Employees’ Manual

Revised October 16, 2009 Title 5

Chapter D

QUALITY CONTROL

Iowa
Department
of
Human Services
Title 5: Centrally Administered Programs Table of Contents
Chapter D: Quality Control
Revised October 16, 2009 Page 1

Page

Overview ........................................................................................................ 1

Integrity of the Quality Control Review ........................................................... 2

Case Record Review ........................................................................................ 4

Case Sample .............................................................................................. 4
Requesting Case Records From Local Offices ................................................... 5
Date of Review ........................................................................................... 6

Quality Control Case Review Process .............................................................. 6

Client Contact ............................................................................................ 7
Collateral Contacts ...................................................................................... 8
Client Refusal to Cooperate in Review ............................................................ 9
Error Review Committee .............................................................................. 9
Steps 1 and 2 of the Error Resolution Process ................................................ 11
Step 3 of the Error Resolution Process .......................................................... 12
Step 4 of the Error Resolution Process .......................................................... 12

Report of Quality Control Review .................................................................. 13

Federal Quality Control ................................................................................. 13

Record Retention .......................................................................................... 13

Iowa Department of Human Services Employees’ Manual

Title 5: Centrally Administered Programs Page 1
Chapter D: Quality Control Overview
Revised October 16, 2009

Overview

This chapter relates to the federal quality control mandates for:

♦ Medicaid (payment error rate measurement (PERM)),

♦ Medicaid Eligibility Quality Control (MEQC),
♦ Child Care Assistance,
♦ Healthy and Well Kids in Iowa (hawk-i), and
♦ Food Assistance program.

Quality control may conduct state-initiated reviews of other programs or targeted

areas.

The purpose of quality control is to:

♦ Provide a systematic method for monitoring Iowa’s administration of the Food

Assistance, Child Care Assistance, hawk-i, and Medicaid programs.

♦ Provide a means for state accountability for actions of the local offices and the
determination of eligibility for money payment and other services.

♦ Serve as a basis for establishing state agency:

• Liability for errors that exceed the national average, and
• Eligibility for enhanced funding.

The Department uses information gained through quality control reviews to develop
corrective action plans to:

♦ Ensure that programs are implemented according to state and federal rules and
regulations.

♦ Prevent errors from recurring through activities such as modification of policies,

structures, or procedures.

Policies and procedures found in this chapter are based on the Code of Federal
Regulations, which mandates the establishment of quality control systems. The
authorities are for:

♦ Medicaid: Title 42, Part 431, Subpart P (sections 431.800 through 431.804).
♦ Child Care Assistance: 45 CFR 98 Subpart K
♦ Food Assistance: Title 7, Part 275, Subpart C (sections 275.10 through 275.14).

Iowa Department of Human Services Employees’ Manual

Title 5: Centrally Administered Programs Page 2
Chapter D: Quality Control Overview
Revised October 16, 2009

Iowa Code Sections 239B.2(7), 234.12, 249A.4, and 441 Iowa Administrative Code
Chapter 13 are the legal basis for quality control. Quality control operates under
policies and procedures found in the:

♦ State Medicaid manual, Part 7.

♦ Quality control manual of negative case actions in the adult and medical programs.
♦ Supplemental Nutrition Assistance Program Quality Control Sampling Handbook,
FNS 311.

♦ Supplemental Nutrition Assistance Program Quality Control Review Handbook, FNS

310.

Integrity of the Quality Control Review

Legal reference: Section 154, Quality Control 310 Handbook, Federal Quality Control
Policy Memo 05-01

Policy:
State quality control’s goal is to continue to improve program accuracy. The objective
nature of the quality control process must not be compromised in attempts to achieve
this goal. To maintain the integrity of the quality control system, the state is required
to apply consistent, unbiased standards for sampling and reviewing cases.

To ensure that the state quality control sample and reviews remain free from
unacceptable bias, the state and local offices are prohibited from treating:

♦ Sampled cases differently from non-sampled cases, or

♦ One sampled case differently from another quality control sampled case.

If bias occurs, the results of the review will not mirror the state’s overall level of
accuracy. Whether inappropriate actions are intentional or unintentional, it is a form of
bias.

Iowa Department of Human Services Employees’ Manual

Title 5: Centrally Administered Programs Page 3
Chapter D: Quality Control Integrity of the Quality Control Review
Revised October 16, 2009

The following types of actions are examples of inappropriate activities, which, if

conducted, will produce an unacceptable bias in the quality control system. Once a
case has been pulled for a quality control review, the local office may not do any of the
following:

♦ Add or remove documentation from the case record.

