049-1 Wyo. Code R. § 1-3

Current through April 27, 2019

Section 1-3 - FO-DFS Responsibilities for Investigation/Claim Establishment

(a) FO-DFS must determine the person(s) against whom the claim is to be established.

(b) FO-DFS shall establish a claim against the assistance unit as follows:

• (i) the assistance unit that has been overpaid;

• (ii) any member of the overpaid assistance unit (for all programs excluding Food Stamps); or

• (iii) any adult member of the overpaid assistance unit (for Food Stamps only); or

• (iv) any individual member (adult member for Food Stamps) of the assistance unit at the time of the overpayment whether or not currently a recipient.

(c) FO-DFS shall establish a claim against the assistance unit when a payment was made to a provider and the assistance unit is later found to be ineligible for part or all of the payment.

(d) FO-DFS shall establish a claim against the provider when the payment made to the provider exceeds the amount due and the overpayment is not related to the eligibility or the benefit level of the assistance unit.

(e) FO-DFS shall establish a claim against either the alien or the sponsor, whoever is most likely to repay first. Both the alien and the sponsor shall be considered responsible for repayment unless the sponsor has good cause. If there is no documentary evidence that the sponsor misrepresented or failed to report a fact which caused the overpayment, the sponsor shall be considered to have shown good cause and be without fault. The sponsor shall be allowed to request a fair hearing on the amount of the overpayment to prove whether or not the sponsor is at fault.

(f) FO-DFS shall establish the claim on EPICS and/or complete and send an ORP Case Information Document to DFS and determine the error cause as follows:

• (i) the error shall be considered an Agency Error (AG) when the DFS worker took incorrect action or failed to take action on a case;

• (ii) the error caused by the assistance unit shall be considered a documentary evidence error (DE) pending disqualification or prosecution, unless there is evidence in the case file such as, but not limited to:
  • (i) the person did not understand; or
  • (ii) was forced to withhold information.
  • (iii) the error shall be considered a client error (CL) when the assistance unit or provider caused an unintentional error.
  • (iv) the error shall be considered an intentional program violation when a prior disqualification has been made with the same cause and the current months of overpayment postdate the date of disqualification.

(g) FO-DFS shall process the overpayment, recalculate the correct benefit, determine the amount of the overpayment by program, and request DFS-ORP to verify the Medicaid amounts paid per month.

(h) FO-DFS shall process the overpayments on all program cases whether the benefit programs are in open or closed status in the field office caseload including those cases which have been transferred (CARC'ed) in from another field office.

(i) FO-DFS will refer cases to DFS-ORP when information obtained reveals that a need for investigation/claim establishment may be appropriate.

(j) FO-DFS shall refer to the verification section of program manuals to determine acceptable evidence and review the procedures for evaluating the evidence.

(k) FO-DFS shall accept written evidence from or verbal contact with a knowledgeable source and record or place a copy of the evidence in the case file.

(l) FO-DFS shall send the Possible Overpayment Notice to the assistance unit or provider when appropriate.

(m) FO-DFS shall request income verification from each employer and/or resource verification from each financial institution.

(n) FO-DFS shall conduct a follow-up on the original request(s) when there has been no response from mailing an Income Verification Follow-up letter and send a copy of the original Income Verification or a second Resource Verification request to the income or resource source by certified-return receipt requested mail.

(o) FO-DFS shall refer the case by Cover Letter to DFS-ORP describing the sequence of events when all attempts fail to obtain cooperation from the employer or financial institution and FO-DFS shall include a copy of each certified return receipt.

(p) FO-DFS shall assist DFS-ORP when information is requested to petition the Wyoming State Auditor to subpoena wage and/or financial information.

(q) FO-DFS must record the evidence obtained during the verification process in the case file.

(r) FO-DFS shall determine the initial month of overpayment for both client and agency errors and go back as far as specified to recalculate the correct benefit(s), determine the overpayment amount(s), and when appropriate, await verification of the Medicaid overpayment amount.

(s) FO-DFS shall mail the appropriate notices of overpayment and assure the assistance unit and/or provider is notified of the right to a fair hearing.

(t) EPICS will mail billing notices for all programs on the system following the opening of a recoupment case when no payments are made or the first month in which a payment is not received following one or more months of payments.

(u) FO-DFS shall attach evidence to the ORP Case Information Document for documentary evidence errors (DE) of $750 or more to assist in prosecution.

049-1 Wyo. Code R. § 1-3