Measuring Improper Authorizations for Payment in the Child Care Program:
Improper Authorization for Payment Data Collection Instructions [Approved August 31, 2007]
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VI. CONDUCTING CASE RECORD REVIEWS
The case record review is considered a quality control function and is not to be carried out by persons making or approving the eligibility determinations. Eligibility and review staff may be employed by the same agency, but reviewers may not have made or approved eligibility determinations during the review period or be under supervision of persons responsible for eligibility determinations. Staff selected to complete the review must be knowledgeable of their State’s child care policies. The integrity of the review findings requires that all reviewers have a shared view of what constitutes an error for all elements of the review.
Using their chosen coordination strategy, States provide training and instruction to reviewers sufficient that States can certify that the review process is consistent with their policies and there is consistent interpretation of what is an error. To accomplish this inter-reviewer reliability States may choose to:
- Discuss, as a group, the initial case reviews and their findings; and/or
- Conduct several “second level” re-reviews to assure inter-reviewer consistency.
States decide the location where cases are reviewed. Using the customized Record Review Worksheet as a guide, States conduct desk record reviews of the random sample of 22 or 23 cases that were authorized to receive a child care payment during one of the sample review months. For States that have electronic case records, the desk review may be a review of the electronic record and must include any additional documentation State policy indicates must be viewable as part of the case record, such as pay stubs or work schedule. If a case cannot be reviewed for some valid reason, the cases in the replacement sample (3, or more, at State discretion) are used in the order in which they were selected.
General Instructions
Reviewers use the customized Record Review Worksheet to record analysis of the case record and findings. This documentation provides the verification that substantiates the eligibility determination and the amount authorized for payment for the sample review month. Regarding eligibility status, reviewers examine the most recent eligibility determination in effect for the sample review month - either the initial determination or a redetermination and any subsequently reported changes (e.g., income, or status) that might impact eligibility.
To properly review cases, reviewers must identify and examine the documentation within the case records that was used to determine eligibility for a sample review month and calculate payments authorized for that month. This documentation may be permanent portions of the case record (copies of pay stubs, school schedules, birth certificates, etc.) or information specific to the eligibility period which covers the sample month (policy in effect for that month). The review also includes access or inquiry of any relevant screens or files within a State’s automated system, as appropriate and necessary. The review does not include independent verification of eligibility and data elements found in the case record.
Review Identification Information
Reviewers complete identifying information for each review in the first line of the Record Review Worksheet. This information includes: the unique Child ID #, State and County names, the Sample Month/Year and the Review Date (the date the case record is reviewed).
Columns 1: Elements of Eligibility and Payment Authorization and Column 2: Analysis of Case Record
Column 1: Elements of Eligibility and Payment Authorization includes for reviewers what forms, documents and information will assist them in identifying or assessing the accuracy of the specific element of eligibility.
Column 2: Analysis of Case Record is where reviewers summarize any pertinent facts, questions, or conflicts in information found in the case record documentation.
The following identifies each of the elements in Column 1 and the kinds of information that needs to be reviewed. Instructions follow about what companion facts, questions, or conflicts in information to insert in Column 2.
Section I. State Child Care Program Forms
- Element 100 Application/Re-determination Forms—Determine presence, date, and completeness of required eligibility forms. Examples include (1) signed and dated CCDF application form, (2) child care agreement, (3) voucher or certificate, and (4) provider invoice. Specify conditions of dollar error, including (1) form expired, (2) no application form, and (3) no documentation of income and work hours.
Column 1 - Reviewers identify all required child care subsidy eligibility-related forms in their State. If they are not listed in the customized worksheet, look for them in the case record.
Column 2 - Reviewers check to make sure these forms are current and completely filled out, including required signatures. Reviewers then record facts, questions, or conflicts in information.
Section II. Priority Group Placement
- Element 200 Priority Group Placement — Determine if client meets criteria of any State-designated priority groups, e.g., (1) teen parent in high school, (2) TANF recipients in eligible work activities, (3) working parents with very low incomes, and/or (4) foster parents.
Column 1 - Reviewers verify if States have designated priority group(s).
Column 2 - Reviewers look for and record evidence that the case involves a priority group. Reviewers code this element "NA" if there are no State-designated priority groups.
Section III. General Program Requirements
- Element 300 Qualifying Head of Household— Determine if client meets parent definition (parent means a parent by blood, marriage or adoption and also means a legal guardian, or other person standing in loco parentis), e.g., (1) parent, (2) step-parent, (3) legal guardian, (4) needy caretaker relative, or (5) spouse of same.
Column 1 - Reviewers consult the list in the customized worksheet or refer directly to State policy for requirements for a qualifying head of household.
Column 2 - Reviewers check the application form and supplementary documentation to determine if the necessary requirements are met.