♦ Make changes to the record that would affect the eligibility or benefits for the case.
♦ Contact the household or a collateral contact before or during the review in order to:
• Make any changes to the case, or
• Persuade the household into saying or doing anything that might misrepresent
the household’s circumstances.

♦ Obtain additional information in an attempt to clarify the household’s circumstances

after the fact.

♦ Get statements that would alter the findings of the quality control reviewer.

A local office may ask the quality control reviewer to reexamine some aspect of the
case, but the reviewer makes the decision to do so based on quality control policies and
practices.

A quality control reviewer may not contact the worker responsible for administering the
case selected for quality control review. This also includes contacting any person who
participated in the action under review. An exception is made when the quality control
reviewer needs assistance from a local office to locate, or gain the cooperation of the
household.

Normal case management activities are allowed to continue on sampled cases. These
must not be initiated or undertaken at an accelerated pace in order to affect the review.
The local office will continue to conduct routine case management, such as:

♦ Filing household reports,

♦ Acting on reported changes,
♦ Issuing notices of expiration, or
♦ Conducting recertification interviews.

Iowa Department of Human Services Employees’ Manual

Title 5: Centrally Administered Programs Page 4
Chapter D: Quality Control Case Record Review
Revised October 16, 2009 Case Sample

Case Record Review

Legal reference: 441 IAC 13.2(234, 239B, 249A); 7 CFR 275.1(a), 272.1(c), 275.3(c),
and 275.10; 42 CFR 431.800(h); FCS HB 310(110) and (120); and
State Medicaid Manual, Part 7, 7206

Policy:
Quality control reviewers will review all pertinent case records within the Department to
determine if:

♦ The household provided complete, correct, and accurate information necessary for
eligibility determination.

♦ The local office correctly administered state policies in the eligibility determination.
♦ Program benefits for the month of review were correct.
♦ There is indication of fraudulent practice or abuse of the public assistance program
by either the client or the local office.

Case Sample
Legal reference: 441 IAC 13.3(234,239,249A); 13.5(1), 13.7(3), and
13.8(234,239,249A); 7 CFR 275.10(c)(1)(i) and 275.11; 42 CFR
431.800(d); FCS HB 310(160); State Medicaid Manual, Part 7,
7209, 7212 and 7350

Policy:
Each month the Division of Results-Based Accountability selects a random sample
of active and negative case actions for review.

“Active case” means any case that received assistance in the month of review.

“Negative case” means any case that was terminated or denied assistance for the
month of review.

“Random sample” means a systematic (or every nth unit) sample for which each
item in the universe has an equal probability of being selected. Sample size is
determined by federal guidelines.

Iowa Department of Human Services Employees’ Manual

Title 5: Centrally Administered Programs Page 5
Chapter D: Quality Control Case Record Review
Revised October 16, 2009 Case Sample

Procedure:
The sampling period is October through September. Quality control reviews the
following samples:

♦ Medicaid negative actions

♦ Medicaid active cases
♦ Food Assistance negative actions
♦ Food Assistance active cases
♦ Child Care Assistance active cases
♦ hawk-i program negative actions
♦ hawk-i program active cases

The Department may review any active or negative case to:

♦ Ensure compliance with federal and state rules and regulations.

♦ Detect error-prone areas to aid corrective action efforts.
♦ Ensure program integrity.
♦ Determine the state’s error rates.

The quality control process begins by selecting and distributing cases sampled for
review using the following steps:

1. The Bureau of Research and Statistics within the Division of Results Based
Accountability selects the cases using a statistically valid sample.

2. The sample cases are assigned to the state’s quality control supervisors,

3. The sample cases are sent to the state quality control reviewer.

4. The sample information is provided to Management Evaluation.

Requesting Case Records From Local Offices

Policy:
The quality control reviewer will request case records from the local office by
E-mail, phone, in writing, or in person.

The local office will send the case record to the quality control reviewer within two
working days of receiving the request.

Iowa Department of Human Services Employees’ Manual

Title 5: Centrally Administered Programs Page 6
Chapter D: Quality Control Case Record Review
Revised October 16, 2009 Requesting Case Records From Local Offices

Procedure:
If a case requested for review has a pending action, the local office will:

♦ Copy forms and information needed to complete the action.

♦ Send all original forms with the case record to the reviewer.
♦ Complete the pending action.

The quality control reviewer will:

♦ Read and return case records within two weeks from receipt, unless the local
office and the supervisor grant a longer period of time.

♦ Return a case record immediately if a local office asks for it.

Date of Review
Legal reference: 7 CFR 275.12(e); FCS HB 310(233) and (1330); AFDC/Medical
Negative Guides 3320(f)

Policy:
Quality control reviews a specific calendar month for program eligibility and
correctness of benefits.

