CLAIMS HANDBOOK - Department of Human Services

BENEFIT RECOVERY (CLAIMS) HANDBOOK
Notice of Intent to Intercept (1056)
A notice is mailed to a household when the debt reaches TOP delinquency (no payment for
180 days after the claim becomes delinquent). The debtor is notified of the intent to
intercept federal benefits and given a deadline of 60 days to dispute the intercept or make
other arrangements to pay the balance due. The claims manager must review Report
DMJ5803I monthly to verify the validity, liability, delinquency, and the balance of the claim
within 60 days of customer’s receipt of notice to prevent invalid or uncollectable claims
being submitted to TOP. All other inquiries from the debtor should be referred to the
Claims/Collections Unit. Refer to Pgs 28 and 50 for additional information.
Notice of Federal Intercept (0057)
A notice is mailed to the household when the intercept is posted or when rejected and a
refund is indicated. A list of customers notified of a refund is manually reviewed by
Claims/Collections Unit staff. Refunds may not occur if sufficient evidence is available to
retain the payment. If the refund is manually overridden, the intercepted amount will be
posted and a separate manual letter mailed by the Claims/Collections Unit to the customer.
THE OFFICE OF PROGRAM INTEGRITY AND COMPLIANCE (OPIC)
The Office of Program Integrity and Compliance (OPIC) is responsible for determining
whether a recipient has committed an intentional program violation (IPV) by receiving or
using benefits fraudulently, including suspicion of continued misuse and trafficking. An
initial suspicion of misuse must be documented and the customer counseled. Subsequent
acts of misuse must be referred. OPIC investigates those cases referred by DFCS on
Form 5667. The case manager decides if a potential claim should be processed as
inadvertent household error (IHE) or referred to OPIC for investigation.
An IPV is an intentional action by an individual to establish or maintain an AU’s eligibility, or
to increase or prevent a decrease in the AU’s benefits, by providing false or misleading
information or withholding facts.
Consider the following points to determine if a referral to OPIC is appropriate:
• There should be a fraudulent misrepresentation in such form as to be a statement of
fact
• The fact misrepresented must be material or relevant to the program requirements –
result in incorrect benefits being issued.
• The representation must be untrue, and the party making the representation must
know or believe it to be untrue, and to make it with a reckless disregard for its
truthfulness or falsity.
Additionally, OPIC must be able to prove intent. All forms explaining the customer’s rights
and responsibilities must by signed by both the customer and the case manager, and the
case record available.
Rev December ‘10 18