Free Agency Response to FoodShare (FS) Quality Assurance Finding, HCF 16050 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-16050 (07/08)

STATE OF WISCONSIN

AGENCY RESPONSE TO THE STATE QUALITY ASSURANCE (QA) FOODSHARE (FS) FINDING
As described in Section XX of Appendix AL of the State and County Contract Covering Social Services and Community Programs, failure to take corrective action may result in liquidated damages. Complete, sign and return this form with documentation of corrective action to the following address: . Wisconsin Department of Health & Family Services Bureau of Eligibility Management / Room 1050 Attn: FoodShare Quality Assurance Program Supervisor P.O. Box 309 Madison, WI 53701-0309

(Place case information sticker here)

CARES Case Number

Case Name

We agree with the error finding. If necessary, correct the case and submit documentation of your corrective action within 30 days. Corrective action can include termination of current and future benefits, the calculation of overpayment amounts and claims establishment, or restoration of benefits that were incorrectly under-issued, denied or terminated for all months affected by the error. To assist with error reduction initiatives, what information from the client, agency or state would have helped prevent this error. Please respond within 30 days of receipt of the QA error finding. Additional Comments

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AGENCY RESPONSE TO THE STATE QUALITY ASSURANCE (FS) FINDING F-16050 (07/08)

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We disagree with the error finding. Provide additional information and/or documentation to explain why you consider the eligibility determination to be correct. You must respond within 10 days of receipt of the QA error finding. Additional Comments

We disagree with the QA determination of Agency Preventable Error. Defend your agency position that the error could not be prevented by agency action. Attach all documentation that supports your position. Additional Comments

If client error, was this case referred to fraud for further investigation? Additional Comments

Yes

No

Note: Successful refutation of QA identified errors reduces Wisconsin's error rate and reduces potential agency liability for case specific disallowances and sharing of federally imposed sanctions.

SIGNATURE ­ Agency Representative

Date Signed

SIGNATURE ­ Agency Supervisor

Date Signed

Agency Name