Appendix A: Completing the Overpayment Referral Data Input Form (PA 189), ARRC Claim Change Form (PA 1001), and Overpayment Referral (OIG 189)

Completion of the PA 189 is required to refer TANF, GA, SNAP, and MA overpayments

Note:

Refer SNAP employment and training special allowance, MA, Disaster Assistance, LIHEAP, SSP, and LTC overpayments on an Overpayment Referral, OIG 189.

WORKER I.D.: Enter the worker I.D. number of the worker completing the form.

ARCAPA:

Complete on all verified IEVS and on all overpayments for non-IEVS claims.

CASE NAME:

Enter the first name, middle initial, and last name of the CIS case name.

CASEWORKER:

Enter the first initial and last name of the worker completing the document.

CO:

Enter the two-digit CAO code.

RECORD NUMBER:

Enter the seven digit record number. If necessary, use zeros in front of a record number to increase it to seven digits.

DISCOVERY DATE:

For a non-IEVS discovered overpayment, enter the month, day, and year (MMDDYY) the CAO became aware of the overpayment. This could be the date the CAO received a tip or the individual reported the income, etc. Entry is not required if the CAO initially discovered and input the overpayment into ARRC as the result of an IEVS review.

CLAIM NAME LINE #:

Enter the two-digit line number of the member of the household who received the income, owned the resource, or was responsible to report the change, which caused the overpayment. ENTRY is required even if claim name is the case name.

REASON CODE:

Enter the two-digit number that corresponds to the reason for the overpayment. Enter only one code. If there is more than one reason, complete a separate PA 189 for each reason. The reason codes can be found in Using ARRC – Chapter 5.

DISCOVERY CODE:

Enter the appropriate code from the list below for all claims discovered by any means other than IEVS.

ARCAEM:

Complete on all non-IEVS referrals; IEVS referrals for Exchanges 2, 3, 4, 5; IEVS Exchange 1 when suppression of the PA 162 VR or PA 78 is requested; IEVS Exchange 1 to regenerate a second PA 78 to a non-responding employer.

EMPLOYER/SOURCE NAME:

Enter the name of the employer or source where the request for verification is to be sent.

BEGIN DATE:

Enter month, day, year (MMDDYY) for the beginning date for which the wage information is being requested. Claim will not pass to the Office of Inspector General Avoidance and Recovery System (OARS) if this field is left blank.

ADDRESS:

Enter the address (or corrected address of the employer if different than the address listed on IEVS) or source where the request for verification is to be sent.

ADDRESS VERIFIED AS CORRECT OR CORRECTION ENTERED:

Check YES block if the employer’s address is verified as correct; or if a corrected address was entered in the above “address” field.

Check YES block if after contacting the non-responding employer, the employer’s address is verified as correct or incorrect and corrected but the employer refuses to cooperate by not completing or returning the initial PA 78A. The dialogue between the IMCW and the employer must be entered on the CIS case notation screen. See section 910.44, “Insufficient Wage Information from Employers,” for instructions to refer the employer to the OIG.

Leave blank if unable to verify the address of the employer or the employer is out of business or bankrupt and payroll records are no longer available. Access CIS case notation screen and narrate circumstances. Also access ARCAFQ screen and enter an “N” in question #1, “Did an overpayment occur?”

REGENERATE PA 78?:

Use to send a second ARRC PA 78A to a non-responding employer or to pass the name of the non-responding employer to the OIG non-cooperating file.

Check YES, if YES was entered in the “Address Verified as Correct or Correction Entered” field, to initiate action to send a second ARRC PA 78 to the non-responding employer. To complete this action, a date must be entered in the “Second Request Sent” field.

Check NO, if YES was entered in the “Address Verified as Correct or Correction Entered” field, but the employer refuses to complete and return a PA 78, ARRC will pass the non-responding employer to the OIG non-cooperating employer file. See 910.44 for instructions to refer the employer to the OIG.

Check NO, if the “Address Verified as Correct or Correction Entered” field is left blank. Also, access CIS case notation screen and narrate circumstances and access ARCAFQ screen and enter an “N“ in question #1, “Did an overpayment occur?”

PA 78 NEEDED?:

Check the appropriate box YES or NO if wage information verification is being requested. System default is YES for all Reason Code 01 overpayments discovered on IEVS. A NO will suppress the PA 78 from being system generated.

PA 162VR NEEDED?:

Check the appropriate box YES or NO.

DATE PA 162VR SENT:

Enter the date (MMDDYY) to send the PA162VR. Leave blank if not sending PA 162VR. Enter a current or future date.

VERIFICATION REQUEST SENT:

Enter the date (MMDDYY) to send the PA 78A or manual verification request.

SECOND REQUEST SENT:

Enter the date (MMDDYY) to send the second PA 78A to the non-responding employer.

