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Change #2-2010
June 1, 2010
Claims begin with referrals from any source that alleges a Food and Nutrition Services household has received or used benefits inappropriately, or has provided questionable information during the application process. The five basic types of referrals are defined below.
Front End Referrals are used when information provided by the applicant is questionable or conflicting, and eligibility cannot be determined. Front End Referrals are referrals made after application is filed but before an application is approved or denied. The caseworker processing the application should attempt to resolve the eligibility factor using all available sources before referring a case for a Front End. Act on the referral to resolve the eligibility factor, and provide a decision to the caseworker within ten (10) calendar days. Do not delay processing an application unless a DSS-8650, Notice of Information Needed to Complete your FNS, is pending. See Section 840 for policy regarding Front End Investigations. Enter Front End Referrals in EPICS with a referral type code of “F”.
Regular referrals apply to both active and terminated cases. The referral source can be a caseworker, third party source, or automated match. Regular referrals usually result in an Agency Error (AE) or an Inadvertant Household Error (IHE) claim because they do not appear to involve a false statement by the applicant. However, a regular referral may result in an Intentional Program Violation (IPV) claim once the investigation is completed. Establish claims or refer for an Administrative Disqualification Hearing (ADH) or criminal prosecution within 180 days of the date of discovery. Enter regular referrals in EPICs with a referral type code of “R”.
Suspected IPV referrals apply to both active and terminated cases. The referral source can be a caseworker, third party source, or automated match. Generate a suspected IPV referral based on the belief that a false statement was made at application or recertification. Establish a claim or refer for an Administrative Disqualification Hearing (ADH) or criminal prosecution within 180 days of the date of discovery. Enter suspected IPV referrals with a referral type code of “S”.
Project Recall referrals are generated from a Project Recall verification. Counties are provided monthly listings of applications approved two months prior to the current month. Use this list to randomly select cases and check for changes that may have occurred since the application. Counties are not required to participate in Project Recall. Enter Project Recall referrals in EPICS with a referral type of “P”.
Trafficking referrals apply to cases of suspected benefit misuse or abuse. Trafficking referrals can originate from USDA/Food and Nutrition Services or an outside source. Consider each person listed on an USDA store disqualification charge letter a referral. Refer to Section 830, EBT Recipient and Retailer Fraud. Enter trafficking referrals in EPICS with a referral type of “S”.
Complete an investigation before establishing a claim or seeking an IPV disqualification or making a criminal referral. Complete Food and Nutrition Services investigations using the following steps. Mail original notices to the individual suspected of committing the IPV, and a copy of all notices to any known legal or authorized representative.
A. Upon the receipt of a referral:
1. Key the referral in EPICS. (See the EPICS User’s Manual for instructions.)
2. Open an investigative file folder and begin a narrative.
3. Pull the case files for all aid programs the client received, and label to prevent purging. Close the referral if the eligibility file(s) has been purged or lost for the period of suspected overissuance.
B. Investigate the referral:
1. Review all DSS eligibility files for the household under investigation. Check for verifications or other reported pertinent information.
2. Send a written request to all third party verification sources to verify the information reported by the referral that is not part of the Food and Nutrition Services or other agency files. Request a reply within 30 days.
3. Send a second written request to all third party verification sources that did not respond to the first request within 30 days. Request a reply in 15 days.
4. Send a request to the household under investigation for information if the third party verification is not provided at the end of the second request period. Use DSS-8231, Request for Information. Request a reply in 15 days. Mail a copy to any known legal or authorized representative. Do not force the suspected household to cooperate.
C. Client interviews
1. An individual under investigation cannot be forced to:
a. Answer questions,
b. Allow you in their home,
c. Cooperate,
d. Provide documents,
e. Sign a waiver, statement, or agreement.
2. An individual under investigation has the right to:
a. Review any evidence that may be used against him/her,
b. Have an attorney present during an interview, at their own expense,
c. Have a representative present during an interview,
d. Present evidence on his/her own behalf.
3. If an investigation warrants an interview with the individual prior to establishing a claim, mail a DSS-8230, Program Integrity Appointment Notice to notify client of an appointment. Mail a copy to any known legal or authorized representative. Keep a copy in your file.
4. Do not require a client under investigation to come into the agency to discuss the amount of the claim or the type of the claim. Inform the client that his/her participation is strictly voluntary.
5. Schedule and conduct a home visit with the client, if appropriate and the client consents. Mail a DSS-8230, Program Integrity Appointment Notice at least three (3) working days prior to the home visit. Mail a copy of the DSS-8230 to any known legal or authorized representative. Keep a copy in the investigative file. Cancel the home visit if the client declines to allow the home visit.
6. During the interview, advise the individual of his/her rights in 800.05, C, 2.
7. Make reasonable inquiries into the individual’s educational level, reading ability, language barriers, medical or psychological problems, or a victim of domestic violence.
8. Continue the investigation if the client does not cooperate with the interview or home visit. Establish a claim without a client interview if the client does not keep the appointment, and the evidence is clear and convincing to prove the overissuance.
D. Determine the amount of the overissuance:
1. Evaluate all evidence to determine if an overissuance/underissuance of Food and Nutrition Services benefits occurred. If an underissuance occurred due to client’s failure to report a change, no further action is required. Do not restore benefits.
2. Use actual unreported income for each month of the issuance period. Do not reverify reported income unless there is a reason to believe it has changed. For example, reverify the UIB of a person who recently began new employment, since you would have reason to believe the UIB would terminate.
3. Use the SLAW screen in FSIS to calculate the correct allotment.
a. Enter unreported earned income as unearned income to prevent earned income deductions for IHE and IPV claims.
b. Enter all earned income as earned income for AE claims.
