Attachment A to UIPL 27-93

CHAPTER VI INVESTIGATIVE PROCEDURES

  1. Introduction.  The investigation is the mechanism for intensively reviewing payments to determine if they were made to eligible claimants and, if so, whether payments were made in the proper amounts. Each case selected for QC is an original payment for a specific week of unemployment, referred to as a "Key Week". Each Key Week is investigated to verify that all information pertaining to eligibility and payments is treated in conformity with State written law and policy. The data obtained from the investigations will be used to draw inferences about the claimant population as a whole. It is important, therefore, that the investigative requirements are adhered to for each case.

    The investigation also involves gathering data about the claimants and claims sampled for entry into an automated data base. These data, in combination with the classification of the case findings, will be used for State analysis and corrective action.

  2. General Investigative Requirements. The following general requirements must be adhered to during the course of QC investigations:

    1. Investigations are comprised of reviews of SESA records and interviews of claimants, employers, and third parties. Investigations are to be conducted using the primary method detailed in this chapter. Where the use of the primary method of verification is not possible, States must attempt to obtain the information using other methods available. In situations where the primary method is other than in-person, States may use the in-person method at their discretion.

    2. Investigations begin with the assumption that the Key Week was properly paid; however, all areas of eligibility are explored which could directly affect the Key Week and the establishment of the initial claim. This is distinguished from issues arising during weeks claimed prior to the Key Week, which could potentially involve a disqualification including the Key Week. Disqualifying issues of this type must be pursued if discovered, but the SESA need not structure the investigation to uncover such issues (e.g., refusal of suitable work results in 10-week disqualification).

    3. Investigators must conduct new and original factfinding in accordance with the Secretary's Standard for Claim Determinations as prescribed in sections 6010-6019, part V of the ES Manual on all issues which have not been detected previously. Also, the facts of previously resolved issues affecting the Key Week must be verified. State laws or policy which might make an issue moot (e.g., when a decision becomes final by virtue of the expiration of the appeal period without an appeal being filed)must not preclude pursuit of issues for QC purposes. The issues must be pursued until a supportable conclusion is reached. (Non Key Week issues should be referred to other SESA staff for pursuit and resolution unless adjudication by QC staff would only involve incidental time and resources.)

    4. Investigations of new issues must be conducted by obtaining evidentiary facts, as distinguished from ultimate conclusions. Open-ended questions must be asked, and, where feasible, official employer records must be reviewed and copied by the investigator.

    5. Where the information is obtained using the in-person method, the signature of the person providing the information must be obtained on the verification and/or factfinding statement.

      Where the information is obtained using other than the in-person method, the name of the person providing the information must be shown in the signature block.

    6. States' written laws and policies are the bases for all determinations. Written policy is that policy which is distributed SESA-wide and, upon request, may be made available to the public.

    7. All conclusions pertaining to the Key Week that are drawn from the QC process must be formalized in official agency actions if errors are found, except where prohibited by SESA provisions such as finality.

    8. All determinations made as a result of QC investigations must have supporting documentation.

  3. Investigative Guide.

    Investigators must adhere to the minimum requirements presented in the Investigative Guide (Appendix C). The guide summarizes the data sources, initial action, and documentation required for each data item gathered during the investigation.

  4. Forms

    1. Claimant Questionnaire.  The claimant questionnaire is a required standard form (see Appendix B) to be completed by the claimant during the interview (see section 6 of this chapter). SESA's must alter the questionnaire to satisfy unique aspects of their laws. Department approval must be obtained prior to making any change to the questionnaire. Such approval may be obtained by sending a copy of the requested changes to the appropriate Regional Office. When the claimant questionnaire is translated into another language, it must be submitted to the Regional Office for post-review.

      States with dependency allowance provisions in their laws must develop a section of the questionnaire for determining eligibility for dependency allowances. Advance Department approval for the section must be obtained by sending a copy to the appropriate Regional Office.

    2. Standard Forms.  Each SESA must develop a standard QC form to be used in investigations for:

      • Work Search Verification - Employer

      • Work Search Verification - Labor Organization

      • Employment/Wage/Earnings Verification

      • Disqualifying/Deductible Income Verification

      • Authorization to Release Information (where required)

      • Factfinding Statement

      • Dependency Eligibility Verification (if applicable)

      • Summary of Investigation

      • Interstate Request

      The questions on all forms which address eligibility must be adequate to obtain information which the SESA requires to determine whether provisions of law and written policy were adhered to. All forms used for interviews must provide space for the signature of the person being interviewed, the SESA investigator's signature, the method used to obtain the information, and the date of the interview.

    3. Factfinding Statements.  During the course of investigations, it will be necessary on occasion to take factfinding statements and offer the opportunity for rebuttal. In some instances, the forms developed for the remaining sections of this chapter will provide ample space to record the statements. In other instances, it will be more convenient to utilize separate documents. For these latter situations, SESAs' must either develop formats to use exclusively for QC or utilize forms already in use for other purposes.

    4. Claimant Interview.  QC staff must interview all claimants in the sample for the following purposes: (1) to verify claimant information originally used in the claim; (2) to gather information to determine if there are undetected issues or issues improperly treated.

