TX HHS Form H1052-IME. Notice of Delay in Decision for Incurred Medical Expense Action Needed

The TX HHS Form H1052-IME, Notice of Delay in Decision for Incurred Medical Expense, is a crucial document that helps resolve delays in processing medical expense claims. This form is typically used by individuals or authorized representatives who need to notify the Texas Health and Human Services (HHS) about the status of their incurred medical expense deduction.

The form requires specific information from the recipient, including name, address, and details about the provider and place of care. It also outlines conditions for processing the claim, such as the need for an original signature on attached forms. The notice emphasizes the importance of returning the completed form to HHS by a specified date to facilitate further action.

Key features of this form include the requirement for original signatures, specific coding information (CDT and HCPCS), and a privacy notice regarding co-pay amounts. By filling out this form, individuals or authorized representatives can ensure that their medical expense claims are processed efficiently and accurately. To complete the process, it is essential to follow the instructions outlined in the form and return the completed document to HHS by the specified deadline.

• This form is used for delayed decisions on incurred medical expense deductions.
• Requires specific information from the recipient, including name, address, and provider details.
• Outlines conditions for processing claims, such as original signatures and coding information.
• Must be returned to HHS by a specified date to facilitate further action.