37.1 general information—background · 2017-01-23 · 37.1.1 state hearing/appeal a state hearing...

Common-Place Handbook page 37-1Appeals

37. Appeals

37.1 General Information—Background

37.1.1 State Hearing/Appeal

A State hearing or Appeal is a method whereby a dissatisfied client may obtain an impartial review of a County action or inaction. This process is mandated by federal law and is administered by the State Department of Social Services.

This process is called, variously, “State Hearing”, “Appeal”, or “Fair Hearing”. The terms are interchangeable. In this chapter it shall be referred to as “Appeal”.

The right to an Appeal belongs to the client, not to the county.

37.1.2 Appeal Requests

Although there is a statute of limitations for the filing of an Appeal and there are certain regulations regarding proper issues and proper claimants for an appeal, all requests must be accepted and scheduled for hearing by the state.

Note:A separate Appeal system exists for the General Assistance program referred as “County Hearings”.

37.1.3 Appeal Process Not Appropriate

The appeal process is not appropriate in the following circumstances:

• AS A DECISION-MAKING DEVICE. (For example, there are situations when line staff do not know what to do with a particular case and expect the Appeals system to make the decision for them.) An appeal is always a response to a county action, which means that a decision has been made as to what the correct action is in any particular case.

Update # 14-13 Revised: 12/23/16

2 Common-Place HandbookAppeals

• AS A SUBSTITUTE FOR ELIGIBILITY WORKER-CLIENT COMMUNICATION. A request by a client for clarification or explanation must be granted by the line Eligibility Worker. It is not appropriate to suggest an appeal as a substitute for this duty.

37.2 Terms Unique to the Appeal Process

37.2.1 Claimant

A claimant is a person who requests an Appeal. The request is technically a “claim” and the claim will be granted (the claimant prevails) or denied (the County prevails).

37.2.2 Authorized Representative

A claimant may appoint a person to represent him/her in the hearing. This can be anyone (a lawyer, a friend, a welfare rights advocate, or an organization).

After proper authorization, an authorized representative may make a request for a hearing on behalf of a claimant.

Exception:By county policy, it is a conflict of interest for Social Services Agency personnel to represent a client in an Appeal. [Refer to “Role of the EW,” page 37-9 for a further explanation of the role of the Eligibility Worker in the Appeal process.]

37.2.3 Issue

The issue is the specific action or inaction with which the claimant is dissatisfied. This may involve one or more aid programs and one or more actions. Since the right to a hearing rests with the claimant, it is the claimant who determines the issues to be resolved. The Appeals staff is responsible for clarifying the issues on Appeal by contacting the claimant, as appropriate.

Revised: 12/23/16 Update # 14-13


37.3 State Hearing Filing Procedures

37.3.1 General

Requests for an appeal may be oral or written.

37.3.2 Oral Requests

Oral requests are accepted only by the State at 800-952-5253. Oral requests cannot be accepted by the county.

Affordable Care Act (ACA) Hearing requests are accepted by the State at 1-855-795-0634.

37.3.3 Written Requests

A written request can be in any form as long as it provides sufficient information to identify the client and the general issue. The preferred method is for the claimant to complete the back of the NOA which contains the disputed adverse action. Additionally, the “Request for Hearing”, DPA-13 is also available in all district offices for this purpose.

Written requests can be:

• Mailed to the Appeals Unit at 333 W. Julian St. San Jose, Ca 95110 or

• Hand-delivered to the Eligibility Worker or to the Appeals Unit. If a request is mailed to or dropped off at a district office, it must be:

• Date-stamped immediately

• Scanned and email to the Appeals email inbox: [email protected] (including the enveloped stamped by the Postal Service), and,

• Forwarded without delay (within 24 hours upon receipt) to the Appeals Unit



Timely date-stamping, scanning and forwarding the request and envelope is critical to the determination of Aid Paid Pending and to the right to the hearing itself, by establishing the filing date. [Appeals FAX # is (408) 817-6099].

For the information of eligibility staff, the filing date is determined as follows:

• For oral requests, the date the claimant phones the State.

• For mailed requests, the postmark on the envelope.

• For hand-delivered requests, the date received is determined by the date stamp.

37.4 Expedited State Hearing Requests

Only issues that require an expedited decision will be set for an expedited hearing. The issues that will be subject to this process are cases involving:

1. Expedited CalFresh (formerly Food Stamps);

2. California Work Opportunity and Responsibility to Kids (CalWORKs) Immediate Need, including a failure to process applications within 15 days after payment and denial/failure to issue Expedited Grant funds;

3. CalWORKs Homeless Assistance;

4. Denial of supportive services for welfare-to-work which would result in the loss of employment or inability to participate or make satisfactory progress in a Self- Initiated Program (SIP) or approved educational/training activity; and

5. Any other issue of urgency that the CDSS/SHD deems necessary.



37.4.1 Processing The Expedited Hearing Request

Requests for these hearings shall be made to the regional office Presiding Judge or to the SHD at 1-800-743-8525 or fax (916) 651-2789, or for hearings for speech impaired (TDD) 1-800-952-8349.

1. The SHD will field requests for expedited state hearings from claimants/authorized representatives (ARs) and counties. The Presiding Judge (PJ) of the county’s regional office will determine if an expedited state hearing is necessary. The PJ may contact the county appeals representative and the claimant to get, as necessary, further information about the necessity for an expedited state hearing, and may be done through a three-way call. Unless made through a three way call, if such a contact is made, the contact and the information provided must be revealed to the other party no later than the beginning of the hearing and it may be revealed in writing or via telephone or other electronic means.

