
                                                  reason to believe that fraud was                        holding in a decision of a United States              ACQUIESCENCE RULING 16–1(7)
                                                  involved in the individual’s application                Court of Appeals that we determine                       Boley v. Colvin, 761 F.3d 803 (7th Cir.
                                                  for benefits.                                           conflicts with our interpretation of a                2014): Judicial Review of an
                                                  DATES: Effective Date: This SSR is                      provision of the Social Security Act                  Administrative Law Judge’s Order
                                                  effective on March 14, 2016.                            (Act) or regulations when the                         Finding No Good Cause for a Late
                                                  CROSS-REFERENCES: SSR 85–23, ‘‘Title                    Government has decided not to seek                    Hearing Request and Dismissing the
                                                  XVI: Reopening Supplemental Security                    further review of that decision or is                 Request as Untimely—Titles II and XVI
                                                  Income Determinations at Any Time for                   unsuccessful on further review.                       of the Social Security Act.
                                                  ‘Similar Fault.’ ’’ SSR 16–2p, ‘‘Titles II                 This AR explains how we will apply                    ISSUE: May a claimant obtain judicial
                                                  and XVI: Evaluation of Claims Involving                 the holding in Boley v. Colvin to claims              review of an administrative law judge
                                                  the Issue of ‘‘Similar Fault’’ in the                   in which the claimant makes a late                    (ALJ)’s order finding no good cause for
                                                  Providing of Evidence.’’                                request for an ALJ hearing, the ALJ                   a late hearing request and dismissing
                                                  [FR Doc. 2016–05661 Filed 3–11–16; 8:45 am]             dismisses the hearing request and finds               the request as untimely?
                                                  BILLING CODE 4191–02–P                                  that the claimant lacked good cause for                  STATUTE/REGULATION/RULING
                                                                                                          missing the appeal deadline, and then                 CITATION: Sections 205(g) and
                                                                                                          the claimant timely seeks review of the               1631(c)(3) of the Social Security Act (42
                                                  SOCIAL SECURITY ADMINISTRATION                          ALJ’s dismissal by the Appeals Council                U.S.C. 405(g), 1383(c)(3)); 20 CFR
                                                                                                          (AC). We will apply this AR to all                    404.900(a), 404.901, 404.903(j),
                                                  [Docket No. SSA–2015–0070]
                                                                                                          claims in the Seventh Circuit in which                404.933(b)–(c), 404.955, 404.957,
                                                  Social Security Acquiescence Ruling                     the AC denied a request for review of                 404.959, 416.1400(a), 416.1401,
                                                  (AR) 16–1(7), Boley v. Colvin: Judicial                 such a dismissal on or after March 14,                416.1403(a)(8), 416.1433(b)–(c),
                                                  Review of an Administrative Law                         2016. If the AC denied a request for                  416.1455, 416.1457, 416.1459.
                                                  Judge’s Order Finding No Good Cause                     review of an ALJ dismissal between                       CIRCUIT: Seventh (Illinois, Indiana,
                                                  for a Late Hearing Request and                          August 4, 2014 (the date of the Court of              Wisconsin).
                                                  Dismissing the Request as Untimely—                     Appeals’ decision) and March 14, 2016                    APPLICABILITY OF RULING: This
                                                  Titles II and XVI of the Social Security                (the effective date of this AR), the                  ruling applies to claims in which a
                                                  Act                                                     claimant may request that we apply the                claimant resides in a State within the
                                                                                                          AR.                                                   Seventh Circuit and in which an ALJ
                                                  AGENCY: Social Security Administration.                    When we received this precedential                 entered an order finding no good cause
                                                  ACTION:Notice of Social Security                        Court of Appeals’ decision and                        for a late hearing request, the ALJ
                                                  Acquiescence Ruling (AR).                               determined that an AR might be                        dismissed the request as untimely, the
                                                                                                          required, we began to identify those                  claimant requested review by the
                                                  SUMMARY:   We are publishing this Social                claims that were pending before the                   Appeals Council (AC), and the AC
                                                  Security AR to explain how we will                      agency that might be subject to                       denied review.
                                                  apply a holding in a decision of the                    readjudication if we subsequently                        DESCRIPTION OF CASE: Marilyn
                                                  United States Court of Appeals for the                  issued an AR. Because we have                         Boley filed a claim for disability
                                                  Seventh Circuit that we have                            determined that an AR is required and                 insurance benefits. We denied her claim
                                                  determined conflicts with our                           are publishing this AR, we will send a                at the initial and reconsideration levels
                                                  interpretation of the law regarding                     notice to those individuals whose                     of administrative review. Although she
                                                  judicial review of an administrative law                claims we have identified. In the notice,             was represented by an attorney at the
                                                  judge’s (ALJ’s) order finding no good                   we will provide information about the                 time we denied her request for
                                                  cause for a late hearing request and                    AR and the claimant’s rights under the                reconsideration, we sent notice of the
                                                  dismissing the request as untimely.                     AR. However, claimants may request                    reconsidered determination to Ms.
                                                  DATES: Effective: March 14, 2016.                       that we apply this AR to their claims                 Boley, but not to her attorney. After
                                                  FOR FURTHER INFORMATION CONTACT:                        even if they did not receive a notice, as             learning that we had denied Ms. Boley’s
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                                                  Todd Lewellen, Office of the General                    provided in 20 CFR 404.985(b)(2) and                  request for reconsideration, the attorney
                                                  Counsel, Office of Program Law, Social                  416.1485(b)(2).                                       requested a hearing. An ALJ dismissed
                                                  Security Administration, 6401 Security                     If we later rescind this AR as obsolete,           that request as untimely because the
                                                  Boulevard, Baltimore, MD 21235–6401,                    we will publish a notice in the Federal               regulations at 20 CFR 404.933(b) and
                                                  (410) 965–3309, or TTY 410–966–5609,                    Register to that effect, as provided in 20            416.1433(b) require a claimant to
                                                  for information about this notice. For                  CFR 404.985(e) and 416.1485(e). If we                 request a hearing within 60 days of the
                                                  information on eligibility or filing for                decide to relitigate the issue covered by             claimant’s receipt of a reconsidered


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Document Created: 2016-03-12 01:00:26
Document Modified: 2016-03-12 01:00:26
CategoryRegulatory Information
CollectionFederal Register
sudoc ClassAE 2.7:
GS 4.107:
AE 2.106:
PublisherOffice of the Federal Register, National Archives and Records Administration
SectionNotices
ActionNotice of Social Security Ruling (SSR).
ContactDan O'Brien, Director of Office of Vocational Evaluation and Process Policy in the Office of Disability Policy, Social Security Administration, 6401 Security Boulevard, Baltimore, MD 21235-6401, (410) 597-1632 or TTY 410-966-5609, for information about this notice. For information on eligibility or filing for benefits, call our national toll-free number, 1-800-772-1213 or TTY 1-800-325-0778, or visit our Internet site, Social Security Online, at http://www.socialsecurity.gov.
FR Citation81 FR 13436 

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