DATE OF APPOINTMENT:

Enter the date of the appointment. Leave blank if the individual is to mail verification to CAO or no 162VR is needed.

RECEIVED:

Enter the date the PA 78A or other verification document was received.

TIME OF APPOINTMENT:

Enter the time of the appointment. Leave blank if the individual is to mail verification to CAO or no 162VR is needed.

CONTACT PERSON:

Identifies the eligibility worker’s name taken from the IVARRC screen. If discovery other than IEVS, the contact person can be entered directly on this screen.

PHONE NUMBER:

Enter the phone number of the contact person.

PA 78 COMMENT:

Enter comments (up to 60 characters) to be included on the PA 78A.

ARCAFA:

Complete on all verified overpayments.

CO RECORD NUMBER IN WHICH OVERPAYMENT OCCURRED:

Complete only if the overpayment occurred in another county, otherwise leave blank.

CATEGORY:

Enter the category of cash or MA (Medicaid) overpayment.

GRANT GROUP:

Enter the grant group number in which the overpayment occurred. (Leave blank if only one grant group in the case record.)

SAR:

Enter the SAR Code to identify which food stamp semi-annual reporting code to use for food stamp uncounted income dates (food stamp referrals only).

SAR Code 1 = 130% FPIG
SAR Code 6 = Over the $100 threshold

NOTE:

If the SAR Code is 1, Individual Error Only, ARRC will add 30 calendar days to the last day of the month the household first exceeded 130%. If the SAR Code is 6, Individual Error Only, ARRC will add 30 days to the first income date entered. This ARRC procedure will apply to claims that occur on or after May 27, 2003, but before October 21, 2005.

NOTE:

ARRC will add 33 calendar days for SAR Codes 1 and 6 for all individual caused overpayment claims with the certification period beginning October 21, 2005.

NOTE:

Food stamp agency error overpayments will not have calendar days added to the income date entered.

A/R/W/S:

Enter the monthly application code to identify when the food stamp claim period begins (food stamp referrals only).

A = Application Month
R = Re-certification
W = Within the Certification Period
S = SAR Month

TYPE OF OVERPAYMENT:

Check the appropriate box to identify the program in which an overpayment exists. More than one box may be checked for concurrent claims that require only one PA 189 to be prepared.

PROJECT CODE:

Use a project code only when specifically instructed. Enter 00 or the project code assigned for the specific Project Match.

TOTAL LIABILITY:

Used for cash overpayments only. Check the appropriate box to indicate if the unreported income should be considered available to all budget group members.

INDIVIDUAL ERROR:

Was overpayment caused by individual error? Check the appropriate box. Check NO if the overpayment was caused by agency error or individual error caused by circumstances beyond the individual’s control, such as serious illness, death, or accident which makes it impossible to expect the usual reporting requirements. For all other individual caused overpayments, check YES. (910.45)

CHILD CARE (agency error only):

Do not enter data in this field. Child care deductions are no longer given for cash/TANF cases.

NA DEPENDENTS:

Leave blank or enter the number of NA dependents.

MA CLAIM PERIOD:
FROM: The date the reason for ineligibility began.
THROUGH: The date of closing and/or adjustment for Medical Assistance overpayments.

INELIGIBLE LINE NUMBERS:  Used for MA overpayments only.   If only part of the budget group is affected, identify by line number those ineligible. Leave blank if ineligibility affects the grant budget group.

MA CLAIM AMOUNT: No CAO entry required. In most cases the CAO will not be aware of the amount of Medical Assistance granted under the medical card.

NUMBER OF UNREPORTED PERSONS IN  HOUSEHOLD (REASON CODES 22 AND 23):

Used with SNAP reason codes 22 and 23 only.  Identifies the number of unreported individuals in the household.  This number is added to the reported number to determine the total number of persons who should have been considered household members for the calculation of individuals with earned or unearned income.

ARCAUI:

Complete for all overpayments caused by income related reason codes.

NOTE:

Enter the budgeting method for claim periods that begin and end prior to May 27, 2003.

IF REASON CODE FOR OVERPAYMENT IS:

01 – Wages

Enter the date and amount of each unreported/unconsidered pay check received during the overpayment period. For SNAP overpayments enter the appropriate SNAP budgeting method (P=Prospective, R=Retrospective, or B=Both) for each pay check. Use “B” (only for first two months of overpayment) for transition and reapplication months when there is a failure to report income timely and the income should have been counted both prospectively and retrospectively. If more than three pays are received during the overpayment period, check “See attached” block and attach the PA 78 to the PA 189. On the back of the PA 78, highlight the date of pay and gross amount of each pay check received during the overpayment period. For SNAP overpayments, enter the appropriate budget method code (P/R/B) in the column provided on the PA 78. Cash budgeting method is determined by ARRC.