2. If the request for an expedited state hearing is granted, the PJ shall ensure the case is calendared on an expedited basis, giving both claimants/ARs and the county at least ten (10) calendar days advance notice of the time, date and the type of hearing that will be convened and conducted by the Administrative Law Judge (ALJ). Notices to county and claimant/AR will be transmitted in writing or by other electronic means specifying the expedited state hearing has been set.

3. If the request for an expedited state hearing is denied, the PJ or his or her designee shall notify the claimant/AR and the county of the determination, and the case will be set for a regular state hearing. Notices to county and claimant/AR will be transmitted in writing or by other electronic means specifying the expedited state hearing has been denied.

37.4.2 Conducting The Expedited Hearing

1. Generally, the most expeditious way the SHD can conduct an expedited state hearing within its resource limits is by telephone. However, if the expedited state hearing can be incorporated into an existing in-person calendar, the SHD will set the case accordingly. If the expedited hearing cannot be set within the existing in-person calendar, the claimant shall be informed via telephone that the matter will be set by telephone. If the claimant wants the hearing conducted in-person, the matter will set for the next regular in-person calendar offered by the county.

2. The Statement of Position (SOP) must be available for the claimant to pick up at the county office two working days before the scheduled hearing, including for expedited hearings. If the SOP is not it available at the required time, the claimant can request and receive a postponement or can opt to proceed without the SOP. The SHD will reset the hearing immediately if the claimant opts for a postponement,



in order to attempt to resolve the urgent issue as soon as possible. Counties are reminded that offering to “reconsider” a matter, when no new information is needed is not appropriate, as the claimant has the right to receive a decision on the matter.

3. The ALJ will issue a decision in the case within five (5) business days of record closure.

4. The SHD has found that a high percentage of cases involving emergency circumstances are subject to settlement. Therefore, parties are encouraged to engage in settlement negotiations as soon as possible, so that the county can take immediate action if settlement is reached, thereby obviating the need for the administrative hearing. If the matter has been resolved, the county must contact the SHD and issue a Notice of Action to the claimant/AR specifying the action taken. If the claimant disagrees with the action, the claimant can file a new request for hearing based on the new Notice of Action.

37.5 Aid Paid Pending

37.5.1 Definition

Aid Paid Pending is the continuation of aid or services in the amount the claimant would have received if the proposed action was not taken. In the CalFresh program, benefits will be continued in the amount authorized immediately prior to the notice of adverse action. It must be remembered that in the CalFresh program, benefits can never continue beyond the end of the certification period.

37.5.2 Aid Paid Pending Determinations

Aid Paid Pending determinations are made by the Appeals unit. The District Office will be notified of the claimant's request for a hearing and Aid Paid Pending status by:

• “Notice Of Filing of Fair Hearing” (SCD 555). This form will be forwarded by TMT or Snap Scan as appropriate.

• An E-mail when Emergency Aid Paid Pending is required.



Note:Because of the requirements of the Saldivar court order, Aid Paid Pending time lines are critical during the last week of any month. For this reason, Aid Paid Pending determinations are faxed to the SSPM of the office where the case is carried. The SCD 555 is online, SSA Intranet under FORMS (DEBS Form Library).

37.5.3 Procedures for Implementation

Aid Paid Pending will be implemented only upon written notice from the Appeals unit. Upon written notice an EW must:

STEP ACTION

1. Take immediate action to issue Aid Paid Pending as appropriate (i.e., suspend collection, suspend adjustment, suspend the sanction, restore aid, etc.).

2. Direct any questions regarding Aid Paid Pending to the Appeals Unit.

3. Make all subsequent changes in the case not related to the issue under appeal, and issue any required notice of action for the changes; i.e., continue to process SAR 7’s, make budget changes, generate NOAs, etc., as if no state hearing were pending.

NOTE: SAR 7 issues are unique to the period in question; that is, an Appeal on a May SAR 7 does not preclude negative action regarding an November SAR 7.

[Refer to “Aid Paid Pending (APP) Process,” page 37-24]

37.5.4 Other Overpayment/IHE

If the claimant unconditionally withdraws, or if the claim is denied or dismissed, any Aid Paid Pending becomes an “Other” overpayment for CalWORKs and an Inadvertent Household Error (IHE) overissuance for CF, subject to adjustment and collections. [Refer to CalWORKs Handbook, “Overpayment Definitions/Forms,” page 49-1] and [Refer to CalFresh Handbook, “Overissuance Types,” page 26-6] for the treatment of Aid Paid Pending.

Exception:This does not apply to the Medi-Cal program. Suspension of overpayment adjustments and sanctions do not create overpayments. A sanction or overpayment adjustment is simply reinstated at a later date with no loss of duration.



37.5.5 Intercounty Transfers

Intercounty transfers are to be initiated and aid paid during the transfer period. The receiving county is required to accept the transfer at the end of the transfer period and assume responsibility for any continued Aid Paid Pending.

37.6 Appeals Process

37.6.1 Appeals Representative

Under State regulation, the County must designate a person or persons who will represent the County at hearings. This person must be a disinterested party, to the extent that he/she was not involved in the action under appeal. In this Agency, this function is assigned to the Appeals Unit.

37.6.2 Role of the Appeals Representative

After the filing of an Appeal, the Appeals representative has the following responsibilities and authority:

• To determine the issues to be heard.• To arrange for interpreters.• To request subpoenas.• To request witnesses (EWs and other staff).• To review the case and applicable regulations.• To determine if Aid Paid Pending is appropriate and notify the EW.• To prepare a County position paper.• To negotiate withdrawals and conditional withdrawals. [Refer to “Withdrawals,”

page 37-11.]

