1142.015.00 TYPES OF CLAIMS

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There are three types of claims:

Several factors, including who discovered the potential overpayment, the type of claim and the EU's circumstances, affect whether or not a claim is established, the time period covered by the claim, and the cause code entered in CARS. The type of claim impacts repayment, the order in which claims are repaid, and whether the claim is reviewed by WIU.

Once you have determined a possible overpayment exists, register the discovery. The discovery will either be rejected or a claim will be established.

If a claim will be established, determine the reason the overpayment occurred. Document the circumstances of the overpayment and establish the claim. Refer to CARS User guide REGISTERING A DISCOVERY CLAIM REFERRAL AND ESTABLISHING A CLAIM.

Refer to the CARS Code Sheet or access the OVCD 0003 screen for possible cause codes. Choose the cause code that most closely describes the reason for the overpayment. Overpayments may occur for different reasons during different times of a certification period. Establish separate claims for each reason an overpayment occurs. If there are two reasons for an overpayment in the same time period, establish one claim and use the reason that best describes the cause.

Record the circumstances of the claim including verification received and used to determine the reason, amount, and timeframe of the claim on the Note Add (OVNA) screen.

1142.015.05 Administrative Error

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An administrative error (AE) claim is established against the EU for an overpayment caused by agency action or the agency's failure to take action. Instances of administrative errors, which may result in a claim include, but are not limited to the following:

Register and track all possible overpayments in the CARS discovery system. If it is determined the overpayment is under the threshold for establishing a claim, reject the claim referral using reason code 05 (Overpayment less than threshold). This allows another worker or reviewer to see that the claim has already been explored. Refer to CARS user guide REJECTING A FOOD STAMP DISCOVERY CLAIM REFERRAL.

Continue to establish all claims referred as a result of a Quality Control review, and all SPV/IPV referrals. If an agency error claim was not discovered as a result of a Quality Control review do not establish a claim if the amount of the overpayment is equal to or less than the stated threshold:

Register and establish all claims that are referred as a result of quality control review findings. Calculate an AE claim back no more than twelve months including the month of discovery.

EXAMPLE: A possible overpayment for March 2003 through June 2003 is discovered on May 6, 2004. The 12-month look-back period is June 2003 through May 2004. A claim is established for the month of June 2003 only. Do not establish a claim for March 2003, April 2003, and May 2003.

1142.015.10 Inadvertent Household Error

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An inadvertent household error (IHE) is a claim established against the EU for an overpayment caused by a misunderstanding or unintended error on the part of the EU.

Instances of inadvertent household errors, which may result in a claim include, but are not limited to, the following:

Register and track all possible overpayments in the CARS discovery system. If it is determined the overpayment is under the threshold for establishing a claim, reject the claim referral using reason code 05 (Overpayment less than threshold). This allows another worker or reviewer to see that the claim has already been explored. Refer to CARS user guide REJECTING A FOOD STAMP DISCOVERY CLAIM REFERRAL.

Continue to establish all claims referred as a result of a Quality Control review, and all SPV/IPV referrals. If an Inadvertent Household Error overpayment was not discovered as a result of a Quality Control review do not establish a claim if the amount of the overpayment is equal to or less than the stated threshold:

Register and establish all claims that are referred as a result of quality control review findings. Calculate an IHE claim back no more than twenty-four months including the month of discovery.

EXAMPLE: A possible overpayment for March 2002 is discovered on May 6, 2004. The 24-month look-back period is June 2002 through May 2004. A claim is not established.

1142.015.10.05 Suspected Program Violation

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A suspected program violation (SPV) occurs if there is evidence that a member of the Food Stamp EU intentionally made a false or misleading statement, or misrepresented, concealed, or withheld facts. When the worker determines a claim is an SPV, the claim will be investigated for intentional program violation (IPV). The worker establishes the claim as an IHE and enters an SPV indicator in CARS on the Claim Add (OVTC) screen. Evidence is documented on the Note Add (OVNA) screen.

There is no threshold for referring and establishing SPV claims. SPV claims have a look-back period of thirty-six months, including the month of discovery. If any SPV overissuance month occurred within the 36-month look back period, the over-issuance may be calculated back for up to seventy-two months including the month of discovery. If there is no month in which an overpayment occurred within the 36-month look back period, a claim amount is not calculated. An SPV claim is referred to WIU for investigation of intentional program violation via a report from CARS.

