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Library: Policy

340:2-23-19. Quality control review process

Issued 4-1-98

(a) Case Selection. The QC process begins when a case is selected from the random sample for review and ends when that case finding and data are entered into the IQCS, transmitted, subjected to federal sub-sampling, and federally accepted. • 1

(b) Client contacts. Client contacts are described in this subsection.

  • (1) Initial contact. Except in the Medicaid program, clients are notified in writing they have been selected for a QC review. At the initial face-to-face visit, the ARU reviewer seeks to validate the information provided to the Department at the time of application or recertification.
  • (2) Obtaining information from clients. Any missing or conflicting information between the record and the interview is researched by the ARU reviewer and required to be resolved. The client may be asked to provide written documentation to clarify areas of concern.

(c) Collateral contacts. ARU reviewers seek collateral references to substantiate client or case record information.

  • (1) Role of collateral contacts in the QC review process. The client may be asked to sign a release of information so phone, face-to-face, or written contact can be made with affiliated persons or businesses. Collateral contacts for QC reviews include, but are not limited to: landlords, utility companies, employers, neighbors, banks, schools, post offices, local businesses, and medical vendors. These sources of collateral contacts are asked to validate information regarding the client and may be asked to assist in locating the household if an ARU reviewer is unable to do so.
  • (2) Authority to pursue collateral contacts. If a household refuses to provide collateral contacts or sign a release of information for collateral contacts, the ARU reviewer has the authority, in accordance with Medicaid, and Food Stamp federal policies and TANF and Day Care state policies, to contact any collaterals necessary to verify the correctness of statements made on the application forms for assistance. Application forms denote the Department representative's authority to contact collateral sources necessary to verify the correctness of client statements made at application.

(d) Quality control review findings. The ARU reviewer records all verification obtained on the sampled person or household in the QC file. The ARU reviewer makes a preliminary finding on the case as to the accuracy of the eligibility determination and payment and other information after thorough analysis of the information collected during the QC process.

  1. (a) Case assignment. ARU assigns the case to a reviewer based on program specialty and geography. Cases are assigned geographically to ARU reviewers in a manner to minimize costs to the Department.

    • (b) Obtaining county case records. The QC process requires extensive case record analysis. ARU requests the county case records, which include working, companion, and history when a case is selected in a monthly sample. The county locates the records and mails them to ARU, or places them in a holding drawer for the ARU reviewer to pick up upon arrival in the county to begin the QC review. The ARU reviewer conducts an extensive case analysis and schedules the case as prescribed by the federal requirements. Information from the record is entered by the ARU reviewer on federally approved QC forms. If a county staff person needs information from the official record while a QC review is in progress, ARU locates the record and provides the requested information.

    • (c) Case record security. ARU reviewers keep county case records locked in automobiles or outstationed sites at all times they are not in an office setting. ARU reviewers safeguard the QC file materials as well as county case records. ARU keeps case records the minimum time necessary to complete the QC review process. A system is used by ARU administrative support staff to account for the number of volumes received from the county and to assure the entire set of records is returned at the conclusion of the process.

    • (d) Departmental case consultation and reviews.

      • (1) Consultation and ARU supervisory reviews. Supervisory consultation occurs on most cases prior to the ARU reviewer making a preliminary finding. An ARU reviewer submits the QC file, with supporting documentation and the county case records, to the ARU supervisory staff for an official second party review. All cases receive a second party review although the intensity may vary on a case-by-case basis. An ARU programs supervisor consults with the ARU administrator on cases where information indicates an error is likely, and on cases with situations requiring policy interpretation. Further consultation may occur with FSSD policy staff or Federal QC policy staff regarding complex cases.

      • (2) Review by FSSD and OFO. For the Food Stamp and Medicaid programs, ARU provides FSSD quality assurance staff with the QC file and accompanying county records on all cases found to contain an error. FSSD may keep the case up to ten days to seek additional information and to consult with pertinent parties. The local agency office involved is also provided a copy of the error information and has the opportunity to disagree and/or provide additional information, within five days, to FSSD. For the TANF and Day Care programs, ARU provides a copy of any discrepant case information to both the local agency office and FSSD to be used in the quality assurance process.

    • (e) Final decision-making.

      • (1) Findings reached by consensus. For the Food Stamp and Medicaid programs, based on the results of consultation and negotiation, a decision is made as to a finding on each case. If all Department parties reach consensus, ARU codes and enters the official findings in the NIQCS. For a specified time, the finding can be changed in the NIQCS if additional information on the case becomes available. But, once a case finding is subjected to subsampling by the federal agencies, the finding entered into the NIQCS is locked in, and no further changes are permitted.

      • (2) Findings decided by panel. For the Food Stamp and Medicaid Programs, if FSSD, OFO, and ARU cannot reach consensus, a three-person panel, named by the Director, makes the final decision as to the proper case finding. Following the final ruling, the results are entered in the NIQCS.

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