The State can recover the $200 paid for May, June, August, and September. The State cannot recover any money for April since the claimant was not eligible to receive an SSI payment in April (E02 month). The State cannot recover any money for July since the claimant was not eligible for an SSI payment. The recipient is eligible to receive $286.00 of the retroactive SSI payment ($1,086 minus the $800 reimbursed to the State).

  

The State cannot recover any money for January and February since interim assistance and SSI were not both paid for these months. The State can recover $280.00 for April through June, but can only recover $153.55 for March, the prorated month. A State cannot recover more than the prorated amount for March even if more SSI is available. The recipient is eligible to receive $312.26 of the retroactive payment ($1,305.81 minus $993.55).

Randomly select samples from the IAR Activity List. Determine the sample review size based on the IAR population (number of paid cases on the activity list) as follows:

  

                                  IAR SAMPLE REVIEW WORKSHEET

  

STATE_____________ AUDIT YEAR_________ SAMPLE MONTH_________

  

TYPE OF CLAIM: IC_____ PE______

  

SSN________________________ RECIPIENT’S NAME__________________

  

SSI ELIGIBILITY DATE___________ AMOUNT OF IAR PAYMENT_______

  

Month IAR and SSI first paid in the same month _________

  

Is there a copy of a valid authorization form or comparable electronic proof in the State file? Yes/No

  

Is there a copy of the apportionment notice that the State sends the claimant in the State file? Yes/No

  

Do the IA money amounts the State entered on the eIAR screens match the IA money amounts the State

paid to the SSI recipient for the months SSA reimbursed the State? Yes/No

  

Did the State send the apportionment notice within 10 working days of receipt of the IAR money? Yes/No

  

REVIEWER’S COMMENTS

  

____________________________________________________________________

  

____________________________________________________________________

  

____________________________________________________________________

  

____________________________________________________________________

  

REVIEWER’S SIGNATURE____________________________ DATE_________________

  

                             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]

____________________________________________________________________

  

____________________________________________________________________

  

____________________________________________________________________

  

SIGNATURE_____________________________ COMPONENT______________

  

DATE__________________________