- Element 310 Residency — Determine if client is a resident of the State and for what duration, if client is a resident of the county and for what duration, and whether there is an agreement regarding eligibility among counties.
Column 1: Reviewers examine the case record for the residency documentation required by the State, either customized in the worksheet or found in State policy.
Column 2 - Reviewers compare State residency requirements with case record documentation.
- Element 320 Parental Work/Training Status— To receive services a child's parent or parents must be working or attending a job training or educational program, or have a child receiving or needing to receive protectiveservices.
Column 1 - Reviewers identify State policy requirements for parental activity status, if not already on customized worksheet, and look for corresponding information in the case record.
Column 2 - Reviewers compare State requirements with case record documentation to find out if the child's eligibility determination was appropriate based on the child's protective services status or the job/training/educational activity of the parent(s).
- Element 330 Qualifying Child— Determine if child is eligible for services, including (1) younger than 13 years, (2) younger than 19 years and physically or mentally incapable of caring for himself or herself, or under court supervision, or (3) meets other eligibility requirements defined in the State Plan. Determine if a child is a citizen, as defined by Federal policy.
Column 1 - Reviewers identify State policy requirements for child eligibility status, if not already on customized worksheet, and look for corresponding information about the child in the case record.
Column 2 - Reviewers compare information in the case record with State policy to find out if the child's eligibility determination was appropriate to the child's age, physical or mental needs, and/or other child criteria in State policy.
- Element 340 Qualifying Care— Determine number of hours needing authorization during review period, based on parental work/training status or child's protective services status. Determine hours and type of care authorized.
Column 1 - Reviewers refer to documentation of child protective services status or parent job/training/educational activity.
Column 2: Reviewers compare the hours authorized for services, as recorded in the case record, with the documentation of child protective services status or parent job/training/educational activity.
- Element 350 Qualifying Provider Arrangement— Determine if services are provided by a center-based child care provider, a group home child care provider, a family child care provider, or an in-home child care provider that is legally operating and eligible to receive child care subsidies.
Column 1 - Reviewers check State policy for allowable provider categories and look for documentation of provider category in the case record.
Column 2 - Reviewers check provider information in the case record to verify that the provider is from an allowable provider category.
- Element 360 Provider Requirements— Determine if regulatory requirements are met. Regulatory requirements are requirements necessary for a provider to legally provide child care services in a State or locality, including registration requirements established under State, local or tribal law.
Column 1 - Reviewers check State policy for allowable legal provider status and look for documentation of provider category in the case record.
Column 2 - Reviewers check provider information in the case record to see if there is a license, registration document, or other documentation showing legal provider status.
Section IV. Income and Authorizations
- Element 400 Income— Describe income documentation verification for household members. Specify time period (e.g., based on 4 weeks prior to application) and all income to be considered based on State policies and definitions (e.g., head of household employment).
Column 1 - Look for income verification for household members. Income categories may be customized on the worksheet and may include such income as head of household employment income; spouse employment income; any changes in income reported; income during job training for parent/caregiver; child support, if included as part of income; Food Stamps, if included as part of income; and loss of income during eligibility period.
Column 2 - Reviewers review and describe how household income, both earned and unearned, was verified and computed. This includes reviewing the income documentation information in the case record used for verification, reviewing compliance with State income verification policy, such as the treatment of disregarded income, and checking the computations for accuracy.
- Element 410 Income Eligibility—Determine if household income meets State requirements (e.g., family gross income must be within X percent of State's median income).
Column 1 - Reviewers identify the State income requirements from State policy, if not included in the customized worksheet.
Column 2 - Compare the State income requirements with income data found in Element 400.
- Element 420 Payment Amount Authorized— Determine the amount of subsidy payment authorized for a sample review month. Determine if the amount authorized was based on income and family size, the State's payment rate schedule, and any sliding fee schedule, if applicable.
Column 1 - Reviewers locate in the case record the amount of subsidy authorized for the sample review month.
Column 2 - Reviewers determine if the amount authorized was based on income (Element 400) and State income requirements (Element 410).
- Element 430 Authorization/Computations— Compute the difference between the amount authorized to be paid in a sample review month and the amount that should have been authorized. This difference is the error amount. Indicate if the error amount is an Overauthorization or Underauthorization. This is the method for calculating the error amount in all cases, including those with multiple errors. In cases without errors, this element is not applicable.
Column 1 - There is no separate action required for Column 1.
Column 2 - Reviewers compute the difference, if any, between the amount authorized for payment in the sample review month and the amount that should have been authorized and record any difference, if any. If there are no errors, record as "NA." The review is limited to authorization for payment, regardless of what additional payment information might be part of the case file.
