Form Dss-8566 - First Month Of Overissuance Determination Standard And Simplified Cases
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1Food and Nutrition Services
First month of overissuance determination
Standard and Simplified Cases
Casehead Name _________________________________ EPICS Referral Number ______________________
Completed by ____________________________ Date ________________ Co. Case # ___________________
A. Did the applicant withhold information or provide false information at application? ________
1.
If no, continue to B.
2.
If yes, the first month of overissuance is the first month of the certification period.
B. Did the recipient withhold information or provide false information at recertification? _______
1.
If no, continue to C for Standard/Simplified Cases.
2.
If yes, the first month of overissuance is the first month of the new certification period following
the review in which the recipient withheld or provided false information. Continue to C below if a
change occurred during a certification period and the recipient failed to report the change timely.
C. Did the recipient fail to disclose a reportable change during a certification period? ______
1.
If no, STOP. See note below.
2.
If yes, use the appropriate section below. Section D is for changes that occurred before
2/1/2007, and section E is for changes that occurred after 2/1/2007.
D. Changes that occurred before 2/1/2007.
1. What day did the recipient first know about the change?
__________
2. Add 10 calendar days to determine the date the change was reportable
__________
3. Add 10 calendar days to allow the IMC to react to the change.
__________
(Allow even if IMC could have reacted sooner)
4. Add 10 working days for the Notice of Adverse Action to expire.
__________
5. What is the month following the date the NOAA expires?
__________
This is the first month of overissuance.
E. Changes that occurred on or after 2/1/2007.
1. What day did the recipient first know about the change?
__________
th
2. What is the 10
day of the month following the month in the answer to E, 1? __________
(Required date to report change)
3. Add 10 calendar days to allow the IMC to react to the change.
__________
(Allow even if IMC could have reacted sooner)
4. Add 10 working days for the Notice of Adverse Action to expire.
__________
5. What is the month following the date the NOAA expires?
__________
This is the first month of overissuance.
Note: This information applies to IHE and suspected IPV claims only. The first month of overissuance
for Agency Error Claims is always the first month the change would have been effective had the
agency acted timely and according to policy. Use this form in conjunction with policy in sections
815 and 820. If a change occurred after review interview, but before recertification, follow
instructions in section 815.02 for IHE claims, and section 820.03 for suspected IPV claims.
DSS-8566 (09/09)
Food and Nutrition Services
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