A-880, Documentation Requirements

Revision 21-2; Effective April 1, 2021

Medical Programs


  • Verification of income and unpaid medical bills for the three months prior coverage.
  • Medical insurance other than Medicaid.
  • Method of income computation.
  • Eligibility for transitional Medicaid.
  • Reason for assigning less than the maximum transitional Medicaid coverage.
  • Denial of TP 20 because spousal support payments stopped.
  • Reason for action on a Medicaid EDG.
  • Gross earnings and the dates the person received the earnings.
  • Cost of health insurance premium for the child(ren) before certifying for CHIP.
  • Name and phone number of state hospital employee.

If the household requests continuation of Medicaid for children aging out of TP 44, follow policy in A-825, Medicaid Termination, and document that the child:

  • is hospitalized on their 19th birthday;
  • remains hospitalized through the end of their eligibility period; and
  • meets all other criteria according to A-825 .

If providing prior coverage for more than three months, follow policy in A-831.2.1, Reopening Three Months Prior Applications, and document that:

  • there was an application on file to cover any of the prior months; and
  • the file date on the application was used to cover these months.

TP 40

Document the pregnancy verification method and the anticipated delivery date.

Related Policy
Medicaid Termination, A-825 
Reopening Three Months Prior Applications, A-831.2.1 
Third-Party Resources, A-860 
Documentation Requirements, A-950
Documentation, C-940