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