ARTICLE 4

 

                                                              SECTION 8

                                                                                          

                        RESOLUTION OF INCONSISTENT AND CONFLICTING INFORMATION

 

1.        GENERAL

 

This section provides instructions and procedures for resolving inconsistent or conflicting information.

 

 

2.        DEFINITIONS

 

A.       Inconsistent Information

 

Information provided by an applicant/beneficiary, or otherwise reported to or discovered by the ET, which appears to be incompatible with the applicant/beneficiary’s financial or other circumstances should be considered inconsistent.

 

EXAMPLES:

 

1)       Applicant declares employment as a pizza delivery driver but declares no tip income.

 

2)      Applicant is employed full-time, has two preschool children, and declares no childcare costs.

 

 

 

 MEM

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B.       Conflicting Information

 

Information provided by an applicant/beneficiary or received by the ET from another source, which disagrees with other information known to the ET or declared by the applicant/beneficiary, is to be considered conflicting information.

 

EXAMPLES:

 

1)       Applicant/beneficiary reports that he/she started a new job the prior week and that the first paycheck will be received next Thursday. When the pay stub is provided, it reflects a year-to-date total earnings which conflict with the reported start date of employment.

 

2)       Applicant declares no bank accounts and no transfer of property within the past two years. IEVS Applicant FTB abstract shows $400.00 interest on a bank account for the prior year.

 

 

 

 

 

3.        ET RESPONSIBILITY

 

Prior to granting action, the ET must review all available eligibility/share of cost information for consistency. Inconsistent or conflicting information discovered during the intake process, or at any time a change is reported, must be discussed with the applicant/beneficiary.

 

If the inconsistency remains unresolved, and specific instructions for resolution are not described in this section, refer to MPG Article 16, Section 1 for possible fraud prevention referrals.

 

 

4.        APPLICANT/BENEFICIARY RESPONSIBILITY

 

Applicants/beneficiaries are required to cooperate with the ET in resolving incomplete, unclear or inconsistent information, within their abilities.

 

 

5.        EXPENSES EXCEED INCOME/RESOURCES

 

The most common inconsistent information received by ETs concerns the applicant’s ability to meet his/her living expenses. This occurs when resources and income reported are not sufficient to meet basic living expenses.

 

 

A.       Intake

 

If, during the intake interview, the applicant cannot provide an explanation as to how living expenses will be met, the ET will approve the application if otherwise eligible, and request an explanation via automated letter 976.

 

If the applicant fails to provide the specific information requested by the due date, the ET will discontinue the case for failure to provide essential information.

 

 


B.       Continuing Cases

 

When information reported by a beneficiary results in the beneficiary’s apparent inability to meet basic living expenses according to reported income and resources, the ET will send automated letter 940 to give the beneficiary an opportunity to explain how living expenses will be met. If the beneficiary fails to provide the information requested, by the date it is due, the ET will discontinue the case with timely notice.

 

 

C.       General Relief Recipients

 

The discontinuance of a Medi-Cal beneficiary’s GR case is not, in itself, sufficient reason to discontinue the Medi-Cal case. If the GR case is discontinued, the ET will ask if the beneficiary wishes his/her Medi-Cal benefits to continue. If the beneficiary wishes to continue the Medi-Cal benefits, the ET will request an explanation as to how the client will continue to meet basic living expenses.

 

 

 

D.       Reasonable Explanations

 

When evaluating the client's explanation as to how living expenses will be met, the following are examples of reasonable explanations:

 

1)      Intent to sell an item of property.

 

2)      Possession of an award letter for future benefits.

 

3)      Applicant does not intend to meet a specific obligation such as rent, utilities, etc.

 

4)      Plans to obtain loans for necessities.

 

 

6.        IEVS DATA CONFLICTS

 

IEVS match information which is “significantly different” from applicant/beneficiary reported information must be clarified.  Significantly different means that the difference between the applicant-supplied information and IEVS information could affect current or prior eligibility or share of cost determinations.  Procedures for resolving IEVS data, which conflicts with information reported by the applicant/beneficiary, are different depending on whether the IEVS data is received before or after the intake face-to-face interview.  Refer to Article 16, Section 1 for more information on IEVS.

 

 

A.       IEVS Data Received Before Face-to-Face Interview

 

1)      Discuss the discrepancy with the applicant at the intake interview.

 

2)      If possible, resolve the discrepancy through independent verification.

 

3)      The applicant is responsible for providing the necessary information.  However, if he/she is unable to obtain the requested information, the ET will assist the applicant in obtaining it.

 

4)      If neither the applicant nor the ET can get the information, the ET will accept a sworn statement from the client as verification.

 

5)      Note the resolution or lack of resolution on the abstract and file it under Other Verifications.

 

6)      Take the appropriate case action.

 

 


                NOTE:      The applicant must not be denied benefits on the basis of the IEVS Abstract data as long as he/she is cooperating in resolving discrepant information.

 

 

B.       IEVS Data Received After Face-to-Face Interview

 

1)      Make a narrative entry explaining what information is significantly different from current or prior applicant information.

 

2)      Notify the client in writing of the questionable information using:

 

·          16-20 DSS for wage and UI/DI information, and

 

·          16-18 DSS and 16-19 DSS for asset match information.

 

3)      Allow the client 10 days to respond.  A reasonable extension may be granted if the client requests additional time.  Should the applicant fail to respond, the case is to be denied for failure to cooperate.

 

4)      The applicant is responsible for providing the necessary information.  However, if he/she is unable to obtain it, the ET must assist in getting the requested information.

