Form H1270, Data Integrity SAVERR Notification

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Effective Date: 1/2007


Updated: 4/2007


To notify Data Integrity state office:

  • that an adjustment is required on the eligibility file to reflect the beginning date of vendor (TP 14/BP 10) coverage when a client transfers from a non-vendor MAO program;
  • that an adjustment is required on the eligibility file to reflect the correct dates of change from one MAO TP/BP to another; and
  • of any other adjustment required on the eligibility file that cannot be completed with Form H1000-A or Form H1000-B.


When to Prepare

Prepare Form H1270 when the client transfers from a non-vendor program to TP 14/BP 10 or transfers from one TP/BP to another, or other client information needs correction and processing edits do not permit entry of the:

  • correct effective date of vendor coverage for periods before the Form H1000-B program transfer effective date;
  • correct effective date of any other program transfer;
  • correct medical effective date; or
  • correction of any other information on the eligibility file (for example, SSN, date of death, etc.).

Requests for correction of a Social Security claim number are sent via memorandum to:

Data Integrity Section
State Office, Y-922

Number of Copies

Print a copy for the case record (and for mailing purposes, if sending the form through regular mail channels).


If a paper copy is being mailed, send the document to Data Integrity, State Office, Y-922, reporting only type program (TP) / base plan (BP) changes (no applied income information). File a copy in the case record.


The form may be saved and electronically mailed to Data Integrity. Before electronic transmission, the document must be saved under the client's name. The file name will be: last name.doc. Examples:

Client name: John Doe
Entered as: DOE.doc
Saved as: DOE.doc

Transmit the form under its "Saved As" name (i.e., DOE.doc) to Data Integrity's electronic mailbox:


Note: Do not transmit Form H1270 directly to a specific individual. The electronic mailbox is checked daily and will ensure prompt action by staff.

Reminder: Certain programs (TP 14/BP 20 and TP 23/BP 13) allow date-specific changes to be entered in Items 149 - 151. The program transfer effective date for these programs is controlled by information entered in this section, rather than by Form H1000-B process effective date. Before initiating a force change request, review the OPEN/CLOSE dates shown on the client eligibility file to determine if the coverage change is already reflected.

Example: A TP 14/BP 20 client enters a nursing facility on 05-02-00; case action transferring the case to TP 14/BP 10 is completed on 06-20-00; TP 14/BP 20 end date of 05-01-00 is entered in Item 151 to close CA services; Form H1000-B process effective date is 07-01-00. Client eligibility file shows that TP 14/BP 20 coverage closed on 05-01-00 and TP 14/BP 10 coverage opened on 05-02-00. No Form H1270 is necessary.

The Medicaid for the Elderly and People with Disabilities (MEPD) specialist enters retroactive applied income adjustments (if any) into the Service Authorization System (SAS) at the time the case action is completed or after 12 days if the reconciliation resulted in an increase. In situations where Form H1270 is required, the applied income information will be available in SAS when the force change is completed. If retroactive applied income adjustments are made, the client is sent Form H1259, Correction of Applied Income, with a copy to the facility.

Form Retention

Keep the case record copy according to the retention requirements of the case record.

Detailed Instructions

From — Enter the name of the MEPD specialist completing the form.

Mail Code — Enter the MEPD specialist's mail code.

Telephone Number (inc. A/C and extension) — Enter the MEPD specialist's telephone number (including area code and extension).

Date — Enter the date the MEPD specialist completes the form.

Reminder: This section serves as a reminder that prior to initiating this force change request, review the coverage dates on the client eligibility file to determine if coverage is already reflected.

Client Name — Enter the client's name in the following format: First Name, Middle Initial, Last Name.

Client Number — Enter the nine-digit client/recipient number.

From — Check the appropriate TP/BP box or enter the type program/base plan from which the client transferred, if the adjustment is due to a program transfer.

To — Check the box labeled TP 14/BP 10, or check the other box and enter the TP/BP to which client transferred (if other than TP 14/BP 10).

Effective Date — Enter the date that the new coverage should begin.

Date 1000-B Submitted — Enter the date Form H1000-B was processed.

Adjustment Dates Needed — Enter the beginning and ending dates (from/through) for which an adjustment is required on the eligibility file (i.e., dates prior to the effective date of the Form H1000-B sequence reflecting the program transfer coverage). Example: 08/20/97 through 09/30/97

Other Corrections — Enter the information to be used to correct other data on the eligibility file (for example, correction of a validated SSN, medical effective date, etc.). Please keep comments/explanations brief.

Reason(s) for Request — Mark the appropriate box indicating that a Data Integrity correction is being requested due to:

  • Coverage is being changed due to a decision by the hearing officer and coverage cannot be added by completing Form H1000-A/B. Provide a copy of the hearing officer's final decision and order.
  • Three months prior benefits were not included on the application with ongoing eligibility and coverage cannot be added by completing Form H1000-A/B.
  • Initial coverage was not provided from application month and coverage cannot be added by completing Form H1000-A/B.
  • Coverage must be added for the months preceding the Form H1000-B effective date of a program transfer.
  • Use "Other" for any situation not listed and/or to provide additional comments/information to Data Integrity staff. There are a maximum of three lines available for comments/information.

Reminder: Addition of coverage should be completed using Form H1000-A or Form H1000-B whenever possible. This allows benefits to become immediately available to the client.

Applied Income Adjustments — The MEPD specialist enters any required retroactive applied income adjustments into the Service Authorization System (SAS). The MEPD specialist also sends Form H1259, Correction of Applied Income, to the client and to the facility.


Data Integrity will not return Form H1270 to the MEPD specialist confirming completion of a force change, except in instances where the requested change could not be made.

When a change to the client record cannot be made exactly as requested, Data Integrity will notify the MEPD specialist of the change that was made and the date (MM/DD/YY) the correction was made.

Comments — If the requested action cannot be taken, Data Integrity enters an explanation.

Name/Signature — Data Integrity — Data Integrity staff sign/type name on this form before returning the form to the MEPD specialist.

Date — Data Integrity staff enter the date (MM/DD/YY) of the above signature.