37.6.3 Hearing Presentation

At the hearing, the Appeals representative assumes full responsibility for the presentation of the County's case, including the examination of County witnesses and the cross-examination of the claimant and the claimant's witnesses. Only the Appeals representative has the authority to make agreements or to stipulate on behalf of the County during the course of the hearing. Any appropriate objections or motions will be made by the Appeals representative.



37.6.4 Post Hearing Instructions

After the hearing is concluded, the Appeals representative will inform the Eligibility Worker of additional information/action required and as to the continuation of Aid Paid Pending.

37.6.5 Role of the EW Supervisor

Upon notification of the filing of an appeal by the SCD 555 and/or E-mail, the EW supervisor must:

STEP ACTION

1. Ensure implementation of Aid Paid Pending as required.

2. Ensure compliance for request is correct and timely.

3. Ensure that the Appeals unit is notified timely of the completion of the forms SCD 2293 and/or SCD 1562.

4. Be available and present at the hearing as witness when the EW is not available.

37.6.6 Role of the EW

STEP ACTION

1. Ensure that all current documents are scanned into IDM, for the AO to be able to review the case.

2. Enter clear case comments in CalWIN Maintain Case Comments window.

3. Ensure that the Appeals unit is notified timely on the completion of the forms SCD 2293 and SCD 1562, either by returning back the completed forms or emailing the assigned Appeals Officer

4. Be available and present at the hearing as witness.



37.6.7 Department or District Office Contacted

For the purposes of this section, the Eligibility Worker (EW), Social Worker (SW), or Employment Counselor (EC) to be contacted for corrections will be the EW/SW/EC or Unit to whom the case is currently assigned at the time of the hearing request. This may or may not be the EW/SW/EC or unit who took the action under dispute.

Exceptions to the above condition:

• Hearing decision pertains to an intake denial. The corrective action will be returned to the EW/SW/EC or unit where the denial originated.

• Case is currently assigned to an office or unit who no longer processes the program in dispute. (e.g., CF Appeals currently assigned to BSC). The corrective action will be assigned to an office where the program is administered.

When a hearing decision is assigned to a EW/Counselor/Unit, the expectation is that the hearing decision will be processed timely. Any disputes regarding the assignment must be brought up to the attention of the SSPM for immediate resolution.

Reminder:When assistance from the worker, counselor or unit is required to clarify any questions, such assistance must be sought without delay.

37.6.8 Witness

Attendance of Eligibility Workers or EW Supervisors at hearings as witnesses is at the discretion of the Appeals representative assigned to the case. Because of EW workload, such requests will be made only when, in the best judgment of Appeals staff, the presence/testimony of the EW is essential to the County's case. Thus, it is imperative that EWs honor such requests. The County's case and significant program costs may be adversely affected by the failure of witnesses to appear. Any unexcused failure to appear will be brought to the attention of the appropriate office manager by the supervisor of the Appeals unit.

37.6.9 Representation

Agency policy specifically prohibits staff (EWs and social workers) from representing a client in a State hearing. This is considered a conflict of interest, since the staff member is an employee of the agency against which the appeal is brought.



This refers specifically to representation or advocacy in the hearing itself.

This policy in no way limits the right/obligation of staff to assist clients in knowing and exercising their appeal rights.

37.7 Client Case Review Process

Whenever a client requests to review his/her case or to appoint an Authorized Representative to review his/her case record, procedures must be followed as described in Chapter 42 of the Common Place Handbook.

[Refer to “Case Review by a Third Party (Authorized Representative) When a Request for a Fair Hearing is Filed,” page 42-11]

37.8 Withdrawals

37.8.1 Definition

Withdrawals of an appeal are of two types:

• A straight or unconditional withdrawal, which is generally referred to simply as a withdrawal; and

• A conditional withdrawal.

37.8.2 Withdrawal

A withdrawal is a decision by the client not to pursue the appeal for any reason other than some specific promise by the County.

• The matter may have already been resolved• The client may accept the County's explanation• The client may admit the correctness of the County's position.



Withdrawals are not signed by a County representative. A withdrawal allows immediate implementation of the proposed action without further notice.

37.8.3 Withdrawal Requests

Clients/claimants may withdraw a hearing requests any time before a decision of the Director is signed. Such withdrawals shall be submitted in writing. However, oral withdrawal requests are acceptable and are process as follows:

Withdrawal: For oral requests of Unconditional withdrawals, the county must sent the claimant a letter confirming the withdrawal of the request. The request for hearing must be considered withdrawn unless the county receives notification in writing or verbally that the claimant has not withdrawn the request.

Conditional Withdrawal: Oral request for Conditional Withdrawals must be accompany by an agreement signed by the Appeals representative. and the client/claimant “Withdrawal-Conditional Withdrawal of request for Hearing” (DPA 315). LINE STAFF ARE NOT AUTHORIZED TO SIGN CONDITIONAL WITHDRAWALS.

NOTE: If the DPA 315 is not returned by the claimant, the request for hearing must be considered withdrawn unless the county receives notification in writing or verbally that the claimant has not withdrawn the request. Oral requests for withdrawals must be clearly documented in CalWIN Maintain Case Comments window.

37.8.4 Conditional Withdrawal

A conditional withdrawal represents the claimant's decision to withdraw the appeal based on certain promises made by the County. In order for this to occur, actions required by both parties (claimant and county) must be completed without delay, but no longer than 30 days from the date of the agreement.

Note: There is no need to wait for the signed (DPA 315) in order for the county to take action.

