IAR Sample Review Summary Sheet
SAMPLE MONTH_____________________ AGENCY NAME____________________
Summary of Cases Reviewed
Number of cases reviewed______________ Number of cases that contain no errors______
Number of cases that contain reimbursement amount errors _____
Number of cases that contain procedural errors________
Breakdown of Procedural Errors
Type of Procedural Error Number of Cases
State did not meet 10 working days requirement ____
No authorization in file ____
No apportionment notice in State file ____
No apportionment file given to recipient ____
Summary of State or SSA Field Office Corrective Action(s) Recommended by RO
[Include corrective action target completion dates]
____________________________________________________________________
____________________________________________________________________
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SIGNATURE_____________________________ COMPONENT______________
DATE__________________________