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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OMB Control No. 0970-0323
Expiration date: 08/31/2010
ATTACHMENT 3
STATE IMPROPER AUTHORIZATIONS FOR PAYMENT REPORT AND INSTRUCTIONS (ACF-402)
PART I. PROGRAM ASSURANCES AND CERTIFICATIONS
The Lead Agency, named below, assures and certifies that:
- The data collection process, including sample selection and case record reviews, adhered to all requirements of the " Measuring Improper Authorizations for Payment in the Child Care and Development Fund (CCDF) Program" instructions and regulations at 45 CFR 98 Subpart K;
- The reviews were not conducted by persons who make or approve the eligibility determinations;
- All reviewers have been trained to ensure that the review process is consistent with State policies and that there is consistency within the State in interpretation of what is an error;
- The State agrees to retain Record Review Worksheets, Data Entry Forms, the State Improper Authorizations for Payment Report and any revisions, and any other records pertinent to the case reviews and submission of error rate reports for five years from the date of submission of the State Improper Authorizations for Payment Report or final revision submitted, whichever date is later; and
- The State understands that this information, including the sampled case records and calculations are subject to Federal review.
| Submission Date: | |
| Name: | |
| Signature: | |
| Title: | |
| State: | |
| State Agency: | |
| Phone Number: | |
| E-mail: | |
| Fiscal Year: |
PART II. ERROR MEASURES REPORTING
Improper Authorization for Payment Reporting |
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| Item # | ||
|---|---|---|
| 1. | Number of cases sampled | |
| 2. | Total amount of authorizations for sampled cases in the review period. | $ |
| 3. | Total number of sampled cases with improper authorizations for payment | |
| 4. | Total amount of improper authorizations for payment for the review period (gross amount of underpayment and overpayment authorizations) | $ |
| 4A. | Total amount of improper underpayment authorizations for payment for the review period | $ |
| 4B. | Total amount of improper overpayment authorizations for payment for the review period | $ |
| 5. | Total number of improper authorizations for payment due to missing or insufficient documentation | |
| 6. | Percentage of cases with an error | |
| 7. | Percentage of cases with an improper authorization for payment | |
| 8. | Percentage of improper authorizations for payment (for the review period) | |
| 9. | Average amount of improper authorization for payment | $ |
| 10. | Estimated annual amount of improper authorizations for payment | $ |
| 10A. | Check the appropriate response. 1. _____ Review not based on a sample drawn from pooled funds. 2. _____ Review based on a sample drawn from pooled funds and State has applied the pooling factor found on the most recent ACF-800 reporting form. 3. _____ Pooling factor from the most recent ACF-800 reporting Form, if applicable. |
|
| 10B. | If the State checks #1 or #2 in 10A, skip 10B and proceed to #11. 1. _____ Pooling factor different from that found on the most recent ACF-800 reporting form. 2. Explain the derivation of this pooling factor. ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ |
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11. States indicate the number of replacement cases used each month of the 12 month review period and reason for each replacement. If there are more than three replacement cases in a single month, and there are more than three reasons, the State places an asterisk after the name of the month and includes the additional information below the table.
| Month | Reason(s) for Replacement Cases (please list) |
# Times Reason Used |
|---|---|---|
| October | ||
| November | ||
| December | ||
| January | ||
| February | ||
| March | ||
| April | ||
| May | ||
| June | ||
| July | ||
| August | ||
| September | ||