02 – Rental Income

Enter the PROFIT amount month to month and not gross receipts.

NOTE:

If the amount for cash and SNAP is different, two separate PA 189s must be completed.

04, 05, 08,09, 10, 11,17, 18, 21

Enter the gross amount month to month by date which caused overpayment.

NOTE:

A separate cash and food stamp overpayment must be completed if there are verified allowable deductions. If deductions are applicable for a cash overpayment, enter the net amount after deductions month to month to be used for overpayment.

14 – Income of a Sponsor

Enter the applicable amount month to month that should have been deemed for both cash and food stamp overpayments. Two separate overpayments must be completed since the deeming regulations for cash and SNAP differ for Income of Sponsor.

19 – Educational Grants/Loans

Enter the countable income month to month and not the amount of the grant/loan (amount not used for educational expenses).

24 – Self Employment Income

Enter the PROFIT amount month to month and not gross receipts.

NOTE:

If the amount for cash and SNAP is different, two separate PA 189s must be completed.

03 – Non-Reimbursable Lump Sum

Enter the date and lump sum amount after verified allowable deductions, if applicable. (See CAH, Chapter 157).

07 – Stepparent

Enter the net amount deemed available to the budget group.

NOTE:

If the household contains a person who is both an LRR and stepparent, use the stepparent reason code.

12 – LRR

Enter the net amount deemed available to the budget group.

15 – Lottery

Enter the date and the amount of the lottery winnings.

16 – Child Support Pass-through

Enter the amount and date the SPT was received. Used for administrative error SNAP overpayments only when the SPT was received timely but not adjusted.

22 – Unreported Individual in Household with Earned Income

Enter the gross amount and date month to month.

23 – Unreported Individual in Household with Unearned Income

Enter the gross amount and date month to month.

NOTE:

For all SNAP overpayments, enter the correct budgeting method, P-prospective; R-retrospective; B-both for claims prior to 5/27/03.

78 – Incorrect PA Grant Adjustment

Enter the PA grant amount that should have been used month to month for calculating the SNAP benefit.

ARCANL:

Complete only if the “NO” box in Total Liability of the ARCAFA section was checked. Enter the line #(s) of those members for whom the income or resource should not be considered available.

ARCAFI:

Complete for Reason Code 20 – Incorrect number of persons receiving benefits, cash reason codes 80, 81, 82, 83, 84, 85, 87, 88, 90, 91, 94, 97, and SNAP reason codes 80, 81, 83, 85, 86, 87, 89, 92 OR 97. Enter the start and end change dates and the line number of the individual(s) who left the household or is ineligible for benefits.

START CHANGE:

Enter the date the individual(s) left the household or became ineligible for benefits.

END CHANGE:

Enter the date the individual(s) was removed from the grant, returned to the household, or ineligibility for benefits ceased.

LINE#:

Enter the line number of the individual(s) who left the household or was ineligible for benefits.

ARCASA:

Complete for reason code 40, special allowance.

START CHANGE:

Enter the first day of ineligibility, which is the “From” date shown on the CIS cash medical assistance transcript screen, for the special allowance the individual was ineligible.

END CHANGE:

Enter the last day of ineligibility, which is the “Thru” date shown on the CIS cash medical assistance transcript screen, for the special allowance that the individual was ineligible to receive.

ELIGIBLE IND:

Enter YES if the individual was eligible for part of the allowance. Leave blank if all of the allowance is an overpayment.

ELIGIBLE AMOUNT:

Enter how much of the allowance the individual was eligible to receive. Leave blank if not applicable.

SPECIAL ALLOWANCE CODE:

Enter the special allowance issuance reason code number of the special allowance for which the individual was ineligible.

ARCAER:

Complete for all overpayments caused by resource related reason codes. Ineligibility will exist for a minimum of one month if the resource limit is exceeded.

RESOURCE BEGIN DATE:

Enter the date (MMDDYY) the resource became available.

RESOURCE END DATE:

Enter the date (MMDDYY) the resource is no longer available.

AMOUNT:

Enter the amount of the resource.

REASON:

Enter an explanation or clarification of the resource.

IF REASON CODE FOR OVERPAYMENT IS:

30, 32, 33, 34,35, 36

Enter the resource begin and end date, amount of resource and an explanation or clarification of the resource.

37 – Lump Sum SNAP/Exceeding Resource Limit

Enter the resource begin and end date, amount of resource and an explanation or clarification of the resource.

ARCAEL:

Complete for all overpayments caused by conditions of eligibility related reasons (reason codes 06, 25, 60, 61, 62, 63, 64, 65, 66, 68, 69, 70, 71, 73, 75, 95 or 96).

CASH - BEGIN DATE:

Enter the beginning date of ineligibility (MMDDYY).

END DATE:

Enter the ending date of ineligibility (MMDDYY).