Reviewers summarize the findings of the analysis from Column 2 for each element. If an error is cited, include a detailed description of the cause(s) of the error(s). The description includes whether the error(s) resulted in an authorized Overauthorization or Underauthorization and the amount of the Overauthorization or Underauthorization.
When a reviewer discovers more than one authorization error, the reviewer documents the specific effects of each and selects the error with the largest dollar value to code as the type of improper authorization.
This section also includes summaries of any error(s) that did not result in a dollar amount found in the element.
Based upon the Column 3 summary, the reviewer completes the coding in Column 4 for each Element in each Section of the Record Review Worksheet. Column 4 lists the following codes to summarize the review findings:
- Error –Enter the correct code according to the following key: “0” = no error, “1” = error;
- Reason for error – Enter “Y” if the error is due to missing or insufficient documentation, “N” if the error is not due to missing or insufficient documentation, and "NA" if there is no error;
- Type of improper authorization(s) during sample review month – Enter “U” for Underauthorization, “O” for Overauthorization and "NA" if there is no improper authorization. (For cases with both error types the type of the error responsible for the larger dollar amount is coded.); and
- Total Amount of Improper Authorization – Enter the dollar amount of the error. This is the difference between the authorized payment amount and the amount reviewers found, during the review, that should have been authorized.
The following sample case review examples illustrate how to record analysis and summarize the findings of the case record review across the Columns of the Record Review Worksheet.
Review Identification Information
The reviewer completes identifying information for each review in the first line of the Record Review Worksheet. This information includes: the unique Child ID #, State and County names, the Sample Month/Year and the Date of the Review (the date the case record is reviewed).
Column 1: Elements of Eligibilityand Payment Authorization
Reviewers consider and locate each of the elements specified in Column 1, including any forms, documents and information that can assist the reviewer in identifying or assessing the accuracy of the specific element of eligibility.
Column 2: Analysis of Case Record
Reviewers complete Column 2 at the point in time the record is reviewed. Reviewers summarize any pertinent facts, questions, or conflicts in information found in the case record documentation and the actions taken by the case worker as they relate to the requirements stipulated in Column 1.
While it is not required, States may choose to ask reviewers to include photocopies of specific documentation of an authorization error to support the Column 2 analysis. Additional documentation helps to support and clarify the reviewer’s Column 2 and Column 3 summaries.
The following example illustrates a Column 2 summary of the results of a case record analysis using the Record Review Worksheet Template.
Example of a Column 2 Summary of a Case Record Analysis |
|
| ELEMENTS OF ELIGIBILITY & PAYMENT AUTHORIZATION (1) |
ANALYSIS OF CASE RECORD (2) |
| 310 RESIDENCY | Copies of the customer’s driver’s license and rental agreement were in the case record. |
| Determine if client is a resident of the State and for what duration, if client is a resident of the county and for what duration, and whether there is an agreement regarding eligibility among counties. | |
Column 3: Findings
Column 3 summarizes the findings of the review for the specific Column 1 element. If an error is cited, reviewers include a detailed description of the cause(s) of the error(s). The description includes whether the error(s) resulted in an Overauthorization or Underauthorization and the amount of the Overauthorization or Underauthorization. This section also includes summaries of any error(s) reviewers found in any element that did not result in a dollar error. When a reviewer discovers more than one authorization error, the reviewer documents the specific effects of each and selects the error with the largest dollar value to code as the type of improper authorization in Column 4, with “U” for Underauthorization, “O” for Overauthorization, and "NA" for no improper authorization. In the event of both an Overauthorization and Underauthorization, the net difference is also recorded in Column 3 and is entered in Column 4, #4.
The following example illustrates a Column 2 summary and the Column 3 findings of an authorization error.
Example of Column 2 Summary and Column 3 Finding |
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| ELEMENTS OF ELIGIBILITY & PAYMENT AUTHORIZATION (1) |
ANALYSIS OF CASE RECORD (2) | FINDINGS (3) |
| 310 RESIDENCY | Copies of the customer’s drivers license and rental agreement were in the case record. | The customer’s driver’s license and rental agreement list an address that is an adjoining state. The worker failed to apply the policy correctly causing an Overauthorization/Ineligibility of $256. |
| Determine if client is a resident of the State and for what duration, if client is a resident of the county and for what duration, and whether there is an agreement regarding eligibility among counties. | ||
The following examples provide additional guidance for several common case scenarios illustrating Column 3 error summaries.
Example #1 — One Underauthorization Error
Findings—The child's parent provided her two most recent bi-weekly pay stubs at application. The caseworker converted the income as if it was weekly income. This error caused the income to be overstated by $300 monthly and resulted in a monthly authorization of $50 less than should have been authorized.