37.8.5 Conditional Withdrawal Policy/Procedure

Appeals staff are required to contact and to reach agreement with line staff prior to entering into a conditional withdrawal. Since:

• A conditional withdrawal involves a promise of future action by the Agency, and



• That future action must be taken by the line Eligibility Worker/social worker.

Exception:An exception will be made for conditional withdrawals taken during the course of the hearing. In these cases, although contact will be attempted, time constraints do not allow delay if the worker is unavailable.

37.8.6 Agreement Cannot Be Reached

If agreement cannot be reached between the Appeals representative and the line Eligibility Worker, resolution will be as follows:

• Appeals representative—EW supervisor

• Appeals supervisor—SSPM

37.8.7 Compliance

Conditional withdrawals must be acted upon and appropriate notice issued within 30 days of the date of the signing of the conditional withdrawal. Agreement as outlined above is a commitment to take the action required. Dishonored agreements will result in a reopening of the hearing and in damage to the credibility of the Agency. If situations arise where compliance is impossible, immediate contact with the Appeals supervisor is required

37.9 Decisions

37.9.1 Definition

For any appeal which is ultimately heard by the Administrative Law Judge, a written decision will be issued and adopted by either the State Department of Social Services or the State Department of Health Services.

The written decision will contain:

• A summary of the hearing• The evidence presented by both sides• Applicable regulations• A conclusion and,



• An order.

37.9.2 Action

The decision will indicate the action to be taken as follows:

IF... THEN...

The County's position is upheld in its entirety,

The claim will be denied.

The claimant's position is upheld in whole or in part,

The claim will be granted. The claim may be granted in its entirety or may be granted in part.

37.9.3 Copy of the Decision

A copy of the decision will be forwarded to the current caseworker, to take the required action. When that action has been taken the decision is to be scanned into the IDM system under Benefits- F6:Misc/Court Review/OP/OI or CWES-F2:Application, as appropriate.

37.9.4 General

When the claim is granted in whole or in part, the order at the end of the decision will contain specific instructions as to what the County must do. The County is required to comply with this order within 30 days of its receipt. The County is compelled to comply even if the County plans to request a rehearing.

37.9.5 Appeals Unit

Upon receipt of a decision requiring compliance, the Appeals unit will send to the following to the assigned unit supervisor and cc the Appeals liaison of the office: (if the issue is dealing with collection activity):

• A copy of the decision.• A compliance form “Report of Compliance With Adopted Fair Hearing Decision”,

SCD 1562.

Note:If the issue involves collection activities, the Collection Unit must be notified of the disposition and the required actionn.



37.9.6 Assigned Unit Supervisor/Appeals Liaison

The EW Supervisor must take the following action:

IF... THEN...

The case is closed, Assign the action on the decision and compliance to the designated unit.

The case is open, Assign the action on the decision and compliance to the EW.

Exception:When the EW of record is located in a specialized office (e.g., Benefits Service Center [BSC], General Assistance Bureau, etc.), the case must be sent to the specialized office for action.

NOTE: District Office clerical staff must assign the case to the correct office and mail the Appeals Liaison of that office to inform of the case transfer.

37.9.7 Controls

The EW supervisor or Appeals Liaison is responsible for keeping such controls as may be necessary, to ensure proper compliance within the allotted time period.

37.9.8 Role of the EW

Upon receipt of the decision and compliance forms (SCD 1562), the EW shall take immediate action to comply with the order as follows:

• The response on the compliance form should paraphrase as nearly as possible the directions set forth in the State hearing decision.

• Any questions regarding the compliance should be addressed to the Appeals representative who is assigned to the case in question.

• Each and every element of the order must be complied with.

• If there are aid payments to be made, the compliance form must contain:

• The date on which the payments were made,• The amount,• The month for which the payment was intended.



Note:The EW must timely return the completed SCD 1562 to the Appeals Unit or notify the AO via email of the completion of the form.

37.9.9 Ineligible Due to a Factor NOT Covered in the Appeal

Compliance means that the County has taken definitive action to issue the aid or services to which the claimant was found eligible. In many cases, the phrase “as otherwise eligible” is used in the decision order. This may result in a determination that the claimant is not eligible for aid because of some eligibility factor not covered in the appeal.

NOTE: In such cases, it is a requirement for compliance that an adequate notice of action be issued to the claimant advising him/her of the County's decision. Further appeal may be possible.

37.9.10 Internal Transfers

Compliance occurs only when the County has issued the required aid payment or issued a notice of action advising the claimant of ineligibility. Internal transfers are not considered by the State to be compliance and are not to be used as a method of compliance unless such transfer will result in the required payment or NOA within the 30-day time period.

37.10Rehearing Request

37.10.1 Who May File

Either the claimant or the County has the right to request a rehearing on any decision issued. The State is not required to grant the request and frequently does not.

37.10.2 EW Request

If a EW believes that a rehearing request is appropriate, this information must be forwarded to the Appeals Unit in a memo. EWs must be aware that:

• Compliance with the original decision is still required.



• Rehearings may be meaningless for certain issues because of the required compliance. This should be kept in mind when considering whether to make a request.

• Rehearing requests are granted only in cases where there is new evidence that was not available at the time of the original hearing, or where the judge made a factual error.

• Findings of fact within a decision are not subject to rehearing unless it can be shown that the judge abused his/her discretion in coming to that conclusion. It is exceedingly rare that such rehearing requests are granted.

37.11Appeals Business Process

The following charts provide step by step detail of the Appeals Business Process.

37.11.1 Initial Process for Hearing Request

The following process is followed when a client submits a hearing request via fax, mail, email, in-person or telephone:

STEP WHO ACTION

1. Claimant • Initiates the hearing request

2. Appeals Clerk

• Receives and date stamps the state hearing request.

