TX HHS Form 5205. Breast and Cervical Diagnostic Procedure Complication Reimbursement Request

The TX HHS Form 5205, "Breast and Cervical Diagnostic Procedure Complication Reimbursement Request", is a tool used to request reimbursement for medical complications resulting from breast or cervical diagnostic procedures. This form should be completed by case managers, patient navigators, or contacts when a client experiences a complication following a procedure such as CO-percutaneous biopsy, LEEP conization, breast biopsy, excisional or incisional treatment.

The form requires contractor information, including name, phone number, and email address. It also asks for client information, including name, date of birth, and medical ID number. The most critical section is the "Complication occurred following which procedure" field, where the type of procedure that led to the complication must be specified. Additionally, the form requires a list of medical care and services received by the client following the complication.

This form should be used when a client experiences an adverse event or complication after undergoing a breast or cervical diagnostic procedure. The completed form, along with supporting documentation, should be emailed to [email protected] for reimbursement processing.