Example #2 — Two Overauthorization Errors
Findings—The child's parent provided her two most recent bi-weekly pay stubs at recertification. The caseworker used the net income figure rather than the gross figure. This caused a $20 Overauthorization in the monthly subsidy. On the application the parent had listed $300 monthly in child support. This was the amount used by the worker. The case record did not contain any verification of this income. Using the required child support screens, the reviewer verified that the customer actually received child support of $400 monthly. The child support income caused a monthly authorization of $60 more than should have been authorization. The two errors amount to an Overauthorization of $80 coded in Column 4.
Example #3 — Two Underauthorization Errors
Findings—The child's parent provided all required information about her self-employment income and business costs. The caseworker miscalculated the parent’s gross income, resulting in an overstatement of monthly earnings by $100. This resulted in an Underauthorization of $15. The worker also failed to include a business cost that was documented in the case record. The inclusion of the business cost lowered the client’s income further resulting in an additional $10 Underauthorization. The two errors amount to a $25 Underauthorization. This amount is the figure used for the total amount of the authorization in Element 430 Column 4.
Example #4 — One Error - Improper Authorization
Findings—The payment form in the record was signed by the worker but not by the supervisor. As this error has no dollar value, enter "1" for error, "Y" for error due to missing or insufficient documentation, "N/A" for no improper authorization.
Example #5 - Two Errors - One Overauthorization and One Underauthorization
Findings—The client provided all required information about her self - employment income and her business costs. The caseworker miscalculated the customer’s gross income and this resulted in it being overstated by $100 monthly. This would have resulted in an Underauthorization of $15. However, the worker also included a business cost that is not allowed under state policy. The net difference of the two errors, a $5 Underauthorization, is the amount recorded in the total amount of the improper authorization in Column 4 in the Record Review Worksheet
Column 4: Results
Based upon the Column 3 summary, the reviewer completes the coding in Column 4 for each Element in each Section of the Record Review Worksheet. Column 4 lists the following codes to summarize the review findings:1. Error –Enter the correct code according to the following key: “0” = no error, “1” = error;
2. Reason for error – Enter “Y” if the error is due to missing or insufficient documentation, “N” if the error is not due to missing or insufficient documentation, and "NA" if there is no error;
3. Type of improper authorization(s) during sample review month – Enter “U” for Underauthorization, “O” for Overauthorization and "NA" if there is no improper authorization. (For cases with both error types the type of the error responsible for the larger dollar amount is coded.); and
4. Total Amount of Improper Authorizations for Payment– Enter the dollar amount of the error. This is the difference between the authorization amount and the amount reviewers found, during the review, that should have been authorized.
Example of Column 2 Summary, Column 3 Findings and the Column 4 Results
Using the Record Review WorksheetELEMENTS OF ELIGIBILITY & PAYMENT AUTHORIZATION (1)
ANALYSIS OF CASE RECORD (2) FINDINGS (3) RESULTS (4) 310 RESIDENCY Copies of the customer’s driver’s license and rental agreement were in the case record. The customer’s driver’s license and rental agreement list an address that is in an adjoining state. The worker failed to apply the policy correctly causing an Overauthorization of $256 for the monthly subsidy. 310 RESULTS Determine if client is a resident of the State and for what duration, if client is a resident of the county and for what duration, and whether there is an agreement regarding eligibility among counties. 1. 1 No Error
Error2. N Insufficient/
Missing Documentation3. O Underauthorization
Overauthorization4. $256 Total Amount ofImproper Authorization for Payment
Example of Column 2 Summary, Column 3 Findings and the Column 4 Results |
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| ELEMENTS OF ELIGIBILITY & PAYMENT AUTHORIZATION (1) |
ANALYSIS OF CASE RECORD (2) | FINDINGS (3) | RESULTS (4) | |
| 400 INCOME | The client provided her two most recent bi-weekly pay stubs at recertification. Monthly income amount used in subsidy calculation was $400. The customer listed $300 as monthly child support income. |
The client provided her two most recent bi-weekly pay stubs at recertification. The caseworker used the net income figure rather than the gross figure. This caused a $20 Overauthorization for the monthly subsidy. On the application the client had listed $300 monthly in child support. This was the amount used by the worker. The case record did not contain any verification of this income. Using the required child support screens the reviewer verified that the customer actually received child support of $400 monthly. The child support income caused a $60 Overauthorization for the monthly subsidy. The two error amounts combined result in an $80 Overauthorization for the month. | 400 INCOME | |
| Describe income documentation verification for household members. Specify time period (e.g., based on four weeks prior to application) and all income to be considered based on State policies and definitions (e.g., head of household employment). | 1. 1 | No Error Error |
||
| 2. Y | Insufficient/ Missing Documentation | |||
| 3. O | Underpay-ment Overpayment | |||
| 4. $80 | Total Amount ofImproper Authorizations for Payment | |||
VII. COMPLETING THE DATA ENTRY FORM: >>