- To document original denials that do not require completion of Form H1200.
- To document a special review NOT involving the rebudgeting of income (including variable income) and/or incurred medical expenses.
When to Prepare
If it is apparent from the information on the Form H1200 that an applicant is ineligible, the worker completes Form H1202-B to document a determination of the original denial.
If completion of a new Form H1200-A, Medical Assistance Only (MAO) Recertifications, is not required, the eligibility specialist completes Form H1202-B to document non-review activity and incomplete reviews NOT involving the rebudgeting of income (including variable income) and/or incurred medical expenses.
Note: Form H1202-A is used to document budget changes and income/incurred-medical-expense reviews.
Number of Copies
The eligibility specialist completes an original Form H1202-B in legible handwriting. For special reviews, the eligibility specialist files the form in the case record on top of the last complete review. For original denials, the worker files the form in the case record behind the corresponding Form H1200.
Form H1202-B is kept in the case record for three years after the case is denied.
Complete/Incomplete/Non-Review— Check the appropriate box to indicate whether this is documentation of a complete review, an incomplete review, or a non-review. The "Complete" box should be checked for original denials.
Identifying Information— Enter the client name, application/client number, category, and type program. Enter the same information for the client's spouse, if any.
Check the appropriate box to indicate the type case; that is, individual, companion, or couple. Enter the source of the information and the date the information is obtained.
Comments/Verification— Use this section to document the case action and supporting verification(s).
Agency Action— Check the appropriate box to indicate whether the case is being denied or sustained.
Action Code— Enter the action code used on the Form H1000-A/B; the special review date, if appropriate, and the reason; the date Form H4808 is sent, if appropriate; and the date of the 1000-A/B transmittal.
Signature/Date— The worker completing the form signs his name and enters the date of the signature.