MONTHLY CASH AMOUNT ELIGIBLE:

Enter the monthly amount of assistance the budget group was eligible to receive during the period of the overpayment. Leave blank if the budget group was ineligible for all assistance received during the period of overpayment.

SNAP - BEGIN DATE:

Enter the beginning date of ineligibility (MMDDYY).

END DATE:

Enter the ending date of ineligibility (MMDDYY).

MONTHLY SNAP AMOUNT ELIGIBLE:

Enter the monthly amount of SNAP benefits the household was eligible to receive during the period of the overpayment. Leave blank if the household was ineligible for all benefits received during the period of overpayment.

NOTE:

If the period of ineligibility is more than one month, ARRC will subtract the monthly amount entered in the amount eligible field for each month.

REASON:

Enter a brief (up to 74 characters) explanation clarification of the condition of ineligibility.

ARCACW:

Complete for overpayment reason code 41, Child Care Works (CCW) special allowance.

START CHANGE:

Enter the first day of ineligibility, which is the “From” date shown on the CIS cash medical assistance transcript screen for the CCW special allowance that the individual was ineligible.

END CHANGE:

Enter the last day of ineligibility, which is the “Thru” date shown on the CIS cash medical assistance transcript screen for the CCW special allowance that the individual was ineligible.

ELIGIBLE IND:

Enter YES if the case was eligible for part of the allowance. Leave blank if all of the allowance is an overpayment.

ELIGIBLE AMOUNT:

Enter how much of the allowance the individual was eligible to receive. Leave blank if not applicable.

CHILD CARE WORKS CODE

Enter the child care works allowance issuance reason code number of the allowance for which the individual was ineligible.

ARCAOF:

Used for SNAP overpayments only. Incorrect SNAP Deductions. Beginning and Ending date must be entered.

Complete for Reason Code 74.

BEGIN:

Begin Date: Enter the beginning date of the change or reduction, which was not used properly in the calculation of the original benefit. Enter date in month-day-year (MMDDYY) format.

END:

End Date: Enter the ending date of the change or reduction that was not used properly in the calculation of the original benefit. Enter date in month-day-year (MMDDYY) format.

ELIGIBLE MEDICAL DEDUCTION:

Enter the correct medical deduction that should be allowed in the calculation of the SNAP benefit. If no medical deduction should have been allowed, enter 0.

CORRECTED SHELTER COSTS:

Enter the correct shelter costs that should have been used in the calculation of the SNAP benefit for the identified period. If no shelter costs are to be allowed, enter 0.

CORRECTED UTILITY COSTS:

Enter the correct utility costs that should have been used in the calculation of theSNAP benefit for the identified period. If no utility costs are to be allowed, enter 0.

CORRECTED CHILD SUPPORT DEDUCTION:

Enter the correct amount of the child support deduction to be included in the calculation of the SNAP benefit for the identified period. If no deduction is to be allowed, enter 0.

ARCAFD:

Complete for food stamp dependent care deductions if reason code is 01, 02, 04, 05, 08, 09, 10, 11, 14, 16, 17, 18, 19, 21, 22, 23, 24, and 78.

DATE:

Enter the date (within the period of overpayment) the recipient incurred a dependant child care deduction. List each occurrence during the period of the overpayment separately.

AMOUNT:

Enter the amount of the childcare payment. Childcare amount is not to exceed the maximum allowed.

CO

Enter two-digit numeric county number or the county in which the case is currently active or most recently closed. If the overpayment occurred under a different county, that will be identified on a later screen.

RECORD

Enter seven-digit numeric record number in which the individual who caused the overpayment is currently active or most recently closed. If the overpayment occurred under a different record, that will be identified on a later screen.

DISCOVERY DATE

Enter discovery date in MMDDYY format. Discovery date is the date the potential overpayment was discovered. The ARRC system will automatically establish this date for IEVS referrals.

CASE NAME

Enter the first name, middle initial, and last name of the CIS case name.

CSLD

Enter the four-digit code of the caseload.

ARCHAP APPEAL REQUEST

CASH APPEAL REQUEST

Enter a “Y” in this field if the individual appeals a cash claim.

DATE OF REQUEST

Enter the date of the cash appeal request or the date the CAO received the appeal request from the individual. Date must be entered in MMDDYYYY format. The date cannot be greater than the current (today’s) date.

FOOD STAMP APPEAL REQUEST

Enter a “Y” in this field if the individual appeals a food stamp claim.

DATE OF REQUEST

Enter the date of the food stamp appeal request or the date the CAO received the appeal request from the individual. Date must be entered in MMDDYYYY format. The date cannot be greater than the current (today’s) date.

ARCHAP APPEAL DISPOSITION

CASH APPEAL DISPOSITION

Enter the appropriate code from the selections listed above that reflects the result of the fair hearing decision.