Quality Control Case Review Process

Legal reference: 42 CFR 431.800(d); 7 CFR 275.12 and 275.13; 441 IAC 13.5(3); FCS
HB 310(212), Chapter 3 and (1340)-(1343); State Medicaid Manual,
Part 7, 7215 and 7248

Policy:
The review process is an examination of each eligibility factor that relates to
determining a household’s eligibility for the program under review.

The quality control reviewer will concentrate on information applicable to the case as of
the review date, including applications, worksheets, case recordings, correspondence,
etc., to become familiar with family situations and to note gaps or deficiencies in
information.

The quality control reviewer must independently establish and verify the facts about
each element of eligibility and benefit as of the date of review. See Date of Review.
Also, see Integrity of the Quality Control Review.

Iowa Department of Human Services Employees’ Manual

Title 5: Centrally Administered Programs Page 7
Chapter D: Quality Control Quality Control Case Review Process
Revised October 16, 2009 Client Contact

Procedure:
Quality control will review each active case for eligibility as follows:

♦ For Food Assistance cases, review the correctness of the eligibility determination
and the basis of issuance, and

♦ For Child Care Assistance, review the correctness of the authorization amounts,
♦ For Medicaid cases, review the correctness of the eligibility determination of the
client participation and premium amounts.

♦ A negative action review determines the correctness of termination or denial of

assistance and the timeliness of the notice of adverse action.

Quality control will conduct the review as follows:

♦ Examine documentation the local office used in determining program eligibility, and
any benefits the household received.

♦ Analyze the case record to ascertain that policies and procedures were followed.
♦ Gather factual information to confirm eligibility factors.

If an action taken is out of compliance with policies and procedures, the reviewer will
apply the correct policies or procedures to determine if a difference in the benefits the
client received exists, and what benefits the client should have received.

Comment:
See 5-D-Appendix for the various forms used in the processing of a quality control
review.

Client Contact
Legal reference: 441 IAC 13.5(3); 7 CFR 275.12(c)(1) and 275.13(b); 42 CFR
431.800; FCS HB 310(213) and (400)-(424.7); State Medicaid
Manual, Part 7, 7215B-2 and 7254

Policy:
Personal interviews:

♦ Are required on all active Food Assistance cases,

♦ May be required for Medicaid reviews, and
♦ Occasionally, may be required on a negative sample to substantiate an item in
the case record.

Iowa Department of Human Services Employees’ Manual

Title 5: Centrally Administered Programs Page 8
Chapter D: Quality Control Quality Control Review Process
Revised October 16, 2009 Client Contact

Procedure:
Conduct the interview at a location that is agreeable to the client.

Use form 470-1627, Notice of Interview, to notify the client:

♦ That the household’s case has been selected for a quality control review
interview, and

♦ Of the location, date, and time of the scheduled interview.

At the interview with the client or the household’s representative:

♦ Tell the household it and others were selected at random. And, the purpose is
to make sure households are getting the correct benefits.

♦ Establish identity, relationship, and living arrangements of all members of the

household.

♦ Discuss each element as applies to each household member,

♦ View the household’s verification, and
♦ Explore any changes in the household’s circumstances as they relate to factors
in the case record.

Collateral Contacts
Legal reference: 441 IAC 13.5(4); 7 CFR 275.12(c)(2) and 275.13; 42 CFR
431.800(d)(5); FCS HB 310(430)-(424.7B) and (1344); State
Medicaid Manual, Part 7, 7215B-3 and 7257

Policy:
A collateral contact is a source of information that can be used to verify a client’s
circumstances. Collateral contacts are required whenever:

♦ The client is unable to provide needed information, or

♦ More information must be obtained to establish the correctness of the case
under review.

Procedure:
Ask the client to:

♦ Help identify and select the best collateral contact for the information that is
needed.

♦ Consent to contacting collaterals by signing the appropriate release of

information form.

Iowa Department of Human Services Employees’ Manual

Title 5: Centrally Administered Programs Page 9
Chapter D: Quality Control Quality Control Review Process
Revised October 16, 2009 Client Refusal to Cooperate in Review

If the client refuses to cooperate with the quality control review attempt to
complete the review by contacting collateral sources.

Client Refusal to Cooperate in Review

Legal reference: 441 IAC 13.6(234, 239B, 249A); 7 CFR 273.2(d)(2) and
275.12(ii); 42 CFR 431.800

Policy:
Client’s are required to cooperate with a quality control review as a program
eligibility requirement.

