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 enter Cash Assistance, SNAP, and MA overpayments and refer them through ARRC. Complete the ARCAPA (and ARCAEM if applicable) section of the PA 189 to enter Buy-In, Disaster Assistance, LIHEAP, SSP and LTC overpayments in ARRC.

Note:

Refer Buy-In, 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.

CAO DISC:

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 #NO:

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, which caused the overpayment. ENTRY of the claim name line number is required even if claim name is the case name.

REASON CODE:

Enter the two-digit number that identifies the reason for the possible overpayment. Once a reason code is entered, it cannot be changed. If a different reason code is needed, answer "N" to Question #1 on the ARCAFQ screen. Enter a new claim with a new discovery date and correct reason code on the ARCAPA screen. The reason codes can be found in Using ARRC – Chapter 5.

DISCOVERY CODE:

Enter the one-digit numeric code that identifies how the possible overpayment was discovered. One-digit alpha codes will be entered into this field by the system for IEVS discoveries.

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 the beginning date for which the information is being requested. This date is refreshed if 189X was established as a result of an IEVS initiation.  For manual discovered overpayments, a “Y” must be entered in the PA 78 Needed field along with a BEGIN DATE.  The PA 78A will always request information from the identified begin date to present.  Completion of this field is mandatory for Reason Code 01 overpayments.   

ADDRESS:

Enter the complete address including zip code of the employer or source of income.  This information is refreshed if 189X was established as a result of an IEVS initiation.  Employer address can be corrected directly on this screen by typing over existing information.  This is the address to which the PA 78 will be mailed.

ADDRESS VERIFIED AS CORRECT OR CORRECTION ENTERED:

To be completed only after the address has been verified or an address correction entered.  Verification of an employer address normally occurs after an employer appears on the non-responding employer report.  If the address can be verified as correct, or an address correction has been entered, a “Y” is to be entered on this question.  If the address cannot be verified (i.e.:  the company is no longer in business) this field should remain blank and NO entry should be made to this question.  The 1st question on ARCAFQ should be changed to “N” as the potential overpayment cannot be verified.  A detailed narrative entry needs to be entered.

NOTE:

If contact is made with an employer who specifically states that they will not cooperate if a 2^nd PA 78 is sent, the IMCW should forward the information through their chain-of-command to the Executive Director or designee.  The Executive Director should provide the Office of Inspector General (OIG) with written details via a memo, of the caseworker’s attempts at getting the information from the employer, as well as who they spoke with at the employer and exactly what the employer said about refusing to return the information.  The memo to the OIG should be forwarded to the Director of the Bureau of Fraud Prevention and Prosecution.  The CAO should not regenerate another PA 78.  Answer the “Regenerate PA 78” question on ARCAEM with an “N.”

REGENERATE PA 78?:

Enter a “Y” to generate a second PA 78.  A “Second Request Sent Date” MUST be entered.  The second request date MUST be the CURRENT DATE.  A second PA 78A will be systems generated in an overnight batch process.  This action will remove the employer from the non-responded employer report and restart the 45-day clock for response.  After the 45 days has passed with no response, the 1st question on screen ARCAFQ should be changed to “N” as the potential overpayment cannot be verified.

PA 78 NEEDED?:

If the 189X had been established as a result of an IEVS Exchange 1 initiation, the PA 78 indicator is passed from IEVS.  Generation of the PA 78A is normally delayed 14 days.  Corrections or comments can be entered anytime within this delay period.  The system will automatically enter a sent date when the first PA 78A is generated.  Operator has the option to override the PA 78A generation by entering an “N” in this field.  For manual discovered overpayments, a “Y” must be entered in this field along with a BEGIN DATE.  If the potential claim in non-IEVS Reason Code 01, the default in this field is “N”.  If reason code is 01, the system will generate the PA 78A if a “Y” and the Date Sent is entered.

PA 162VR NEEDED?:

If the 189X had been established as a result of an IEVS hit Exchange 1, the indicator default is “Y”(yes).  System will automatically produce a PA 162VRA.  In situations where a 162VRA is not needed, the operator has the option not to produce the PA 162VRA by entering an “N” in this field within 24 hours of the claim initiation.  For non-IEVS claims, the default is “N”.  A “Y” must be entered in this field for automated production of the PA 162VRA.  Multiple employers identified on the same IEVS hit are listed on the same PA 162VRA.   