Note: Questionable state hearing requests are forwarded to the Appeals Supervisor/Lead for assessment.

• Initiates appeals case review forms and folder.

• Reviews and prints screens from CalWIN/MEDS/CDS such as Case Inquiry and Case Members (if applicable).

Note: For conflicts with between system and hearing request, informs the Appeals AO lead to clarify.

If hearing requests is...

Then...

Received by the State

• IDs the case name in the State Hearing System (SHS) and obtains the 9 digit state hearing number.

• Documents the state hearing number on the Appeals Case Review form.



2. (cont)

Appeals Clerk (cont).

Received by the County Appeals Unit

• Date stamps the request to establish the filing date and Aid Paid Pending (APP) determination.

• IDs client in SHS and ASB Clerical Log

• Adds additional filing date to record in SHS if request is a duplicate.

Note: For clients not known to the SHS and/or when requests is not a duplicate, creates a new SHS record.

• Creates a Hearing Request folder.

• Updates ASB Appeals Clerical Log.

• Completes clerical portion of the Appeals Case review form.

• Submits hearing request folder to Appeals Supervisor for assignment.

3. Appeals Supervisor

• Receives Hearing Request folder from clerk.

• Identifies the hearing issue and program through case information, correspondence and case comments in CalWIN.

• IDs case in CalWIN and Assignment log to identified if previously assigned AO.

• Assigns case to next available or previous AO as appropriate.

• Updates Assignment log (AO number and assignment date).

• Forwards State Hearing folder to the Appeals Clerical to update in SHS.

4. Appeals Clerk

• Receives folder from Appeals Supervisor.

• Updates SHS with the assigned AO worker number for changes or corrections.

• Prints out SHS Case Change Screen.

• Copies Hearing request State Hearing Cover Sheet

• Sends Hearing Request folder to assigned AO.

• Requests case folder though CDS as needed by AO using a “Case Tacking Request Form:” (SCD 2292).

STEP WHO ACTION



For instructions on entering data in CalWIN State Hearing Subsystem, Refer to Standardization of Hearing Subsystem, CA 254.1

Note:Following the instructions on CA 254.1 will trigger the correct data for the Hearing Caseload Summary Report ASBX0436.

5. Appeals AO

• Receives Hearing Request folder from Appeals Clerk.

• Reviews Hearing Request issue.

• Performs preliminary case review and determines Aid Paid Pending (APP) [Refer to “Aid Paid Pending (APP) Process,” page 37-24]

• Submits Hearing Request Form, SCD 555 and copy of Hearing request to clerical as follows:

• Snap scans and emails to BSC, IHSS, FC, R&L. • For all other offices follows TMT procedures.

NOTE: For closed cases, sends documents to Appeals liaison for EW assignment.

• Completes and submits State Hearing Cover Sheet to the appeals clerk’s basket.

6. Appeals Clerk

• Receives documents from Appeals AO for processing

• Records request in Maintain Filing Information for State Hearings in CalWIN as needed.

• Completes the following tabs [Issues] [Claimant] [Auth Rep] [Scheduling] in CalWIN Maintain Hearing Details window.

• .Returns packet to Appeals AO.

Note: For SCD 555, follow the Compliance Request and Escalation Process for District Office, as appropriate.][Refer to “Compliance Request and Escalation Process,” page 37-26]

STEP WHO ACTION


http://intranet.ssa.co.santa-clara.ca.us/calwin/calwin_searchable/calwin_announcements/ca_254.pdf




37.11.2 Review of Hearing Case File

WHO ACTION

Appeals AO • Receives assigned hearing case file.

• Reviews APP determination [Refer to “Aid Paid Pending (APP) Process,” page 37-24] and [“Aid Paid Pending,” page 37-6]

• Determines claimant’s: issue, time period, evidence required.

• Reviews information in VACS for OP/OI related cases.

• Reviews case in CalWIN and IDM

Note: For IHSS cases which are not in IDM and CalWIN, refer to IHSS process [Refer to “In-Home Support Services (IHSS) Program - Appeals Process,” page 37-27]

• Determines responsible District Office for Action.

• Sends the form “Authorized Representative” (DPA 19) to client as required.

Reviews county action as follows:

Is Withdrawal or Conditional Withdrawal requested/granted?

Then...

Yes Follows Withdrawal and Conditional Withdrawal process [Refer to “Withdrawal and Conditional Withdrawals,” page 37-23]

No • Prepares a Position Statement.

• Requests and notifies witnesses for Hearing.

• Follows State Appeals Hearing Day Process [Refer to “State Appeals Hearing Day,” page 37-21]



37.11.3 State Appeals Hearing Day

WHO ACTION

Appeals Clerk • Downloads the Hearing Schedule from the State Secure File Transfer (SFT) System.

Note: For cases that have no assigned Worker number, follow step 3 of the Initial Process for hearing request chart [Refer to “Initial Process for Hearing Request,” page 37-17]

• Provides AOs with copies of the Hearing Schedule.

• Retains hearing requests tables for the Administrative Law Judge (ALJ) folders upon hearing.

• Prepares Hearing Room.

Appeals AO-Lead Conducts daily tracking during Hearing Week.

Appeals AO • Coordinates the appearance of witnesses and interpreters, prior to the Hearing Date as specified in section [Refer to “Witness,” page 37-10]

• Appears at the Hearing

• Updates Hearing Schedule (for each Hearing Day)

• Updates CalWIN as appropriate.

Appeals AO-Lead • Forwards completed Hearing Schedules to Appeals Clerk at the end of each Hearing Day.

