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DHS home | SPD Staff Tools | Generic Program Elements | J. Quality Control

Generic Program Elements

J. Quality Control

Effective 6/14/13

1. Intent

Quality Control (QC) provides information about eligibility and the correctness of benefits. This is a part of a federal and state Performance Reporting System.

The results of information gathered by QC serve as a management tool and a means to help office staff discover and correct errors. Information discovered is also used to update training.

Federal agencies or state management may use the information gathered by the Program Integrity Unit, which is the program where QC is housed. QC's review of information may influence agency policy decisions or legislative actions. The QC information also influences corrective action plans.

A part of the QC data includes case and household characteristic information.

2. Overview

QC is a multipurpose system. QC conducts reviews to determine:

QC conducts QC reviews on federally matched programs, including SNAP, TANF and Medicaid. Cases for review are chosen randomly each month for review and are from a statistically reliable statewide sample.

QC uses specific review methodology to conduct the reviews based on federal requirements using state policy, approved waivers after implementation, federal regulations, and state and federal laws.

An important function of QC is to determine the number and types of errors in the total caseload. QC analyzes case findings and shares the results with management.

3. Client cooperation

Cooperation with QC is an eligibility requirement for programs receiving a federal match. Therefore, customers must cooperate with the QC review process; if they refuse, their benefits will be terminated. The QC reviewer notifies the branch office when a client fails to cooperate. When this happens, send a 10-day notice to end benefits for the entire eligibility group; the QC disqualification may last a lifetime for OHP.

See SS Family Services Manual, SNAP I.7 for SNAP disqualification information.

461-105-0410

4. Local action on cases selected for QC review

A local office must do all the following when notified that a case has been selected for review:

5. QC review process

The QC review process focuses on verification of all factors of eligibility, benefit amount, and if the customer received the correct benefit type. The QC reviewer obtains verification through case record review and field investigation, including home visits. Case record review includes the paper case file, the agency computer screens, and field investigation. Field investigation includes a personal interview with the customer and any collateral contacts needed to obtain verification.

The QC reviewer looks at eligibility and the amount of benefits for a specific time. The reviewers make a determination about eligibility for the sampled month. If eligible, the reviewer determines if the correct benefit amount and type was authorized. If the review is for a denied or terminated case, the QC reviewer determines if the decision to deny, suspend or terminate was correct, and if the notice was correct and sent to the correct address in a timely manner.

6. QC relationship with local offices

QC uses information from the records in the branch office and may use branch office resources for gaining additional information. The review itself must be completely independent of the branch office, with one exception. The exception is to gather additional medical information needed to prove eligibility. The reviewer may ask the branch to request medical information or a report.

QC staff is responsible for evaluating the information and making an eligibility determination. QC does not share this responsibility with the branch.

7. Distribution of QC findings

QC shares individual case review decisions with branch and program staff when the review is completed. The branch has five (5) working days to agree or disagree with the QC findings. If the branch does not respond by agreeing or disagreeing within the five-day time frame, the reviewer's findings and conclusions are considered final.

To disagree with the review findings, the branch must present factual evidence and documentation about why the review finding is in error. QC must receive facts supporting the disagreement within the five (5) working day period.

In addition, when there is a disagreement with the QC decision, local offices can ask QC to expand the review and make further contacts or look at different policies. However, the final decision on the review is with QC alone.

QC and the agency must resolve the disagreement before the QC completion deadline. Program or other appropriate staff may help resolve the disagreement.

8. Data analysis

The Program Integrity Unit analyzes QC data to give management a clear picture of QC findings. The analysis includes the following:

The Program Integrity Unit distributes information monthly to appropriate management and central office staff and generates semi-annual and annual reports for corrective action planning.

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