TX HHS Form H1053-IME. Provider Notice of Incurred Medical Expense Decision

The Provider Notice of Incurred Medical Expense Decision (Form H1053-IME) is a crucial document that helps resolve disputes between healthcare providers and recipients regarding medical expenses. This form is typically used in situations where the provider seeks approval or denial of incurred medical expenses, ensuring that both parties are aware of their responsibilities and obligations.

The form requires specific information from the recipient, including their name and individual number, as well as facility details such as name and address. The request for incurred medical expense is either approved with a total amount and ongoing co-payment adjustment or denied with comments provided. It's essential to note that confidentiality is safeguarded by only providing co-payment amounts to providers with written authorization from the recipient or authorized representative.

Key features of this form include the approval or denial of incurred medical expenses, adjustments to co-payments, and the requirement for written authorization for confidential information sharing. The following key points summarize the use of Form H1053-IME:

• The form is used by healthcare providers to seek approval or denial of incurred medical expenses.
• It requires specific recipient information, including name and individual number, as well as facility details.
• The request for incurred medical expense is either approved with a total amount and ongoing co-payment adjustment or denied with comments provided.