Procedure:
Quality control makes the determination that the client has refused to cooperate
with a review. Quality control will send form 470-0479, Noncooperation Notice, to
the local office as notification of the noncooperation. This notification will specify a
date by which the review must be completed for federal reporting.

The Noncooperation Notice instructs the local office on the appropriate action. The
local office must act on the Noncooperation Notice within ten days from the date of
receipt.

If the client reapplies for the same program, but:

♦ Before the date on the Noncooperation Notice, the client remains ineligible for
that program until cooperation.

♦ After the date on the Noncooperation Notice, the deadline has passed for
Quality Control to complete the review. However, the client must be willing to
cooperate with future quality control reviews as an eligibility requirement.

Error Review Committee

Legal reference: Section 154, Quality control 310 Handbook, Federal Policy Memo,
Quality Control, No. 05-01

Policy:
The purpose of the error review committee is to ensure the correctness of the
review findings while maintaining the integrity of the review. The error review
committee reviews potential errors before they are released to the local offices
and service areas. The error review committee is made up of quality control
supervisors and monitors, program managers, and policy trainers.

Iowa Department of Human Services Employees’ Manual

Title 5: Centrally Administered Programs Page 10
Chapter D: Quality Control Quality Control Review Process
Revised October 16, 2009 Error Review Committee

The committee reviews potential errors to:

♦ Explore all factors of the case for the month of review, prior months if
necessary, and the certification month;

♦ Correct any policies determined to have been misapplied by the worker or the
reviewer;

♦ Identify any policies or quality control procedures overlooked; and

♦ Determine if the reviewer needs to explore any missed factors of the review.

Lessons learned during the weekly error review meeting receive immediate
attention. During the potential error review if it is learned that:

♦ There is a need for making a change in training; the trainers use this
information right away when developing materials and training.

♦ A specific policy or procedure contributed to an error, the program managers

use the knowledge when drafting manual material.

♦ Quality control reviewers need guidance in an area; it is acted on right away.

The standing committee also provides an opportunity for the:

♦ Quality control supervisors and monitors to get policy or procedure

clarification, and seek input on reviews in process.

♦ Committee members to discuss how to use policies and quality control

procedures together to craft policies for the employees’ manual.

♦ Committee to ensure program integrity is maintained on each case.

Once the committee agrees that the error is valid, the preliminary error report is
released to the local office.

Iowa Department of Human Services Employees’ Manual

Title 5: Centrally Administered Programs Page 11
Chapter D: Quality Control Quality Control Review Process
Revised October 16, 2009 Steps 1 and 2 of the Error Resolution Process

Steps 1 and 2 of the Error Resolution Process

Policy:
A preliminary error report may be reviewed during an error resolution conference
call. Quality control will offer the field an opportunity to hold a conference call to
discuss the error and offer a proposed date and time, set within five working days
of sending the error report.

Conference call participants will be staff who are most familiar with the case.
Participants include the following:

♦ Income maintenance worker (if possible, the worker responsible for the case as
of the date of the review),

♦ Income maintenance supervisor,

♦ Quality assurance and improvement coordinator,
♦ Quality control monitor, and
♦ Other persons, as appropriate.

The quality control monitor is responsible to facilitate the conference call. During
the conference call:

♦ Review findings are discussed.

♦ Participants try to come to agreement on the error findings.
♦ Participants analyze issues revealed in the review.

A second purpose of the call is to focus on best practices. The quality assurance
and improvement coordinator will analyze the error and provide feedback.

If a resolution cannot be reached, the review will proceed to Step 3 of the error
resolution process.

Iowa Department of Human Services Employees’ Manual

Title 5: Centrally Administered Programs Page 12
Chapter D: Quality Control Quality Control Review Process
October 16, 2009 Step 3 of the Error Resolution Process

Step 3 of the Error Resolution Process

A conference call is held with the:

♦ Income maintenance administrator,

♦ Income maintenance supervisor,
♦ Quality control bureau chief,
♦ Quality control supervisor,
♦ Policy bureau chief and/or the program manager.

The purpose of the call is to:

♦ Review case findings,

♦ Discuss discrepancies between what the local office believes to be correct and
that of the error review committee, and

♦ Attempt to reach a resolution.

If a resolution cannot be reached, the review will proceed to Step 4 of the error
resolution process.

Step 4 of the Error Resolution Process

Case findings are discussed with the quality control panel. The quality control
panel members are the:

♦ Administrator of the Division of Financial, Health and Work Supports,

♦ Administrator of the Division of Results Based Accountability, and
♦ Another service area manager representing the field.

The quality control panel has final authority in determining the error.

