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2. Proof that payment was made by the beneficiary or a person legally responsible for the beneficiary between the date of the erroneous denial and the date of the successful appeal decision. The completed form and required documentation is returned to the appropriate department representative. D. If either the bill or proof of payment is not included with the Application form, the Medicaid agency representative offers to assist the beneficiary in obtaining the required documentation and sends a reminder notice requesting return of the required information within thirty (30) days from the date of receipt of the Application for Reimbursement form. If all documents are not received within thirty (30) days, or if the documentation provided indicates that medical service or payment was not made between the date of Medicaid denial (or termination) and the date of Medicaid acceptance (or reinstatement), the agency representative denies the request for reimbursement. E. Otherwise, the agency representative forwards a referral form, attaching the beneficiary's written request for reimbursement and all supporting documentation to the Medicaid agency for a decision on payment. The Medicaid agency is responsible for providing the individual with written notification of the agency's decision and rights to appeal.