DATE OF DISPOSITION

Enter the date of the fair hearing decision. Date must be entered in MMDDYYYY format.

FOOD STAMP APPEAL DISPOSITION

Enter the appropriate code from the selections listed above that reflects the result of the fair hearing decision.

DATE OF DISPOSITION

Enter the date of the fair hearing decision. Date must be entered in MMDDYYYY format.

CHANGE CODE

Enter the appropriate code from the selections below that accurately describe the change in the individual’s case.

1.

Used to correct a claim that is two years or greater in which the original transcripts are purged from CIS.

2.

Used to correct a claim less than two years. Current transcripts from CIS will be retrieved for recalculation.

3.

Correction required due to pre-hearing conference/fair hearing decision. Requires entry of same or reduced claim period and/or same or reduced claim amount. The claim need not be in an appeal status to use this code.

4.

Correction required due to pre-hearing conference/fair hearing decision. Requires completion of appropriate ARRC screen. Since change code 4 automatically re-computes the ARRC claim, the CIS cash/SNAP transcripts must be available for re-computation.

NOTE:

All change codes except change code 3, result in a re-computation of the claim.

DISPOSITION CODE

Enter disposition code “22” – (claim rescinded in full by CAO). Disposition code “22” is the only valid entry in this field if the CAO intends to rescind the claim. Otherwise, leave blank.

DATE OF DISPOSITION

Enter the date the claim was rescinded by the CAO. Date must be entered in MMDDYYYY format.

Change Code 3 Only

Enter same or reduced cash claim period or same or reduced claim amount.

NOTE:

This section should only be used to enter the same cash claim period/cash claim amount or to enter the reduced cash claim period/cash claim amount. To lengthen the claim period requires completion of a separate claim referral.

CHANGE CASH OVERPAYMENT CLAIM PERIOD TO:

FROM DATE: Enter the new “From Date” to shorten the claim period.
TO DATE: Enter the new “To Date” to shorten the claim period.
CLAIM AMOUNT TO: Enter the same or reduced claim amount.

CHANGE FOOD STAMP PORTION OF THIS CLAIM

Check the appropriate “YES/NO” box if changing the food stamp portion of this claim.

CHANGE CODE

Enter the appropriate code from the selections below that accurately describe the change in the individual’s case.

ARCHFC CHANGE/DISPOSITION CODES

1.

Used to correct a claim that is two years or greater in which the original transcripts are purged from CIS.

2.

Used to correct a claim less than two years. Current transcripts from CIS will be retrieved for recalculation.

3.

Correction required due to pre-hearing conference/fair hearing decision. Requires entry of same or reduced claim period and/or same or reduced claim amount. The claim need not be in an appeal status to use this code.

4.

Correction required due to pre-hearing conference/fair hearing decision. Requires completion of appropriate ARRC screen. Since change code 4 automatically re-computes the ARRC claim, the CIS cash/SNAP transcripts must be available for re-computation.

NOTE:

All change codes except change code 3, result in a re-computation of the claim.

DISPOSITION CODE

Enter disposition code “22” – (claim rescinded in full by CAO). Disposition code “22” is the only valid entry in this field if the CAO intends to rescind the claim. Otherwise, leave blank.

DATE OF DISPOSITION

Enter the date the claim was rescinded by the CAO. Date must be entered in MMDDYYYY format.

Change Code 3 Only

Enter same or reduced food stamp claim period or same or reduced claim amount.

NOTE:

This section should only be used to enter the same food stamp claim period/SNAP claim amount or to enter the reducedSNAP claim period/food stamp claim amount. To lengthen the claim period requires completion of a separate claim referral.

CHANGE SNAP OVERPAYMENT CLAIM PERIOD TO:

FROM DATE: Enter the new “From Date” to shorten the claim period.
TO DATE: Enter the new “To Date” to shorten the claim period.
CLAIM AMOUNT TO: Enter the same or reduced claim amount.

CHANGE CASH PORTION OF THIS CLAIM

Check the appropriate “YES/NO” box if changing the cash portion of this claim.

DISPOSITION CODE

Valid disposition code is 22-- Claim rescinded by the CAO.

DATE

Enter the system date the CAO rescinded the claim (equal to or earlier than today's date). Date must be entered in MMDDYYYY format.

OTHER CHANGE REQUIRED

Enter the information next to the appropriate ARRC screen that is to be changed.

COMMENTS

Enter a brief written explanation of why the change is being requested.

SIGNATURES

Each signature block must be signed and dated.

The OIG 189 is the manual referral form used when referring MA, Disaster Assistance, Low-Income Home Energy Assistance Program (LIHEAP), SNAP employment and training special allowance, State Supplementary Payment (SSP) program, and Long Term Care (LTC) overpayments.

