View Ineligible Decisions
Retroactive Month 1
| Coverage Type | Household Member | Primary Client | From | To | ||
|---|---|---|---|---|---|---|
| [Benefit Sample] | [field-value] | [A. Name] | [Date] | [Date] |  |
Retroactive Month 2
| Coverage Type | Household Member | Primary Client | From | To | ||
|---|---|---|---|---|---|---|
| [Benefit Sample] | [field-value] | [A. Name] | [Date] | [Date] | |
Retroactive Month 3
| Coverage Type | Household Member | Primary Client | From | To | ||
|---|---|---|---|---|---|---|
| [Benefit Sample] | [field-value] | [A. Name] | [Date] | [Date] | |