Appeals Clerk • Receives completed Hearing Schedules form the Appeals lead.

• Sends the completed Hearing Schedules to the State and to the Administrative Support Bureau (ASB) Management Analyst (MA) via email and cc’s the Appeals Supervisor and AO Lead.

ASB MA • Receives completed Hearing Schedule form.

• Creates a report for submission to DSR and Management.



37.11.4 State Appeals Disposition and Decision

The hearing disposition is received from the state SFT system 60 to 90 days from the hearing date. The following steps are to be follow:

STEP WHO ACTION

1 Appeals Clerk • Receives Hearing Disposition from SFT.

• Sends soft copies to the assigned AO and Appeals Supervisor.

2 Appeals AO • Receives Hearing Disposition from the Appeals Clerk.

• Reviews Hearing Disposition and required action.

• Forwards documentation (SCD 2294, SCD 1562 and copy of the Hearing Disposition) to the appropriate District Office for processing for any required action.

• Updates the [Issues] [Tracking] [Decision] and [Comments] tabs in CalWIN Maintain Hearing Details window.

• Prepares case for IDM and submits to the Appeals Clerk.

Note: If not completed within time frame, follows Compliance Request and Escalation process as required. [Refer to “Compliance Request and Escalation Process,” page 37-26]

3. Appeals Clerk • Receives case from Appeals AO and initiates IDM process.


• Receives the soft copy of the Hearing Disposition from the Appeals Clerk.

• Reviews information in CalWIN Caseload listing.

• Emails copy of Hearing Disposition to the specific Program Coordinator (if granted).



37.11.5 Withdrawal and Conditional Withdrawals

Follow the steps below to process Withdrawals and Conditional Withdrawals

STEP WHO ACTION

1. Appeals AO • Reviews case to determine county’s action.

• Contacts the claimant or AR to discuss and/or resolve the issues when the county’s action is NOT correct or when it is correct and a hearing is not warranted.

If withdrawal is... Then...

Requested • Sends the Compliance Response to Withdrawal or Conditional Withdraw (DPA 315) to the client for approval and signature.

• Requests Appeals Clerk to create a request for District Offices as follows:

• Snap scans and emails documents to BSC, IHSS, FC, R&L.

• For all other offices follows TMT procedures.

• Signs DPA 315 when it is returned by the client.

• Sends a copy of the DPA 315 to the client/AR and to District Office as available.

• Updates CalWIN.

• Closes and forwards the case file to the Appeals Clerk.

Note: Follows up with District Office Compliance. [Refer to “Compliance Request and Escalation Process,” page 37-26].

Is NOT requested or Hearing is warranted

• Prepares a Statement of Position.

• Requests and notifies witnesses for hearing

• Follows State Appeals Hearing Day procedures. [Refer to “State Appeals Hearing Day,” page 37-21]



37.11.6 Aid Paid Pending (APP) Process

The process below must be followed when evaluating a hearing request for Aid Paid Pending:

2. Appeals Clerk • Creates compliance request according to District Office Notification as requested by the Appeals AO. [Refer to “Compliance Request and Escalation Process,” page 37-26]

• Receives case files from AO and prepares/initiates for IDM process.

WHO ACTION

Appeals AO • Receives Hearing Request folder already prepared by the Appeals Clerk [Refer to “Initial Process for Hearing Request,” page 37-17]

• Reviews documents and program(s) issue(s).

• Performs preliminary case review and determines APP eligibility as follows:

If... Then

• Notice of Action (NOA) is not issued • NOA is not timely or adequate and,• Hearing is requested timely

Issue Aid Paid Pending

• NOA is issued • NOA is adequate and timely and,• Hearing is NOT requested timely

Deny Aid Paid Pending

• Completes a “Notification of Filing for a Fair Hearing” (SCD 555)

• Completes AO portion of the State Hearing Cover Sheet (yellow form).

• Submits State hearing Cover sheet, SCD 555 and copy of Hearing request to Appeals clerk’s basket.

Note: Client has the option to waive APP to avoid potential O/P and O/Is.

STEP WHO ACTION



Appeals Clerk • Receives documents from Appeals AO for processing

• Snap scans and emails documents to BSC, IHSS, FC, R&L and follows TMT procedures for all other offices.

• Records request in Maintain Filing Information for State Hearings in CalWIN as needed.

• Completes the following tabs [Issues] [Claimant] [Auth Rep] [Scheduling] in CalWIN Maintain Hearing Details window.

• .Returns packet to Appeals AO.

Note: For SCD 555, follows the Compliance Request and Escalation Process for District Office, as appropriate. [Refer to “Compliance Request and Escalation Process,” page 37-26]

WHO ACTION



37.11.7 Compliance Request and Escalation Process

The following steps are to be followed to ensure the assignment and compliance of requests made to District Offices:

STEP WHO ACTION

1. Appeals Clerk

• Receives instructions to create Compliance Request for District Office.

• Creates compliance request according to District Office (DO) as follows:

For District Offices that use CCS Management Tool (TMT)

If the Case is... Then...

Active • Creates a TMT for subsequent assignment.

Closed • Creates a TMT

• Emails the Appeals Liaison requesting to open the case for TMT to be assigned.

• Returns folder to Appeals Officer (AO)

• Monitors TMT for assignment and completion as follows:

TMT assigned within 24 hours?...

Then...

YES No action needed

NO Emails OMC, Appeals Liaison and cc’s Appeals Supervisor

TMT assigned within 24 hours?...

Then...

YES No action needed

NO Informs Appeals Supervisor

For District Offices that DO NOT Use CCS -TMT

If the case is... Then...