      All requirements which SESAs normally apply to contacts with non-English speaking claimants must also be applied to contacts for QC.

      In SESAs where an "Authorization to Release Information" form is required, the investigator must have this form signed and dated by the claimant during the claimant interview.

      The investigator is to conduct the interview in person and sign the questionnaire in the space provided to certify that the interview was conducted in accordance with the requirements of this Handbook. If it is not possible for the investigator to conduct the interview in person, the investigator must detail attempts to interview the claimant in person and the reasons why other means were used to complete the questionnaire. When it has been documented that an in-person interview cannot be acquired, the telephone or mail may be used as a secondary method of completing the claimant interview. If the questionnaire was not completed, an explanation must be entered on (or attached to) the signature page, in which case it will be sufficient to retain this page only in the case folder, in lieu of retaining the entire questionnaire. A claimant's return to work or exhaustion of benefits is not in and of itself, adequate justification for failure to obtain an in-person interview.

    5. Work Search Contact Interviews.  The investigator must conduct interviews of all work search contacts to verify that the contact satisfied State requirements and to uncover any potential issues bearing on eligibility and payment of benefits.

      The primary method for verifying work search contacts is the in-person method. Investigators must continue to explain and document deviations to the in-person method on a case-by-case basis except as indicated below.

      In the following situations, SESAs may choose to utilize other than the in-person method without explanation. However, the documentation in the case file must support the fact that these conditions exist:

      When the claimant's Key Week work search contact is made by telephone/FAX or mail, verifications may be by telephone/ FAX or mail.

      When the Key Week work search contact(s) is more than forty-five (45) days old at the time of the sample selection due to the late payment of Key Week benefits, verifications of such contacts may be done by telephone/ FAX or mail.

      When a Key Week work search contact with Job Service constitutes a valid work search contact under State Law and policy, agency records may be reviewed and photocopied to verify and document the contact.

      If the investigator determines, during the process of arranging the employer interview, that the employer can verify that the claimant made a work search contact during the Key Week, that will be coded as acceptable, it is not necessary to make an in-person visit to the employer. This does not apply to unverifiable or unacceptable contacts since further in-person investigation might uncover information which could lead the employer or investigator to a better conclusion about the claimant's Key Week contact.

      If State law and/or policy permits job contacts made during other weeks to be applied to the Key Week, then verifications must be made on all such contacts. Theseverifications are to be made following the same guidelines for Key Week contacts.

      If SESA records or the investigation indicates that the claimant is a union member and obtains work through that union, verification must be made with the union following the general guidelines for verifying work search contacts. This is done to detect potential issues resulting from union referrals to employers, referral refusals, or job refusals and to confirm that any deferrals from Job Service registration and/or work search requirements have been properly granted.

      In all cases, the work search verification form(s) must indicate the method used to verify the contact.

    6. Employer Interviews.  Contact with all prior or current employers, with whom employment could affect the Key Week, must be made by the investigator to verify the facts and reason for separation, base period wages, and benefit year earnings.

      The primary method for verifying wages and earnings is by use of telephone/FAX. States may choose to utilize the secondary methods of wage verifications, in-person or mail, at their discretion. If issues arise, SESA law and policy should be the catalyst in determining if in-person follow-up is necessary.

      The primary method for verifying separation information from employers is by telephone/FAX. In-person contacts may be necessary to obtain information on new or mishandled issues or other circumstances dictated by State Law, policy or procedures. All contacts must be made in accordance with accepted factfinding procedures. The name and position of the person providing the information must be obtained.

      Interstate wage/earnings/separation verifications are to be done by the liable State utilizing the telephone/FAX or mail methods. If circumstances prevent the liable State from obtaining the information, the agent State should be requested to obtain the necessary information using all methods available.

      When changes in wages/earnings/separations are detected via phone/FAX/mail, in-person follow-up may be necessary if SESA law or policy requires signatures or other documentation to effect official determinations. If contacts with an employer or review of UI records indicate potential fraud, further investigation must be conducted in-person.

    7. Third Party Verifications. Third party verifications are required when issues arise that could affect a claimant's eligibility. The primary method for verifications is by telephone/FAX.

      Potential able and available issues related to medical condition, school attendance, etc., may be verified by telephone/FAX.

      Registration with Job Service may be verified and documented by obtaining a printout or a copy of the Job Service records which indicate whether the claimant is actively registered for referral during the Key Week.

      Prior verification by the SESA of alien status will be acceptable for QC purposes if properly documented. If SESA records are inadequate to verify alien status, QC must conduct verification.

      Interstate third party and other verifications should be completed by the liable State using the primary method of telephone/FAX to the extent possible. Agent State assistance may be requested where necessary.

    8. Disqualifying/Deductible Income Verifications.  Verifications must be made of receipt of all remuneration which could directly affect the Key Week for which claimants could bedisqualified or have benefits reduced.

      The primary method for verifying this income is by use of telephone/FAX. States may choose to utilize the secondary methods of verification, in-person or mail, at their discretion.

