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3. Reimbursement is only available if the original decision was reversed. Reimbursement is not made, for example, if the original decision is reversed because information or documentation, not provided during the application period, is provided at the time of the appeal. 4. The beneficiary submits the following: a. A completed Application for Reimbursement form; b. A copy of the medical provider's bill or a written statement from the provider which includes the date and type of service; c. Proof of the date and amount of payment made to the provider by the beneficiary or a person legally responsible for the beneficiary. A cash receipt, a copy of a canceled check or bank debit statement, a copy of a paid medical bill, or a written statement from the medical provider may be used as proof of payment, provided the document includes the date and amount of the payment and indicates that payment was made to the medical provider by the beneficiary or a person legally responsible for the beneficiary. 5. Payment for the medical service was made during the period between a denial of Medicaid eligibility and a successful appeal of that denial. That is, payment was made on or after the date of the written notice of denial (or the effective date of Medicaid termination, if later) and before the date of the written decision issued by the EOHHS Appeals Office, or decision by the Regional Manager/Chief Casework Supervisor after, reversing such denial is implemented (or the date Medicaid eligibility is approved, if earlier). 1.8 Procedure and Notification A. Notices of Medicaid ineligibility provide applicants and beneficiaries with information about their rights to appeal the agency's decision. These notices also contain specific information about the availability of direct reimbursement if a written appeal is filed and the State’s initial decision is overturned as incorrect. The rules governing appeals and hearings are located in "Appeals Process and Procedures for EOHHS Agencies and Programs" (Subchapter 05 Part 2 of this Chapter) regulations. B. The EOHHS Appeals Office must provide individuals who may qualify with an Application for Reimbursement form to request repayment for medical expenses which they incurred and paid while their appeal was pending. C. The individual must complete and sign the Application for Reimbursement form and include: 1. A copy of the provider's bill showing date and type of service; and