Intake Investigation Referrals (FRED)
Overview
The intake investigation referral process is known as FRED. It is primarily used by intake workers, a FRED referral may also be initiated by a continuing worker in many circumstances. For example, the continuing worker should initiate a FRED referral if there are reasonable grounds for suspicion of fraud when adding a program to an existing case or restoring benefits when the client reapplies within one month of discontinuance.
The primary intent of the FRED program is to discover fraud before the applicant is granted any type of assistance (i.e. to stop fraud before it happens). In addition, it is believed that FRED will reduce the number of overpayment/overissuance calculations and collections.
Referrals for early fraud investigations on Medi-Cal only cases at the point of Intake, are not processed by the SIU investigative staff. Medi-Cal only referrals are done using the “Confidential Medi-Cal Complaint Form” (MC 609). These referrals are processed by Investigators from the DHCS Investigations Branch in Sacramento.
Refer to “Overpayment Rules,” page 49-23 of the Medi-Cal handbook for detailed information regarding the process of MC overpayments.
Prior to Referral
Prior to making a referral to FRED, the EW must refer to Pre-Referral Requirements, When to Refer, and Possible Criteria for FRED/General On-Going Fraud Referral. This ensures that the referral is appropriate based on reasonable suspicion and prevents erroneous referrals that based solely on eligibility problems or administrative errors.
Time Frames
A referral to FRED should be made immediately and prior to completion of the application or prior to the granting of benefits. The SIU shall investigate these cases on a priority basis in order to resolve any questions of possible fraud in time to allow the county to complete the determination eligibility with the time limits imposed upon the particular program. The information concerning a referral to the SIU shall not be disclosed to any unauthorized persons. Investigators are to be allowed five (5) days from the receipt of the referral to complete a FRED investigation.
SIU will have three days (72 hours) to complete the FRED investigation, if a client is eligible for CalWORKs Immediate Need (IN), Homeless Assistance (HA), CalFresh Expedited Service (ES), or Medi-Cal Immediate Need (client is pregnant or needs immediate medical care). It is not intended that a FRED referral delay the eligibility determination process. However, a delay of one to two days in the approval and issuance of benefits may occur in certain situations, based on EW Supervisor or manager approval.
Initiating A Referral
There are two methods that may be used to initiate a FRED referral.
| If the referral is for. . . | Then the EW must. . . |
| CalWORKs, General Assistance, IHSS, CalFresh or Child Care, |
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| Medi-Cal only, |
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Note: If the fraud investigator requires any additional information, he/she will contact the EW. The EW must take immediate action to comply with the Investigator’s request.
EW Action - Pending Investigations
After the referral for investigation is made, the Intake EW is expected to reply promptly to requests for case information from the Investigator and continue to take action as follows:
| IF IT IS DETERMINED THAT: | THEN... |
| The applicant is ineligible and the investigation is still pending, |
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| Apparent eligibility for CalWORKs exists and the applicant meets the specific requirements for Immediate Need (IN), |
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| Apparent eligibility for CalWORKs exists and the applicant meets the specific requirements for Homeless Assistance (HA), |
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| Apparent eligibility for CalFresh exists and the applicant meets the specific requirements for Expedited Services (ES), |
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| Apparent eligibility for Medi-Cal exists and the applicant meets the specific requirements for Immediate Need (pregnant or needs Medi-Cal within two days), |
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The Intake EW must immediately (i.e. no later than the close of that business day) inform the Investigator, either verbally or in writing, of any other case changes relevant to the investigation. For referrals, if the Investigator is unavailable, the EW must contact the SIU Justice System Clerk.
It is important for the assigned EW to understand the role of the SIU Investigator. The Investigator's role is NOT to determine eligibility. That is the role of the assigned EW. The Investigator is responsible for confirming or denying the accuracy of the information provided by the applicant in applying for benefits.
Note: Eligibility determinations should not be delayed past the program processing timeframe due to a pending investigation. If the household has complied with all necessary requirements benefits need to be approved without delay.
Investigator Action - SIU
Upon receipt of the FRED referral, the SIU support staff will enter such referral into the SIU database and assign it a SIU case number. The Supervising Welfare Fraud Investigator (or designee) will assign the referral to a SIU Investigator.
Upon receipt of the FRED referral, the SIU Investigator will:
- Notify the EW that the referral has been assigned and ask if there is any change in the situation.
- Conduct an investigation to gather facts that prove or disprove the allegations.
- Inform the EW verbally, of the findings of the investigation.
- Complete an investigation report with all information which supports his/her findings, within 7 working days.
- Email a copy of the report to the EW and TMT Priority Assignment.
Investigator Action - DHCS
Upon receipt of the referral, the DHCS Investigator will:
- Conduct an investigation to gather facts that prove or disprove the allegations.
- Inform the EW via telephone call (within 10 days) of the results of their investigation.
- Send to the EW (within three days of the telephone call) the Investigator's Report with all information which supports his/her findings.
- Attach a “FRED Eligibility Action Report” to the Investigator's Report, for completion by the EW.
EW Action on Completed Investigations
Once the investigation is completed a Fraud Referral Report will be sent to the client's assigned EW for action.
- Evaluate the investigation report as it affects case/person eligibility. Seek clarification from the Investigator, if needed.
- Review all eligibility factors.
- Attempt to resolve any inconsistencies resulting from the investigation, that may affect eligibility/ineligibility. EXAMPLE: The client applies for CalWORKs for herself and two children based on absence of the children's father. The investigation places the unemployed father in the home. The EW shall contact the client and explore U-Parent deprivation.
- Take appropriate action to approve, deny or discontinue the case or any ineligible person, and document the action taken on CalWIN Maintain Case Comments window.
- Send an electronic "Fraud-Referral Disposition" referral [Need] response to SIU via CalWIN Client Referral System with information on the action taken on the case.
- For Medi-Cal only cases, complete the "Confidential Medi-Cal Complaint Form" (MC 609) and forward it to DHCS.
- Submit the completed investigation report for IDM scanning following District Office procedures.
- Attach a copy of the investigation report to the referral to DCSS, if the information is connected to the Absent Parent referral. If a DCSS referral has previously been made, send a copy of the Investigator's report to DCSS using the “SSA/DCSS Communication Form” (SCD 1603).
SIU Investigator Disagreement With EW Action
| IF... | THEN... |
| The SIU Investigator disagrees with the action taken by the EW, | The SIU Investigator shall bring the issue to the Supervising Investigator for resolution. |
| The Supervising Investigator is unable to resolve the issue with the investigator, |
The Supervising Investigator will discuss the issue:
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