CLAIMS HANDBOOK - Department of Human Services

BENEFIT RECOVERY (CLAIMS) HANDBOOK
Claims Management Duties
1. Monitoring to assure timely processing of all unprocessed and pending overpayments and underpayments
(DMD6483I, DMD6486I). All benefit errors must be processed within 60 days of establishment. All data
found on reports should be processed monthly to assure processing within standard of promptness.
2. Maintaining Claims files. Each claim listed on the DMD6471I, Claims Management Monthly Report, must
have a corresponding claim file containing all necessary documentation.
3. Monitoring of suspended claims. The Claims in Suspended Status Report (DMD6484I) must be monitored
monthly. Claims that are suspended incorrectly must be returned to collection status.
4. Monitoring claims for termination eligibility. Claims must be terminated when it is no longer cost effective to
attempt collection.
5. Purging claims data. The claim file is stored for three years after a claim is paid in full or terminated. The
file is then purged per ESS policy. The documents supporting program disqualification supplied by OPIC
(Disposition letter, DRS print for FS, and Consent Agreement, Court Order, Administrative Hearing
Determination, etc.) are retained permanently in either a central alphabetic file or individually.
6. Posting manual payments. Manual payments must be posted within five (5) calendar days of receipt.
Exception: payments must be posted within the month they are received. A source document is forwarded
to in-house accounting for consolidation. It is recommended that a copy of the posting screen be used as
the source document.
7. Reconciliation of monthly Grant in Aid Adjustment report (DMD 6450I). Each entry must be validated prior to
the report being forwarded to accounting. To be validated, the entry must have a corresponding source
document and a copy of the payment receipt.
8. Over-collections and Refunds. The Claims Management Monthly Report (DMD6471I) must be monitored
monthly and over-collected balances either transferred to another claim or refunded to the customer. For
refunds, a communication form must be completed, including the source of and reason for the refund, and
the current address of the recipient. A source document must be generated and attached to communication
form. It is recommended that a copy of the posting screen be used as the source document. The
communication form and source document are forwarded to accounting. A copy must be retained for
reconciliation and for the claim file.
9. Adjustment of claim balances. Claim balances must occasionally be adjusted. The correct balance must be
verified and any error corrected.
10. OPIC referrals. All suspected fraud referrals to the Office of Program Integrity and Compliance must be
entered onto a central log and monitored for timely completion. Completed investigations are reported via
disposition letters, which are used to update the central log. Referrals may be sent individually or batched
weekly to OPIC.
11. System entry of program disqualification data. Disqualifications must be entered timely to avoid additional
overpayments. The Disqualified Recipient Subsystem (DRS) must also be updated timely for FS. Data
entry is usually the responsibility of the claims manager, but may be reassigned as necessary.
12. Renegotiation of payment. Monthly payment amounts are renegotiated as the customer’s financial
circumstances dictate. A new repayment agreement is obtained. Exception: IPV claims are NEVER
renegotiated without specific instructions from OPIC or from the courty. Initial balances (prior to payment)
may be compromised for non fraud claims.
13. Federal and State intercepts. Assist Claims / Collections Unit and customers with questions regarding
interception of taxes and other federal benefits. Review DMJ5803 monthly to confirm validity and liability of
any debt referred for federal intercept.
14. Bankruptcies. Paperwork must be completed if necessary and returned to the bankruptcy court timely, with
copies forwarded to the Claims / Collections Unit. Claims are suspended or terminated as appropriate.
Rev December ‘10 55