Active • Scans documents

• Emails materials to the Unit Supervisor and cc’s Rotating Appeals Liaison.

Closed • Scans documents

• Emails materials to Rotating Appeals Liaison.

• Documents request in Compliance Request Log



37.12In-Home Support Services (IHSS) Program - Appeals Process

37.12.1 Initial Notification of (IHSS) Cases Going to Hearing


• Emails OMC and Appeals Liaison for TMT case assignment, after being informed by the Appeals clerk.

3. Appeals AO • Monitors assigned TMT for completion as follows:

If assignment not completed within...

Then...

10 days Emails Unit Supervisor for assignment completion

14 days Escalates delinquent assignment completion to the Appeals Supervisor


• Emails Unit Supervisor requesting assignment completion

• Escalates delinquent assignment completion to ASB SSPM, if not completed within 17 business days.

5. ASB SSPM Emails District Office SSPM requesting assignment completion.

STEP WHO ACTION

1. Appeals Clerk

• Uploads and copies un-calendared hearing list from the State Hearing System (SHS) on Friday of the current hearing week, or on Monday of week #1, and gives to Appeals Supervisor.

• Uploads and copies calendared hearing list from the State Hearing System (SHS) on Thursday or Friday of week #1, and gives copy to Appeals Supervisor.

For hearing Week Patterns [Refer to “Notifying IHSS of a Hearing with “Notice of Filing of Fair Hearing” (SCD 555),” page 37-29].

STEP WHO ACTION




• Enters all available information from the uncalendared hearing cases into the Excel Spreadsheet on the “S” drive to complete the following columns: Case name, State Fair Hearing #, IHSS case # or SSN, hearing Date/Time, Appeals Representative, Social Worker, APP, Notes.

• Emails IHSS Excel Spreadsheet (IHSS Hearing Log to IHSS Social Services Program Manager (SSPM) and Appeals Representatives with as much information as possible, by the end of the current Hearing Week or by first day of Week # 1.

• Update IHSS Spreadsheet on the “S” drive with Hearing Date/Time and any other information that is available. Include comments on this lists as appropriate.

• Emails updated IHSS Excel Spreadsheet to IHSS SSPM and Appeals Representative by Friday of Week #1.

3. Appeals AO

• Receives the IHSS Excel Spreadsheet from Appeals Supervisor

• Validates the information on the Spreadsheet in accordance to scheduled hearings

• Prepares SCD 555 and sends directly to IHSS SSPM for Social Worker assignment.

• Enters appropriate notes in the IHSS Excel Spreadsheet for hearing cases.

• Submits updated/validated list to Appeals Supervisor

Reminder: Re-hearing cases do not required a new SCD 555. However this must be noted in the IHSS Excel Spreadsheet. Example: “ Re-hearing case. No SCD 555 needed”


• Receives updated/validated list from all Appeals AOs

• Resubmits updated/revised IHSS Excel Spreadsheet to IHSS SSPM and Appeals Representatives.

5. IHSS SSPM

• Enters the assigned Social Worker’s (SW) name on the IHSS Spreadsheet.

• Enters the IHSS Fair Hearing information into the Case Management Information and Payrolling System (CMIPS) II.

• Emails the completed IHSS Excel Spreadsheet back to the Appeals Supervisor, by Wednesday of Week #2. Include comments on this lists as appropriate.

STEP WHO ACTION



37.12.2 Notifying IHSS of a Hearing with “Notice of Filing of Fair Hearing” (SCD 555)

STEP WHO ACTION

1. Appeals AO • Reviews the hearing request to determine the issue and eligibility for APP [Refer to “Aid Paid Pending (APP) Process,” page 37-24]

• Completes the SCD 555 as follows:

Section “TO”

Office IHSS - 1888 Senter Rd

Supervisor SSPM’s name and H4AA

Liaison Leave blank

Date Current date

Case Name Claimant’s Name

Case Number Claimant’s CMIPS II number or if unknown, claimant’s SSN

Section “FROM”

1st line Enters who the hearing request is from (if from AR, enter AR’s name and organization)

State Hearing # Enters State hearing Number

Filing Date Enters the Filing Date

Notice of Action (NOA) Date

Enters NOA date or leave blank if unknown.

Section “ AID/SERVICES PAID PENDING STATUS”

1st box Checks the first box if eligible for APP and enters “IHSS” on the corresponding line

3rd box Checks the third box if eligible for APP. Enters APP beginning date on the corresponding line (if known)

4th box Checks the fourth box if NOT eligible for APP. Enters the aid type on the corresponding line and selects the box that most fits the issue.

Section “FAIR HEARING ASSIGNED TO”

Assigned to Enters Appeals AO’s name and worker number

• Prints completed SCD 555

• Attached completed SCD 555 to a copy of the hearing requests and place it in the Appeals clerk snap scan basket.



2. Appeals Clerk

• Snap scans SCD 555 and Hearing requests and forwards to IHSS SSPM

• Date stamps and initials SCD 555

• Returns SCD 555 and copy of hearing request to the Appeals AO.

3. IHSS SSPM • Receives SCD 555 and hearing request

• Logs into CMIPS II

• Emails SCD 555 and hearing request to the assigned Social Worker (SW) and Social Work Supervisor (SWS)

• Emails Appeals AO with the name of the assigned SW and SWS.

4. Appeals AO • Sends an email invite to the SW cc’s SWS for the scheduled hearing. (provides hearing date and time)

NOTE: This invite serves as a reminder of their mandatory attendance.

5. SW and SWS • Reviews the Hearing requests to try to resolve the issue:

If issue is... Then...