NOTE:

For SNAP claims that compute to $125 or less, where the case is closed, the CAO will make an annotation in case comments that the claim amount does not meet the food stamp threshold and then file the OIG 189 in the case record. Do not forward the referral to the OIG.

NOTE:

Disaster Assistance overpayments are not completed by CAO staff.

Enter the claim in ARRC and answer question #1 on the ARCAFQ screen with “M” indicating manual referral (paper OIG 189) completed.

EXCEPTION: This entry does not apply to LTC overpayments.

Mail the completed OIG 189 and supporting documentation (if appropriate) for Disaster Assistance, LIHEAP, SNAP employment and training special allowance, and SSP overpayments to:

Office of Inspector General
Bureau of Fraud Prevention and Prosecution
Attn: Operations Support Division
P.O. Box 8016
Harrisburg, PA 17101

Mail or fax the completed OIG 189 for LTC overpayments to the appropriate OIG Regional Office:

Regional Manager
Office of Inspector General
Central Regional Office
555 Walnut St, 7th floor
Harrisburg, PA 17101
Fax: (717) 772-2225

Regional Manager
Office of Inspector General
Southeast Regional Office 2
801 Market St, Suite 6034
Philadelphia, PA 19107
Fax: (215) 560-2423

Regional Manager
Office of Inspector General
Northeast Regional Office
22 East Union Street, Suite 300
Wilkes-Barre, PA 18711-2722
Fax: (570) 826-2381

Regional Manager
Office of Inspector General
Western Regional Office
2121 Noblestown Road, Suite 400
Pittsburgh, PA 15205
Fax: (412) 920-2545

PREVIOUS REFERRALS

Check no.

INDIVIDUAL NUMBER FOR CLAIM NAME

Enter the nine-digit individual number.

ITEM 1

TYPE OF REFERRAL

Check Food Stamp block.

ITEM 2

COUNTY

Enter the two digit county identifier code.

ITEM 3

RECORD NUMBER

Enter the seven digit record number. If necessary, use zeros in front of the record number to increase it to seven digits.

ITEM 4

CAT/GG

Complete for the individual who was the payment name of the overpayment

ITEMS 5--7

Leave Blank

ITEM 8

DISTRICT

Enter the appropriate district identifier.

ITEM 9

PAYMENT NAME

Leave blank.

ITEM 10

SNAP PAYMENT NAME

Enter the last name, first name, middle initial, and Social Security number of the Food Stamp payment name.

ITEM 11

CLAIM NAME

If different from Item 10, complete, otherwise leave blank.

ITEM 11A

ADDRESS

Enter the current mailing address of the Food Stamp payment name.

ITEM 12

TELEPHONE NUMBER

Enter the area code and the telephone number for the payment name.

ITEM 13

Leave blank.

ITEM 14

CAO DISCOVERY DATE

Enter the date (mm/dd/yy) the CAO first became aware of a possible overpayment. This is the date a tip was received, etc.

ITEM 15

DISCOVERY CODE

Enter the one digit number from the back of the OIG 189 which best describes how the overpayment was discovered.

ITEM 16

DATE VERIFIED

Enter the date (mm/dd/yy) the overpayment was verified. This is the date the documentation verifying the overpayment was received in the CAO.

ITEM 17

CAO RECOMMENDATION

Enter the appropriate one digit number from the back of the OIG 189. Enter any additional information regarding this recommendation in Item 40.

ITEM 18

Leave blank.

ITEM 19

REASON CODE

Enter 42.

ITEM 20

SAR CODE

Leave blank.

ITEM 21

MONTHLY APPLICATION CODE

LEAVE BLANK

ITEM 22 A--B

EMPLOYER NAME/ADDRESS

If appropriate enter the employer name and address if reason code 01 is entered in Item 9.

ITEM 23-25

If Yes, explain in Item 40 and identify appropriate individuals and indicate dates of contacts. Explain any misleading or concealing statements

ITEM 26--36B

Leave blank.

ITEM 37

PERIOD OF INELIGIBILITY

Enter the period of ineligibility

ITEM 38

LINE NUMBERS

Enter line numbers of all ineligible members, including minors.

ITEM 39

MA AMOUNT

Enter total amount of MA received by all ineligible members.

ITEM 40

EXPLANATION/COMMENTS

Enter the following information:

1.

The reason or the cause of the overpayment.

2.

The amount of the special allowance overpayment.

ITEM 41

EXPLANATION/COMMENTS

Enter the following information.  Sample reasons:

• A member of the grant group failed to report a countable resource which when added to other countable resources, exceeded the resource limit.

• A member of the grant group failed to report countable income which when added to other countable sources, exceeded the limit.

ITEM 42 - 44

SIGNATURES

Each signature block must be signed and dated.

ITEM 45

OIG REC.

Leave blank.

NOTE:

A Food Stamp Overpayment Computation Sheet (OIG 711-C) is not required for this type of overpayment.

