Notice of Decision

Body

Revision 13-4; Effective October 1, 2013

CHIP, CHIP Perinatal

Form TF0001, Notice of Case Action, advises the household of the:

potential household eligibility and who is potentially eligible;

need for the household to return a health plan selection and enrollment fee, if required;

reason the application was denied, terminated or reinstated;

effective date of the denial, termination or reinstatement; and

right to request a review.