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:

Date PA 78 or other verification request was mailed.  Date will be systems entered for Reason Code 01 referrals when the system generates the PA 78A.  Generation of the PA 78A can be forced by entering the current date in this field.  This date must be manually entered for all other reason codes when the other verification request is mailed.

SECOND MANUAL REQUEST:

Date second manual PA 78 or other verification request was mailed.  Entry can be a current or future date only.  This date must be manually entered for IEVS Exchanges 4 and 5 when a second manual verification request form is sent.

SECOND REQUEST SENT:

Date second PA 78 or other verification request was mailed.  This date must be manually entered to generate a second PA 78A.  Entry can be a current or future date only.  Date will also require manual entry for all income reason codes other than 01 when a second verification request form is sent.  Generation of the second PA 78A requires the “RECD” date to be 00/00/00.  

DATE OF APPOINTMENT:

This date will be printed on the PA 162VRA.  If the discovery was initiated through IEVS, this information would have been entered on the IEVS Verification Request Screen.  Changes can be made to this field only on the day following completion of the IEVS Verification Request Screen because of the 24-hour delay in production of the PA 162VRA.  If discovery other than IEVS, the appointment date can be entered directly on this screen.

TIME OF APPOINTMENT:

This time will be printed on the PA 162VRA.  If the discovery was through IEVS, this information would have been entered on the IEVS Verification Request Screen.  Changes can be made to this field only on the day following completion of the IEVS Verification Request Screen because of the 24-hour delay in production of the PA 162VRA.  If discovery other than IEVS, the appointment time can be entered directly on this screen.

RECEIVED:

Date the PA 78 or other verification form is received.  This date is entered by clerical upon receipt of the completed PA 78 or other verification request form.  The documentation is then forwarded to the caseworker for review and disposition of potential overpayment.  Entry of this date moves the potential referral from a status of awaiting verification to a status of awaiting disposition.

CAO FAX NUMBER:

Enter the CAO fax number.  This number must be manually entered for the PA 78A

CONTACT PERSON:

Identifies the eligibility worker’s name taken from the IVARRC screen. Changes can be made to this field only on the day following completion of the IEVS Verification Request Screen because of the 24-hour delay in production of the PA 162VRA. If discovery other than IEVS, the contact person can be entered directly on this screen.

PHONE NUMBER:

Identifies the telephone number taken from IVARRC.  Changes can be made to this field only on the day following completion of the IEVS Verification Request Screen because of the 24-hour delay in production of the PA 162VRA.  If discovery other than IEVS, the telephone number can be entered directly on this screen.

PA 78 COMMENT:

Provides a free form area up to 60 characters for printed comments on the PA 78A.

ARCAFA:

Complete on all verified overpayments.

CO RECORD NUMBER IN WHICH OVERPAYMENT OCCURRED:

Required entry of a County Code and Record Number ONLY if the overpayment occurred in a county or case record different than the current county record.

CATEGORY:

Enter the category of cash or MA (Medicaid) overpayment. Do not enter "MA" and do not leave blank for medical.

GRANT GROUP:

Enter the grant group number in which the overpayment occurred.

SAR:

Enter the SAR Code to identify which SNAP semi-annual reporting code to use for SNAP uncounted income dates (SNAP referrals only). Required entry for SNAP category.

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 33  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 33 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:

SNAP 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 SNAP claim period begins (SNAP referrals only). Required entry of the Monthly Application Code for SNAP category.

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

TYPE OF OVERPAYMENT:

The default for each of these referral types is “N” to indicate no overpayment.  Enter a “Y” in the appropriate field to identify the type of referral being completed.  CASH OVERPAYMENT, SNAP OVERISSUANCE, MEDICAL OVERPAYMENT.  A “Y” can be entered in any or all fields for the appropriate combination or referral type.