PREVIOUS REFERRALS

Check no.

INDIVIDUAL NUMBER FOR CLAIM NAME

Enter the nine-digit individual number.

ITEM 1

TYPE OF REFERRAL

Check LIHEAP block.

ITEM 2

COUNTY

Enter the two-digit county identifier code.

ITEM 3

RECORD NUMBER

Enter the seven digit record number. If necessary, use zeros in front of the record number to increase it to seven digits.

If no record number exists, enter the first seven digits of the payment name’s Social Security number.

ITEM 4-7

Leave blank.

ITEM 8

DISTRICT

Enter the appropriate district identifier.

ITEM 9

PAYMENT NAME

Enter the last name, first name, middle initial, and Social Security number of the payment name.

ITEM 10

FOOD STAMP PAYMENT NAME

Leave blank.

ITEM 11

CLAIM NAME

Leave blank.

ITEM 11A

ADDRESS

Enter the current mailing address of the payment name.

ITEM 12

TELEPHONE NUMBER

Enter the area code and the telephone number for the payment name.

ITEM 13-38

Leave blank.

ITEM 39A

HEATING SEASON

Enter the appropriate heating season.

ITEM 39B

OVERPAYMENT AMOUNT

Enter the LIHEAP overpayment amount.

ITEM 40

EXPLANATION/COMMENTS

Enter the following information:

1.

The reason or cause of the overpayment, e.g., incorrect wage computation, incorrect household size, wrong fuel type, heating area, etc.

2.

Record the computation figures.

=

The amount of LIHEAP which the recipient received.

=

The amount of LIHEAP which the recipient was entitled to receive.

=

The difference will equal the amount that the recipient was overpaid.

ITEM 41-43

SIGNATURES

Each signature block must be signed and dated.

ITEM 44

OIG REC.

Leave blank.

NOTE:

The CAO must attach a copy of the Low Income Home Energy Assistance Application (PWEA 1) and any other supporting documentation; e.g., copy of inquiry screen, wage documentation, letter, etc.

PREVIOUS REFERRALS

Check NO.

INDIVIDUAL NUMBER FOR CLAIM NAME

Enter the nine digit individual number.

ITEM 1

TYPE OF REFERRAL

Check SSP block.

ITEM 2

COUNTY

Enter the two-digit county identifier code.

ITEM 3

RECORD NUMBER

Enter the seven digit record number. If necessary, use zeros in front of the record number to increase it to seven digits.

ITEM 4-7

Leave blank.

ITEM 8

DISTRICT

Enter the appropriate district identifier.

ITEM 9

PAYMENT NAME

Enter the last name, first name, middle initial, and Social Security Number of the individual that received the SSP. This may be the representative payee.

ITEM 10

FOOD STAMP PAYMENT NAME

Leave blank.

ITEM 11

CLAIM NAME

If different from Item 9, complete, otherwise leave blank. This could be the payment name or representative payee.

ITEM 11A

ADDRESS

Enter the address of the payment name or claim name, if different from payment name.

ITEM 12

TELEPHONE NUMBER

Enter the area code and the telephone number of the payment name or claim name, if different from payment name.

ITEM 13

Leave blank.

ITEM 14

DATE IDENTIFIED

Enter the date (mm/dd/yy) the CAO first became aware of a possible overpayment. This is the date a tip was received, etc.

ITEM 15

DISCOVERY CODE

Enter the one digit number or letter from the back of the OIG 189 which best describes how the overpayment was discovered.

ITEM 16

DATE VERIFIED

Enter the date (mm/dd/yy) the overpayment was verified. This is the date the documentation verifying the overpayment was received in the CAO.

ITEM 17

CAO RECOMMENDATION

Enter the appropriate one digit number from the back of the OIG 189. Enter any additional information regarding this recommendation in Item 39.

ITEM 18

PROJECT CODE

Enter “SS.”

ITEM 19

REASON CODE

Enter the appropriate overpayment reason code. Refer to the reverse of the OIG 189 for appropriate entry.

ITEM 20

SAR CODE

Leave blank.

ITEM 21

MONTHLY APPLICATION CODE

Leave blank.

ITEM 22A-B

EMPLOYER NAME/ADDRESS

Enter the employer name and address if reason code 01 is entered in Item 19.

ITEM 23-25

If YES, explain in Item 40 and identify appropriate individuals and indicate dates of contacts. Explain any misleading or concealing statements.

ITEM 26

PERIOD OF OVERPAYMENT

Enter the inclusive period of the overpayment.

ITEM 27

CASH AMOUNT

Enter the amount of the SSP overpayment.

ITEM 28-30

If YES, explain in Item 40 and identify type and amount of expenses, work incentives, and resource adjustments, as appropriate.

ITEM 31-35B

Leave blank.

