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Effective Date: 
3/2009

Documents

Instructions

Updated: 3/2009

Purpose

To manually report an overpayment claim or to report an offset due to a restored benefit on a case with an existing claim. Note: Texas Works staff use this form only to report an offset on an existing claim.

Procedure

When to Prepare

Office of Inspector General (OIG) or investigation staff complete Form H1018 to:

  • report claims that need to be manually entered into the Accounts Receivable Tracking System (ARTS); or
  • modify or suspend collection on an established claim.

Texas Works staff complete Form H1018 to report an offset due to a restored benefit on a case with an existing claim. A copy of the completed form should be maintained in the case records.

Detailed Instructions

To: — Enter the ARTS contact person and mail code. If unknown, send a fax to ARTS Initial Receipt Processing at 512-487-3400.

From: — Enter the name and mail code of the staff initiating the claim.

Reason for Report — Check the appropriate box to indicate a new claim or modification of an existing claim.

ARTS Claim No. — If this is a modification of an existing claim, enter the system-assigned claim number.

Investigation No. — Enter the case number for the investigation, as assigned by the investigating unit.

Investigator Employee No. — Enter the employee number of the investigator assigned to the case.

Region/Div. — Enter the number of the region or division within the state where the overissuance occurred.

Investigator Telephone No., Mail Code, Unit No. — Enter the telephone number, mail code and unit number of the office responsible for initiating the claim.

Primary Liable Client Information — Enter the appropriate information for the primary liable client.

Group Members — Check the box to default to group membership assigned by a System for Applications, Verifications, Eligibility Reports and Referral (SAVERR) case or a Texas Integrated Eligibility Redesign System (TIERS) Eligibility Determination Group (EDG). To identify additional group members that are not currently appearing on the SAVERR case or TIERS EDG, complete the group members section on Page 2 of this form.

Claim Category — Check the "Recipient" box if overissued benefits were issued directly to the client. Check the "Provider" box if overissued benefits were issued to the rehabilitation center or provider for distribution.

SAVERR Case/EDG No. — If assigned, enter the SAVERR case or EDG number for the appropriate program (for example, Temporary Assistance for Needy Families (TANF), food stamps, or Medicaid).

Personal Account No. — Enter the assigned personal account number for the primary liable client. This entry is for Women, Infants and Children (WIC) program participants only.

Client ID No. — Enter the assigned client identification number for the primary liable client (WIC only).

Family ID No. — Enter the assigned family identification number for the primary liable client (WIC only).

OIG Disp. Code/Claim Type — Enter the type of claim: fraud, client error or agency error. If the claim was initiated by OIG, enter the disposition code. If the claim is pending, enter the correct pending type:

  • ADH for Administrative Disqualification Hearing
  • DA for District Attorney

Overissuance Begin Date — Enter the month and year of the first benefit overissuance covered on the claim.

Overissuance End Date — Enter the month and year of the last benefit overissuance covered on the claim.

Total Amount Owed — Enter the total amount of benefit overissuance.

Amount to be Recovered — Enter the exact amount to be recovered on the claim by ARTS.

Collection Recovery Effort — Indicate if to pursue or suspend the collection.

Uncollectible Amount — Enter the amount of the claim that will not be collectible.

Payment Plan/Method of Recovery — The payment schedule, amount and frequency can be determined by ARTS. Check the method of recovery and enter the payment begin date.

Probation Information — Enter the beginning date and ending date of court ordered probation, the county code number for the county where the probation office is located, the cause number the court assigned to the client's case, the total amount due as a result of excess benefits to the client, and the payment amount due at regular intervals.

Offset Payments — Indicate if the offset payment is a result of restored benefits.

Worker Name/Employee No. /Mail Code — Enter the name, employee number and mail code of the person initiating the claim.

Signature/Date — The worker signs and dates the form.

Page 2, Overpayment Claim (Supplement) — Enter the information for additional group members, in order of liability.