    9. Dependency Eligibility   . In States with dependency allowance provisions in their laws, the investigator must verify the dependents who were claimed. This verification must, at a minimum, consist of the methods prescribed by State law and/or policy.

    10. UCFE.  The same investigative procedures should be applied to cases involving Federal employers. QC staff should work with the SESA's Federal Programs Coordinator to determine the most expedient way of obtaining wage and separation information from Federal installations.Form ES-936 may be utilized to obtain wage and separation information from a Federal employer. The Federal Programs Coordinator may also be able to assist QC investigators in gaining access to Federal installations for the purpose of in-person work search verifications.

      Additionally, the review of the original claim file must include examination of the response from the Louisiana Claims Control Center (LCCC) to ensure that the Federal wages were not used more than once to pay a claim. If no documentation is on file to indicate that the LCCC was notified of the claim, QC is to initiate a request as specified in the UCFE Handbook (No. 391) and examine the response from LCCC when it is received.

    11. UCX.  In-person employer contacts are not to be made with the military. Verifications of military wages and separations are accomplished through review of claims documents.

      When a UCX claim is taken, the SESA sends an inquiry to the LCCC. The LCCC response to each inquiry enables the SESA to (1) validate the legitimacy of the DD-214 which the claimant used to establish the claim and (2) detect duplicate claims. The response contains the following data:

      • beginning and ending dates of military service,

      • tabulation of net amount of time served,

      • number of days of accrued leave paid,

      • character of service, pay grade, and

      • date of receipt by LCCC of any previous notice of claim filed.

      QC must compare the DD-214 to the response from the LCCC to verify that the wages have not been previously assigned. The pertinent information on the DD-214 must be compared with the corresponding information on the LCCC response to ensure that the DD-214 has not been altered. Ensure that the information on the claims documents has been accurately copied from the DD-214. Also, ensure that the monetary determination was based on the appropriate Federal Schedule of Remuneration, i.e., the one in effect at the time the claim was filed.

      Copies of the DD-214, the response from the LCCC, and the Federal Schedule of Remuneration should be retained in the QC case file.

      If the LCCC has not been contacted, or if potential issues have not been resolved, they must be pursued by QC.

    12. Interstate Requests.

      The standard rule for QC interstate activities is that the same procedures which apply to intrastate QC activity also apply to interstate. However, it is the final responsibility of the liable State to obtain all the necessary data to complete the case investigation.

      Claimant interviews, for interstate claimants, must continue to be done in person. If the claimant is located beyond the liable State's normal interstate travel range, the agent State must be requested to conduct an in-person interview. If an in-person interview is not possible by the agent State it must be documented and explained, and obtained by other means, i.e., telephone or mail if possible.

      Benefit year earnings, Requalifying Wages, and Base Period Wage Verifications should be done by the liable State using telephone/FAX or mail as the primary methods of verification. If the verification cannot be obtained by the liable State, the agent State should be requested to obtain the necessary information using all methods available to it.

      Separation information should be obtained by the liable State using telephone/FAX or mail methods. If unable to obtain adequate information or if in-person contact is necessary to obtain information on new or mishandled issues, agent State assistance should be requested.

      Interstate work search verifications must be done in-person. However, the exceptions which apply to intrastate contacts also apply to interstate contacts. When an in-person verification is necessary beyond the liable State's normal interstate travel range, the agent State must be requested to conduct an in-person verification. If an in-person verification is not possible by the agent State, it must be documented and explained, and obtained by telephone/FAX, or mail if possible.

      Third party and other verifications should be done by the liable State using the primary method of telephone/FAX to the extent possible. Assistance may be requested of the agent State where necessary.

    13. Summary of Investigation.

      Each completed case must contain a Summary of Investigation. Each SESA must develop a format which includes, at a minimum, a narrative that explains the pertinent facts of the case: the basis for any decision, and any complexities of the case, e.g., difficulty obtaining information, evaluation of statements taken, reasons for delay, or any special circumstances that occurred. Alternately, this may be satisfied by appropriate reference to explanations elsewhere in the case file. In order for each case to be able to stand on its own, the Summary must be substantiated by documentation in the case file.

    14. Appeals.  All appeals hearings resulting from QC determinations affecting the Key Week must be attended by the QC investigator responsible for obtaining the information which led to the determination. The investigator will provide testimony concerning any questions on the QC process and the facts upon which the determination was based. When an appeals hearing is not attended by a QC staff member, an explanation must be provided in the QC case file.

    15. Completion of Cases and Timely Data Entry.  Prompt completion of investigations is important to ensure the integrity of the information being collected by questioning claimant and employers before the passage of time affects recollections. Associated data entry is necessary for the Department to maintain a current data base and to monitor SESA performance. Therefore, the following time limits are established for completion of all cases for the year (this includes all batches of weeks ending in the Calendar Year):

    A case is complete when the investigation has been concluded as required, all official actions for the Key Week (except appeals)have been completed, the supervisor has signed off, and the results have been entered into the computer.

    If a SESA's rates for completion of cases sampled for investigation for any 12-month period ending December 31 are less than the time lapse requirements, the Department will determine, based upon information supplied by the SESA, whether or not good cause existed for not achieving the requirements.