ITEM 36

PERIOD OF INELIGIBILITY

Leave blank, unless the individual was ineligible for medical assistance during the period of overpayment.

ITEM 37

LINE NUMBERS

Claim Name Line Number: Enter the line number of the claim name. The claim name is the adult member of the household who had the income, owned the resource, or was responsible to report the change that caused the possible overpayment. Entry of claim name line number is required even if claim name is case name. The claim name could be the payment name or the representative payee.

ITEM 38

MA AMOUNT

Leave blank, unless the CAO is aware of a specific medical charge, an amount may be entered.

ITEM 39A-B

Leave blank.

ITEM 40

EXPLANATION/COMMENTS

Enter the following information:

1.

The reason or cause of the overpayment, such as:

=

A CIS error (Agency Error) resulting in the issuance of a duplicate SSP or OTI; or

=

The individual failed to report or failed to report timely a change in circumstances to the SSA that caused ineligibility for SSI, and subsequently caused ineligibility for the SSP; or

=

Failure to close the SSP-Only budget timely (based on information provided by the SSP Central Unit) resulting in the issuance of a benefit for which the individual was not eligible.

2.

Record the following overpayment computation figures:

=

The amount of the SSP the individual received.

=

The amount of the SSP the individual was entitled to receive.

=

The difference will equal the amount that the individual was overpaid.

NOTE:

Refer to Chapter 910.474, under General Policy, for examples of manual SSI/SSP and SSP-Only calculations of overpayment amounts.

ITEM 41-43

SIGNATURES

Each signature block must be signed and dated.

ITEM 44

OIG REC.

Leave blank.

PREVIOUS REFERRALS

Check YES or NO.

INDIVIDUAL NUMBER FOR CLAIM NAME

Enter the nine digit individual number.

ITEM 1

TYPE OF REFERRAL

Check LTC block.

ITEM 2

COUNTY

Enter the two-digit county identifier code.

ITEM 3

RECORD NUMBER

Enter the seven digit record number. If necessary, use zeros in front of the record number to increase it to seven digits.

ITEM 4-7

Leave blank.

ITEM 8

DISTRICT

Enter the appropriate district identifier.

ITEM 9

PAYMENT NAME

Enter the last name, first name, middle initial, and Social Security Number of the individual.

ITEM 10

FOOD STAMP PAYMENT NAME

Leave blank.

ITEM 11

CLAIM NAME

If different from Item 9, complete, otherwise leave blank. (Example: name of personal representative or Power of Attorney (POA Power-of-attorney.))

ITEM 11A

ADDRESS

Enter the address of the payment name or claim name, if different from payment name.

ITEM 12

TELEPHONE NUMBER

Enter the area code and the telephone number of the payment name or claim name, if different from payment name.

ITEM 13

Leave blank.

ITEM 14

DATE IDENTIFIED

Enter the date (mm/dd/yy) the CAO first became aware of a possible overpayment. This is the date a tip was received, etc.

ITEM 15

DISCOVERY CODE

Enter the one digit number or letter from the back of the OIG 189 which best describes how the overpayment was discovered.

ITEM 16

DATE VERIFIED

Enter the date (mm/dd/yy) the overpayment was verified. This is the date the documentation verifying the overpayment was received in the CAO.

ITEM 17

CAO RECOMMENDATION

Enter the appropriate one digit number from the back of the OIG 189. Enter any additional information regarding this recommendation in Item 40.

ITEM 18

PROJECT CODE

Leave blank.

ITEM 19

REASON CODE

Enter the appropriate overpayment reason code. Refer to the reverse of the OIG 189 for appropriate entry. If there is no appropriate reason code, explain in Item 40.

ITEM 20

SAR CODE

Leave blank.

ITEM 21

MONTHLY APPLICATION CODE

Leave blank.

ITEM 22A-B

EMPLOYER NAME/ADDRESS

If appropriate, enter the employer name and address if reason code 01 is entered in Item 19.

ITEM 23-25

If YES, explain in Item 40 and identify appropriate individuals and indicate dates of contacts. Explain any misleading or concealing statements.

ITEM 26-35B

Leave blank.

ITEM 36

PERIOD OF INELIGIBILITY

Enter the period of ineligibility.

ITEM 37-39B

Leave blank.

ITEM 40

EXPLANATION/COMMENTS

Enter the following information:

Sample reasons:

=

The individual or individual’s representative failed to report a countable resource which, when added to other countable resource(s), exceeded the resource limit.

=

The individual or individual’s representative disposed of a countable resource for less than fair consideration and the uncompensated value, when added to other countable resource(s), exceeded the resource limit.

=

The individual or individual’s representative failed to report the sale of the resident property.

ITEM 41-43

SIGNATURES

Each signature block must be signed and dated.

ITEM 44

OIG REC.

Leave blank.