PROJECT CODE:

A unique code used to identify overpayments discovered through a special project.  It can be changed any time prior to computation, but it cannot be changed after the claim has been computed.  These codes are assigned by the Office of Inspector General as a result of special projects which can be initiated by the Office of Inspector General or the Office of Income Maintenance. Special instructions will be issued for completing these referrals.  All other referrals are completed with a “00” project code, which is also the default code entered automatically by the system.   

TOTAL LIABILITY:

An indicator used for cash overpayments only.  It identifies the non-liable grant group members not affected by the income, resource, or change.  This is the liability of the claim name (the individual who owned the income or resource) to all other household members based on relationship.  The default entry is “Y” indicating the income or resource should be considered available to all household members.  If the income or resource should NOT be considered available to all household members, enter an “N” in this field.  Entry of an “N” in this field will queue the ARCANL (non-total liability action screen) on which non-liable members will be identified.

INDIVIDUAL  ERROR:

Was overpayment caused by individual error? Check the appropriate box. Check NO if the overpayment was caused by administrative error. For all other individual caused overpayments, Select "YES" if individual error, regardless of whether that error was intentional or unintentional and beyond the individual's control. (See Section 910.45)

SA Code:

Enter “SA” to identify a SNAP Special Allowance Referral type.  This is used with Reason Codes 42 and 43 only.

CAT ELIG:

For SNAP only.  Is the client categorically eligible for SNAP.  Enter Yes or No.

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 entire grant budget group.

MA CLAIM AMOUNT: Enter the amount of the computed Medical Assistance overpayment based on the results of the Data Warehouse Query and Excel Computation. (Refer to OPS-15-03-01).

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 beginning and ending before May 27, 2003 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.

NOTE: For Cash and SNAP overpayment claims periods on or after May 27, 2003, the prospective budgeting method will be applied in the computation of the claim.

NOTE: The budgeting codes for CASH ONLY referrals are system determined for claim periods beginning and ending prior to May 27, 2003.

02 – Rental Income

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

NOTE:

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

03 – Non-Reimbursable Lump Sum

Enter the date and lump sum amount after verified allowable deductions, if applicable. (See Cash Assistance Handbook, 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 beginning and ending before May 27, 2003.

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 total liability indicator is entered as “N” (no) on the ARCAFA Screen, and it is a Cash Overpayment Referral. 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,  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, or the date the individual(s) 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 date the change or ineligibility began.  Enter date in month – day – year (MMDDYY) format.

END CHANGE:

Enter the end date of the special allowance eligibility.  This is normally the THRU DATE from the CIS Cash Medical Assistance Transcript, CQCTRN.

ELIGIBLE IND:

Eligibility Indicator:  Default is an “N” to indicate ineligible.  If partial eligibility existed, enter a “Y” to indicate partial eligibility for a portion of the special allowance for which the overpayment referral is being completed.

ELIGIBLE AMOUNT:

Entry required only if the individual remained eligible for a portion of the special allowance.  Enter the amount eligible.  If the special allowance was included in the monthly grant, enter the monthly amount the individual was eligible to receive.  If the eligible amount varied from month to month, separate referrals must be completed for each month a special allowance was issued.

SPECIAL ALLOWANCE CODE:

Enter the special allowance code 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 no longer exceeds the limit.

AMOUNT:

Enter the amount of the resource.

REASON:

A free form data entry area of up to 74 characters is provided to enter an explanation or clarification of the resource.

IF REASON CODE FOR OVERPAYMENT IS:

30, 32, 33, 34,35, or 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, 26, 60, 61, 62, 63, 64, 65, 66, 68, 69, 71, 72, 73, 75, 95 and 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 eligible amount of cash assistance for the month.  If the amount eligible is left blank, the entire amount of assistance received during the overpayment period is considered as an 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 eligible amount of SNAP benefits for the month.  If the amount eligible is left blank, the entire amount of SNAP benefits received during the overpayment period is considered as an 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:

A free form data entry area of up to 74 characters is provided to enter an explanation or clarification of the condition of eligibility.  

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.

INDICATOR FOR SNAP COMP:

Enter a “Y” or “N” to indicate if there is a change in the medical deduction that should be allowed in the calculation of the SNAP benefit.  NOTE:  A dollar amount greater than zero must be entered in the Eligible Medical Deduction box if selecting “Y”.