Resolvable • Notifies IHSS SSPM and Appeals AO and provides and explanation on how it was resolved.

Note: The Appeals AO uses this information to determined if a withdrawal or conditional withdrawal is needs to be sent to the claimant.

NOT resolvable • Notifies IHSS SSPM and Appeals AO for a regular State hearing process.

• Emails Appeals AO Forms and Verifications needed for Hearing NO later than Tuesday of Week #3 [Refer to “Forms and Verifications for IHSS Hearings,” page 37-31]

IMPORTANT: The Forms and Verifications must be submitted timely in order to prepare the State required Statement of Position.

9. Appeals AO • Sends an email to the SW/SWS immediately to requests Forms and Verifications, IF NOT provided.

• Reminds the SW/SWS via email of their mandatory attendance to the scheduled State Hearing.

STEP WHO ACTION



37.12.3 Forms and Verifications for IHSS Hearings

The following forms and verifications must be provided by the IHSS to the Appeals Officer by the Tuesday of Week #3.

Forms Verifications and/or CMIPS II screens

• In Home Support Service Program - Paramedical Service Form (SOC 321)

• In-Home Support Services Program - Health Care Certification Form (SOC 873)

• In Home Support Program - Assessment of Need for protective Supervision (SOC 821)

Note: This form is needed if a review for Protective Supervision is conducted. This form must be accompanied by notes/comments related to the issue.

• Both sides of current NOA mailed out to the client, including its attachments. (all programs).

• Case comments and narratives related to the assessment.

• Service Evidence screens (showing the ranks of each need and hours assessed).

• View Service Type Detail screen for each task whether or not hours were given.

• Program screen (providing home visit date).

37.12.4 Notifying to IHSS of Hearing Decisions

The following process is followed to notify IHSS of hearing decisions:

STEP WHO ACTION

1. Appeals Clerk • Receives Hearing Decision from the State

• Emails copy of hearing decision to Appeals AO

2. Appeals Officer • Receives hearing decision from Appeals Clerk

• Completes the “Notice from the State Appeals Representative (SCD 2294) form as follows:

DATE: Current date

TO: IHSS QA Manager’s name and the QA Manager’s worker number

FROM: Appeals Officer’s name, worker number, works address and email address

CASE NAME: Claimant’s Name

CASE NUMBER CalWIN case number

ST. FH # State Fair Hearing Number



2. (cont)

Appeals Officer (cont).

REMARKS: Check all boxes that pertain to hearing decision.

Check the box “Other” to enter any necessary comments.

• Completes the “Report of Compliance with Adopted Fair Hearing Decision” (SCD 1562) form, for granted or partially granted decisions, as follows:

• IHSS QA manager’s name

• Case name

• Case Number

• State FH #

• Name and worker number of Appeals Officer

• Date Compliance to be returned by (Usually the 30th day after the Decision is being sent to the QA Manager)

• Scans completed SCD 2294, SCD 1562 and Hearing Decision

• Forwards the scanned documents to the IHSS QA Manager using the following email format:

• Email Subject Line: Decision from Fair Hearing and Claimant’s name

• Email Body: IHSS case number, State Fair Hearing number

• Any important information pertaining to IHSS.

• Scans and emails copy of denied/dismissed decision to IHSS QA Manager.

Reminder: Any decision, whether granted or denied/dismissed, must to be forwarded to IHSS QA Manager.

3. IHSS QA Manager

• Receives the email from the Appeals Officer

• Assigns to QA SW

• Replies to the Appeals Officer’s email with the assignment information (QA SW’s name and worker number)

STEP WHO ACTION



37.13Hearing Week Patterns

The Hearing Weeks start on Mondays and are described as follows:

Week Description

Hearing Week Week when hearings take placed

# 1 First Monday after Hearing Week

# 2 Second Monday after Hearing Week

# 3 Third Monday after hearing Week

37.13.1 Annual State Hearing Schedule (2017)

State hearings are scheduled as follows:

4. QA SW • Receives Hearing Decision from the IHSS QA Manager

• Complies with the Hearing Decision

• Enters all necessary information into CMIPS II

• Completes the SCD 1562 and emails back to Appeals Officer along with a copy of the NOA.

5. Appeals Officer • Receives completed SCD 1562 from the IHSS QA SW

• Files it in the Appeals case folder

• Closes out the Appeals case folder and gives to Appeals clerk to file in Appeals closed files and IDM.

Window Period to File Hearing For Hearing Week

12/2/16-12/16/16 1/10/2017

12/17/16-1/26/17 2/20/2017

1/27/17-2/23/17 3/20/2017

2/24/17-3/23/17 4/17/2017

3/24/17-4/20/17 5/15/2017

STEP WHO ACTION



37.13.2 Annual Affordable Care Act (ACA) Hearing Schedule (2017)

ACA hearings are scheduled as follows:

Hearing Week

1/2/2017

1/30/2017

2/27/2017

3/27/2017

4/24/2017

5/22/2017

6/19/2017

7/17/2017

8/14/2017

9/11/2017

10/9/2017

11/6/2017

12/4/2017

1/1/2018

1/29/2018

4/21/17-5/18/17 6/12/2017

5/19/17-6/15/17 7/10/2017

6/16/17-7/13/17 8/7/2017

7/14/17-8/10/17 9/4/2017

8/11/17-9/7/17 10/2/2017

9/8/17-10/5/17 10/30/2017

10/6/17-11/2/17 11/27/2017

11/3/17-11/30/17 12/25/2017

12/1/17-12/28/17 1/22/2018

Window Period to File Hearing For Hearing Week