Example: Mrs. Dash has been claiming her son as an EU member since her initial application three years ago. The worker discovered this month that her son has never lived with her. The worker answers yes to the SPV indicator on the Add Claim (OVTC) screen when adding information to establish the claim. CARS sends a report to WIU, referring the claim for investigation of IPV.

Do not code claims that are administrative error or obviously inadvertent or accidental on the EU's part as SPV. There must be evidence of SPV recorded on the Note Add (OVNA) screen.

1142.015.15 Intentional Program Violation

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An intentional program violation (IPV) is a claim for an overpayment caused when a member(s) of the Food Stamp EU intentionally makes a false or misleading statement, or misrepresents, conceals, or withholds facts, or engages in trafficking. Establish only those claims in which trafficking has occurred as IPV. On the Claim Add (OVTC) screen enter Program 11, Cause Code 91 for trafficking claims. For any other claim to be coded as IPV, the overpayment must be determined an IPV by way of an administrative disqualification hearing (ADH) or through a court hearing or waiver. Establish any claims in which it appears an IPV has occurred, but has not been proven, as an IHE/SPV, by entering Program 12, SPV code Y, and the appropriate cause code on the Claim Add (OVTC) screen. Document evidence of the SPV on the Note Add (OVNA) screen.

There is no threshold for referring and establishing IPV or SPV claims. SPV claims have a look-back period of thirty-six months, including the month of discovery. If any SPV overissuance month occurred within the 36-month look back period, the over-issuance may be calculated back for up to seventy-two months including the month of discovery. If there is no month in which an overpayment occurred within the 36-month look back period, a claim amount is not calculated.

WIU staff investigate the circumstances of SPV overpayments and obtains evidence, if available, to support the SPV. After obtaining evidence of the SPV, WIU staff must determine whether to refer the case to the prosecuting attorney or pursue an ADH. The investigator discusses the evidence with the County Manager, and they make a joint decision to pursue an ADH or not. If the decision is to do an ADH, a Waiver of Administrative Hearing Disqualification Consent Agreement (IM-161 pdf logo) may be obtained. If a waiver of the ADH is not obtained, a referral is made to the county FSD office to do the ADH hearing. Once the decision is made to pursue an administrative disqualification, the WIU investigator works with the county staff to ensure that the ADH will be held. Submit a hearing request and complete the hearing in the same manner as for other hearings. Present information obtained by WIU staff regarding the SPV or request the WIU investigator appear at the hearing. Refer to Food Stamp Policy Manual Section 1145.000.00 DISQUALIFICATION FOR PROGRAM VIOLATION, for specific instructions.

If WIU staff returns the SPV to the county office without obtaining information to prove the SPV and county staff has information that substantiates the IPV, initiate an ADH hearing as outlined in Food Stamp Policy Manual 1145.030.00 USE OF ADMINISTRATIVE DISQUALIFICATION HEARINGS.

If it is determined by administrative disqualification hearing decision, or court order that an IPV occurred, change the claim type from SPV to IPV by changing the program code from 12 to 11 on the CARS Change Claim Information (OVCC) screen. The disqualification is entered by the Hearings Unit on the Sanction/Disqualification (FMAM) screen.

If it is determined by WIU that the overpayment is not an intentional program violation, the WIU agent updates the WIU code to 70-78, changes the SPV indicator to N, and returns the case to the county. If WIU returns the case to the county without changing the SPV indicator to N, the worker should change the indicator.

1142.015.15.05 Trafficking

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A trafficking claim is established against an EU when the EU has intentionally committed any act that constitutes a violation of the Food Stamp Act, the Food Stamp Program Regulations, or any state statute relating to the use, presentation, transfer, acquisition, or receipt of Food Stamp benefits.

WIU staff advise FSD staff when trafficking of Food Stamp benefits has occurred.

A trafficking claim is entered into CARS as an IPV when WIU notifies the worker of the determination that a trafficking violation has occurred. WIU provides the amount and months of the claim. Program 11, with cause code 91, is entered on the Claim Add (OVTC) screen.