Iowa Department of Human Services Employees’ Manual

Title 5: Centrally Administered Programs Page 13
Chapter D: Quality Control Report of Quality Control Review
October 16, 2009

Report of Quality Control Review

Policy:
For correct cases, quality control will issue form 470-0478, No Error Memorandum. If a
case is found to have an error, quality control will send a form 470-0451, Report of
Quality Control Review. This form is also used to let the field know of any new
information verified in the review process.

Comment:
See 5-D, Appendix for information on this report.

Federal Quality Control

Policy:
Federal quality control will review a sample of state quality control reviewed cases to
determine the correctness of the reviews.

Federal Food Assistance quality control uses a formula to calculate the state’s error
rate.

Record Retention
Legal reference: CFR 275.4, 42 CFR 431.17

Quality control records consist of review schedules, worksheets, and other information
supporting the review finding. Quality control retains all records for three-years
following fiscal year closure. Record retention is conducted according to federal
guidelines found in the Federal Quality Control Policy Memo 06-01.

All records for the current reporting period and one prior reporting period are retained
in the Bureau of Quality Control in central office. Studies from earlier reporting periods,
are retained at the State Records Center for two and one-half years.

For the retention of these records, form RM 101, Records Transfer Authorization, must
be completed and submitted to the State Records Center. At the end of the two-and-
one-half-year period, these records are destroyed. Form RM 102, Report of Records
Destroyed, is sent to quality control as notification that the records have been
destroyed.

Iowa Department of Human Services Employees’ Manual

 November 24, 1998

GENERAL LETTER NO. 5-D-50

ISSUED BY: Office of Program Evaluation, Division of Support Services

SUBJECT: Employees’ Manual, Title 5, Chapter D, Quality Control, Title page, new;
Contents (page 1), new; and pages 1 through 11, new.

Summary

This general letter transmits the new Chapter 5-D, Quality Control. This chapter contains
information that was previously in Chapter VI-F. The chapter has been reorganized and rewritten
to reflect Quality Control’s current responsibilities and scope of review.

Title 5 of the Employees’ Manual is being reorganized to contain chapters about public
assistance programs and personnel units which are administered centrally instead of through
county office income maintenance units.

Effective Date

Upon receipt

Material Superseded

None

Additional Information

Refer questions about this general letter to your regional benefit payment administrator.

HOOVER STATE OFFICE BUILDING - DES MOINES, IA 50319-0114

CHESTER J. CULVER, GOVERNOR DEPARTMENT OF HUMAN SERVICES
PATTY JUDGE, LT. GOVERNOR CHARLES J. KROGMEIER, DIRECTOR

October 16, 2009

GENERAL LETTER NO. 5-D-51

ISSUED BY: Bureau of Quality Control,

Division of Results Based Accountability

SUBJECT: Employees’ Manual, Title 5, Chapter D, QUALITY CONTROL, Title page,

revised; Contents (page 1), revised; pages 1 through 11, revised; and
pages 12 and 13, new.

Summary

Chapter 5-D has been revised and reissued in the new format. The language has been
simplified and the policies and procedures reflect the current Department practices.

A new policy, “Integrity of the Quality Control Review,” is added. This section is based
on a federal policy memo that mandates states to ensure that bias is not introduced
into the quality control review. The policy provides guidance on identifying and
avoiding introduction of bias into a quality control review.

New policies are added to incorporate the error resolution process. This process was
produced through the efforts of a workgroup established through the Kaizen process.
This policy section includes the policies and procedures for:
♦ An error review committees, which is the first step in ensuring the correctness of the
quality control review with a preliminary error finding. The error review committee
mission is to find the review, itself, correct. This does not necessarily mean that a
preliminary error will be disposed of during the committee review. The committee
will explore applicable policies and procedures to determine the correct benefit for
the case under review, so federal reporting will be correct.
♦ Rules for error resolution conference calls. Kaizen rules are adopted for error
resolution conference calls. The rules ensure that the purpose of the error
resolution conference call is carried out.
♦ Steps 1 and 2 of the error resolution process, which include the error resolution
conference call, a meeting between quality control and field staff to discuss the
preliminary error findings.
♦ Steps 3 and 4 of the error resolution process. If consensus is not reached in steps 1
and 2, the error resolution proceeds to senior management, with step 4 being the
final decision.

1305 E WALNUT STREET - DES MOINES, IA 50319-0114

 -2-

Effective Date

Upon receipt.

Material Superseded

This material supersedes the entire Chapter D from Employees’ Manual, Title 5, which
includes the following pages:

Page Date

Title page November 24, 1998

Contents (page 1) November 24, 1998
1-11 November 24, 1998

Additional Information

Refer questions about this general letter to your area income maintenance
administrator.