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.

INDICATOR FOR SNAP COMP:

Enter a “Y” or “N” to indicate if there is a change in the shelter costs that should be allowed in the calculation of the SNAP benefit.  NOTE:  A dollar amount greater than zero must be entered in the Corrected Shelter Costs box if selecting “Y”.

CORRECTED UTILITY COSTS:

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

INDICATOR FOR SNAP COMP:

Enter a “Y” or “N” to indicate if there is a change in the utility costs that should be allowed in the calculation of the SNAP benefit.  NOTE:  A dollar amount greater than zero must be entered in Corrected Utility Costs box if selecting “Y”.

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.

INDICATOR FOR SNAP COMP:

Enter a “Y” or “N” to indicate if there is a change in the child support deduction that should be allowed in the calculation of the SNAP benefit.  NOTE:  A dollar amount greater than zero must be entered in Corrected Child Support Deduction box if selecting “Y”.

ARCAFD:

Complete for SNAP 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 dates of childcare payments that are to be allowed or included in the calculation of the overpayment.

AMOUNT:

Enter the amount of the childcare payment identified by date above. Childcare amount is not to exceed the maximum allowed.

ARCADV:

ARCAET:

SA REASON CODE:

Enter the SNAP ETP Special Allowance reason code for which the individual is ineligible.

ARCADC:

Enter the SNAP Dependent Care Special Allowance reason code for which the individual is ineligible.

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.

CAO DISC:

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.

SNAP APPEAL REQUEST

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

DATE OF REQUEST

Enter the date of the SNAP 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.

SNAP 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

Identifies the reason the change is being initiated.  Valid change codes are:

1.

Used to correct a claim that is greater than two years 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

Valid disposition code is 22 – Claim rescinded in  by the CAO.

DATE OF DISPOSITION

Enter the date the claim was rescinded by the CAO (date must be less than or equal to today's date). 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 SNAP PORTION OF THIS CLAIM

Valid entry in this field is "Y" or "N".

CHANGE CODE

Identifies the reason the change is being initiated.  Valid change codes are:

ARCHFC CHANGE/DISPOSITION CODES

1.

Used to correct a claim that is greater than two years 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

Valid disposition code is 22 – Claim rescinded in by the CAO.

DATE OF DISPOSITION

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

CHANGE CODE 3 ONLY:

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

NOTE:

This section should only be used to enter the same SNAP claim period/SNAP claim amount or to enter the reduced SNAP claim period/SNAP 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

Valid entry in this field is "Y" or "N".

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 Buy-In, Disaster Assistance, Low-Income Home Energy Assistance Program (LIHEAP), 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 SNAP 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 Buy-In, Disaster Assistance, LIHEAP 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
205 South Washington Street
Wilkes-Barre, PA 18701
Fax: (570) 826-2291

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 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

Leave blank.

ITEM 14

DATE IDENTIFIED CAO DISC:

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 41.

ITEM 18

PROJECT CODE

Enter the appropriate 2 digit code if any.

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 41 and identify appropriate individuals and indicate dates of contacts. Explain any misleading or concealing statements.

ITEM 26

CATEGORICALLY ELIGIBLE

Leave blank

ITEM 27

WAS THE OVERISSUANCE CAUSED BY CLIENT ERROR:

Check YES if overissuance was caused by client error.  Check NO if the overissuance was caused by administrative error.

ITEM 28-39

Leave blank

ITEM 40A

HEATING SEASON

Enter the appropriate heating season.

ITEM 40B

OVERPAYMENT AMOUNT

Enter the LIHEAP overpayment amount.

ITEM 41

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 42-44

SIGNATURES

Each signature block must be signed and dated.

ITEM 45

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

CO

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

DIS

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

SNAP 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

CAO DISC:

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

DISC 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 REC

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

CATEGORICALLY ELIGIBLE:

Leave blank.

ITEM 27

WAS THE OVERISSUANCE CAUSED BY CLIENT ERROR:

Check YES if overissuance was caused by client error.  Check NO if the overissuance was caused by administrative error.

ITEM 28

PERIOD OF OVERPAYMENT:

Enter the overpayment dates.