4. Use information on the SLII screen in FSIS to determine the amount of the benefits issued.
5. Complete a DSS-1682 as instructed in Section 835 of the Food and Nutrition Services Certification Manual.
6. Verify the benefits issued were used and not expunged.
7. The DSS-1682 must be reviewed, approved, and signed by a supervisor or their designee. The supervisor or designee must ensure the calculations on the DSS-1682 are correct.
8. Close the referral when an overissuance amount cannot be determined due to lack of cooperation by the client or third party verification sources.
E. Determine the type of overissuance:
1. Review all DSS eligibility files to determine if the information was reported to another caseworker.
a. Unless the Medicaid and Food and Nutrition Services Caseworker is the same person, information known to Medicaid and Services (including Child Care) is not considered known to Food and Nutrition Services. Establish an IHE claim if information is reported to Medicaid or Services but not Food and Nutrition Services.
b. Information known to Work First (TANF) is considered known to Food and Nutrition Services. Establish an AE claim if information is reported to Work First and not shared with Food and Nutrition Services.
c. Establish an AE claim if information reported to Food and Nutrition Services was not acted upon promptly and/or correctly. Follow rules in the Food and Nutrition Services Certification Manual regarding reporting requirements, and how the caseworker must respond to the information.
d. Do not establish a claim if the recipient was not required to report the change, the income was excluded, or the income could not have been anticipated.
2. Review the evidence for proof of an intent to commit a violation.
a. A false statement or withheld information at application or review must be present for an IPV claim. Document proof of intent in the file.
b. Reporting change(s) that increase benefits, but failing to report required change(s) that decrease benefits, may demonstrate fraudulent intent.
c. Additional evidence of fraudulent intent may include falsified documents or information withheld for more than one application or review.
d. Consider a claim to be an IHE and not an IPV if DSS records contain evidence of a mental or physical condition that may significantly impair the client’s ability to understand and follow program rules or to communicate clearly and/or accurately with DSS. Consideration should be given to an individual’s possible limited English proficiency and possible illiteracy when determining if the debtor knowingly and willfully intended to commit fraud.
e. Establish an IHE claim when the overissuance is not an agency error or Intentional Program Violation by the client or representative.
f. Factors to evaluate in determining whether there was fraudulent intent include prior reporting history, other incidents of dishonesty by the individual in dealing with DSS, the length of the period of overissuance, and evidence of reasonable efforts by the individual to contact DSS and report the information.
F. Collection of AE and IHE claims:
1. Enter the claim information in EPICS to generate the letter of overissuance. Use the Maintain Client screen in EPICS to add an address when EPICS address fields are blank. Use your best available information.
2. EPICS automatically begins recoupment procedures for active households unless debtor(s) are blocked.
3. Upon establishment of a claim, negotiate a repayment agreement with the debtor(s). Use DSS-8604 to document the agreement. Enter the repayment agreement information in the Repayment Approach Screen in EPICS.
4. Quarterly billing is recommended for all claims that are 90 days delinquent.
5. EPICS automatically begins procedures for TOP, DOR, and NC Education Lottery (NCEL) interception on delinquent claims unless the debtor(s) is blocked.
G. Establishment of IPV claim and disqualification:
Evidence to prove a person committed an IPV must be clear and convincing. Clear and convincing is defined as the measure or degree of proof which will produce, for a reasonable person, a firm belief or conviction of the allegations being sought.
1. Each county must develop Prosecution Guidelines to ensure equitable claim establishment and collection procedures within their county. Prosecution Guidelines determine which suspected IPV claims will be prosecuted in Criminal Court or established with an Administrative Disqualification Hearing (ADH).
2. Complete a second party file review to ensure there is clear and convincing evidence to prove the client committed an Intentional Program Violation. Otherwise, establish the claim as an IHE. The difference between an IPV and an IHE is intent.
3. Determine if the claim is subject to criminal prosecution.
a. Prepare case summary and evidence for appropriate authorities.
b. Enter a claim type of “P” in EPICS on the day the case is released to appropriate authorities.
c. Cooperate with the District Attorney’s office through the completion of the case.
d. Once established, enter the IPV claim and disqualification in EPICS. Follow instructions in the EPICS User’s Guide.
e. Cooperate with the probation officer for claim collection if the client is found guilty of the offense.
4. Decide if the claim is subject to Administrative Procedures.
a. Prepare a case summary and evidence for an Administrative Disqualification Hearing.
b. Prepare and mail via first class or certified mail a DSS-8556, Advance Notice of Disqualification Hearing and a DSS-8588, Waiver of Administrative Disqualification Hearing to the recipient and any known legal or authorized representative. Allow 30 calendar days notice. Do not make threats in an attempt to have the client sign a waiver. Never allow a client to sign a waiver in the presence of an investigator in order to prevent a later claim that they were coerced into signing the waiver against their will.
c. Enter a claim type of ”U” in EPICS on the day the DSS-8556 is mailed.
d. Prepare a copy of the case summary and evidence for the hearing officer and the recipient.
e. Follow policy in Section 710, Administrative Disqualification Hearings.
f. Once established, enter the IPV claim and disqualification in EPICS. Instructions are in the EPICS User’s Guide.
g. Only the individual who signed the Waiver of ADH or was found guilty of the IPV will be disqualified. However, the claim is to be collected from all responsible household members. Responsible household members must be 18 years or old at the time of the overissuance, included in the FNS Unit, someone who should have been included in the FNS Unit, or an emancipated minor head of household. Do not include as a debtor someone who was included in the FNS Unit when it is proven that person no longer lived in the household.
h. Follow collection procedures consistent with an IHE claim.
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For questions or clarification on any of the policy contained in these manuals, please contact your local county office. |
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