 

5)      If neither the applicant nor the ET can get the information, the ET will accept a sworn statement from the client as verification.

 

6)      Note the resolution or lack of resolution on the Abstract and file it under Other Verifications.

 

7)      Take the appropriate case action.

 

                NOTE:      The applicant must not be denied benefits on the basis of the IEVS Abstract data as long as he/she is cooperating in resolving discrepant information.

 

 

C.       If the discrepant information is identified after the case has been granted, the ET will:

 

1)      Follow the action steps outlined in 2) above.  The client's benefits will be continued pending resolution of the discrepancy.

 

 

D.       Abstracts for cases denied prior to the receipt of IEVS information for reasons unrelated to IEVS may be filed in the case under Other Verifications.  The ET will note “No Action - Unrelated Denial” on these abstracts.

 

 

E.       IEVS Abstract Shows Undisclosed Asset

 

When the discrepancy between the IEVS data and the applicant supplied information requires the classification of an undisclosed asset, the ET must determine if the applicant still has the resource.

 

 

1)      Applicant Still Has Resource

 

                        When the applicant still has the resource, the ET will evaluate:

 

a)        The availability of the resource to the applicant.

 

b)        The exempt/non-exempt status of the resource.

 

c)        The eligibility of the applicant when the resource is combined with other resources.

 

                        Refer to MPG Article 9 to determine what effect the resource has on eligibility.

 

                        Refer to MPG Article 10 to determine the effect of interest/dividend income on the share of cost.

 

2)      Applicant Does Not Have The Resource

 

                        When the applicant has disposed of the resource, the ET will evaluate the transfer of property.  The ET will determine if:

 

a)        The applicant was receiving Medi-Cal at the time of the transfer/disposition.

 

b)        The resource was available at the time of the transfer/disposition.

 

c)        The transfer/disposition of the resource was made for the sole purpose of becoming eligible for Medi-Cal.

 

d)        The resource would have caused ineligibility.

 

                        Refer to MPG Article 9 for instructions on evaluating the property transfer/disposition.

 

F.       Situations Requiring Evaluation

 

1)      If prior employment is shown and no current UI/DI benefits are being paid, the ET will question whether the applicant/beneficiary is currently employed.

 

2)      If IEVS shows prior employment or other income, the ET will determine whether the applicant/beneficiary received Medi-Cal benefits during the period shown.  If so, the ET will determine whether the employment/income was reported.  If not, an overpayment may have occurred.  Refer to MPG Article 16, Section 2 for overpayment referral procedures.

 

3)      If AFDC-U linkage is an eligibility factor, the ET will check the wage match to see if the person identified as the Primary Wage Earner (PWE) appears to have the greater amount of earnings.  If not, the ET will ask the applicant/beneficiary to clarify.

 

 

 




7.        NEW FOOTER:  MPG LTR #303; 8/95PAYMENT VERIFICATION SYSTEM (PVS)

 

A.       General

 

The Payment Verification System is a monthly match that provides information on RSDI benefits, UIB, and DIB.  The PVS information is received as a computer printout.  The format of PVS reports, actual examples, and necessary actions regarding County response forms can be found in Article 16, Section 1.

 

B.       Use of PVS Information

 

1)      Benefits reported by PVS are considered verified unless questionable.

 

2)      Recipients will be given a timely notice of any reductions or terminations due to IEVS-PVS information.

 

3)      Workers will complete a County response form on all reductions or terminations.  See Article 16, Section 1.

 

C.       Required Action

 

PVS reports will be compared to information reported by the recipient.  The worker should review the person information in the report to ensure that the information supplied pertains to the recipient.  If it does not, please refer to Article 4, Section 8 or Article 16, Section 1.

 

If the PVS information agrees with the information in the case record, the worker will complete the County Use Only section of the PVS report and file the report with the IEVS report.

 

D.       Significantly Different Information

 

Any information that is "significantly different" from recipient supplied information must be clarified. "Significantly different" means that the difference could impact current or prior eligibility or benefit levels.

 

When information contained on the PVS report is determined to be significantly different from recipient supplied information, the worker will take the following actions:

 


1)      Narrate why the information is questionable.

 

2)      Notify the recipient using Form 16-20 DSS of the questionable information.

 

3)      Allow the recipient 10 days to respond.

 

4)      If the recipient fails to respond or is unable to provide the necessary information, the following actions will be taken:

 

a)        The worker will contact the benefit source (SSA or EDD).

 

b)        The client’s benefits will be continued pending verification.

 

c)        Information received from EDD SSA will then be used in the eligibility/benefit determination.

 

 

E.       Recipient Disputes PVS Information

 

If the recipient claims that the PVS report is inaccurate, the worker will take the following steps:

 

3)      Check the person’s information to ensure that the report is for the recipient.

 

4)      Give the client an ABCD 351 to take to EDD or an 07-94 for SSA.

 

5)      Rescind the action, pending notification from SSA or EDD if the discrepancy cannot be resolved before the date of the adverse action.

 

 

8.        INCONSISTENT ALIEN BIRTHDATES

 

A.       In cases where age is not a factor of eligibility and an alien presents both INS and SSA documents, which show two different birthdates, counties are to use the data of birth, recorded on SSA documents. The worker should inform alien applicants/beneficiaries to reconcile the birthdate discrepancies with INS and SSA.

 

B.       If age is an alien’s only linkage with Medi-Cal, the eligibility worker should inform the applicant that he/she must clear up the birthdate inconsistency with the appropriate agency or the application will be denied.