ITEM 29

CASH AMOUNT:

Enter the amount of the SSP overpayment.

ITEM 30

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

ITEM 31-36B

Leave blank.

ITEM 37

PERIOD OF INELIGIBILITY

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

ITEM 38

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 39

MA AMOUNT

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

ITEM 40A-B

Leave blank.

ITEM 41

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 42-44

SIGNATURES

Each signature block must be signed and dated.

ITEM 45

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

SNAP 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))

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

CAO DISC:

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 RE

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

Leave blank.

ITEM 27

WAS THE OVERISSUANCE CAUSED BY CLIENT ERROR:

Check YES if overissuance was caused by client error.  Check NO if the overissuance was caused by administrative error.

ITEM 28-36 B

Leave blank

ITEM 37

PERIOD OF INELIGIBILITY

Enter the period of ineligibility.

ITEM 38-40B

Leave blank.

ITEM 41

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 42-44

SIGNATURES

Each signature block must be signed and dated.

ITEM 45

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 MA 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 at the time of the overpayment.

ITEM 5-7

Leave blank.

ITEM 8

DIS

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

SNAP PAYMENT NAME

Leave blank.

ITEM 11

CLAIM NAME

If different from Item 9, complete, otherwise leave blank. (Example: someone other than payment name caused the overpayment)

ITEM 11A

ADDRESS

Enter the address of the payment name .

ITEM 12

TELEPHONE NUMBER

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

ITEM 13

Leave blank.

ITEM 14

CAO DISC:

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

DISC 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 REC:

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:

Enter  the appropriate 2 digit code if any.

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 41 and identify appropriate individuals and indicate dates of contacts. Explain any misleading or concealing statements.

ITEM 26

Leave blank.

ITEM 27

WAS THE OVERISSUANCE CAUSED BY CLIENT ERROR:

Check YES if overissuance was caused by client error.  Check NO if the overissuance was caused by administrative error.

ITEM 28-36B

Leave blank.

ITEM 37

PERIOD OF INELIGIBILITY:

Enter the period of ineligibility.

ITEM 38

LINE NUMBERS:

Enter the line numbers of all ineligible members including minors.

ITEM 39

MA AMOUNT:

Enter total amount of MA received by all ineligible members.

ITEM 40A-B

Leave blank.

ITEM 41

EXPLANATION/COMMENT:

Enter the following information:

Sample reasons:

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

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

ITEM 42-44

SIGNATURES

Each signature block must be signed and dated.

ITEM 45

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 MA 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 at the time of the overpayment.

ITEM 5-7

Leave blank.

ITEM 8

DIS:

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

SNAP PAYMENT NAME:

Leave blank.

ITEM 11

CLAIM NAME:

If different from Item 9, complete, otherwise leave blank. (Example: someone other than payment name caused the overpayment)

ITEM 11A

ADDRESS:

Enter the address of the payment name .

ITEM 12

TELEPHONE NUMBER:

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

ITEM 13

Leave blank.

ITEM 14

CAO DISC:

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

DISC 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 REC:

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:

Enter  the appropriate 2 digit code if any.

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 41.

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 41 and identify appropriate individuals and indicate dates of contacts. Explain any misleading or concealing statements.

ITEM 26

Leave blank.

ITEM 27

WAS THE OVERISSUANCE CAUSED BY CLIENT ERROR:

Check YES if overissuance was caused by client error.  Check NO if the overissuance was caused by administrative error.

ITEM 28-36B

Leave blank.

ITEM 37

PERIOD OF INELIGIBILITY:

Enter the period of ineligibility.

ITEM 38

LINE NUMBERS:

Enter the line numbers of all ineligible members including minors.

ITEM 39

MA AMOUNT:

Enter total amount of buy-in payments received by all ineligible members. (This total can be found on the OIG 765 C1).

ITEM 40A-B

Leave blank.

ITEM 41

EXPLANATION/COMMENT:

Enter the following information:

Sample reasons:

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

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

ITEM 42-44

SIGNATURES

Each signature block must be signed and dated.

ITEM 45

OIG REC:

Leave blank.

Reissued August 20, 2015, replacing August 14, 2013