Revision 20-4; Effective December 1, 2020
Form TF0001, Notice of Case Action, is used to notify a recipient, authorized representative (AR), or both that a request for an IME deduction is approved or denied.
Form TF0001P, Provider Notice of Case Action, is used to notify the nursing facility that a co-payment adjustment has been approved.
For approved IME requests, TIERS automatically generates Forms TF0001 and TF0001P with the following information:
- a note that the co-payment adjustment is for an IME allowance and that the funds must be used to pay the IME provider;
- the reason for the IME adjustment (receipt of dental services or durable medical equipment);
- the date the IME item or service was received; and
- the total amount of the IME allowance.
For denied IME requests, TIERS automatically generates Forms TF0001 and TF0001P, but the forms do not reflect changes in the co-payment or provide a reason for denial when the IME request is denied.
IME Provider Notice
For both dental or durable IME requests, use Form H1053-IME, Provider Notice of Incurred Medical Expense Decision, to notify an IME provider that a request for an IME deduction is approved or denied.
- If the IME request is approved, the form will list the services and total amount of the IME allowed.
- If the IME request is denied, the form will list the services not allowed, and staff manually add additional comments to why the IME request was denied.
- Do not add co-payment information to this form.
Reminder: To safeguard confidentiality, do not provide the co-payment amount to any provider (either verbally or in writing) without written authorization from the recipient or the recipient’s AR.
Request for Verification of Delivery
When an IME request does not include proof of delivery or verification of the date services were provided, use the following forms to request verification of receipt of services from the recipient or the recipient’s authorized representative (AR). Do not send the request to the provider. The provider may assist the recipient in providing the requested information, but the recipient or the recipient’s AR must complete the form.
- For durable IME requests, use Form H1051-IME, Receipt of Durable Medical Equipment.
- For dental IME requests, use Form H1054-IME, Proof of Dental Services.
Notice of Delay
For both dental or durable IME requests, use Form H1052-IME, Notice of Delay in Decision for Incurred Medical Expenses, to:
- Notify the recipient of a delay in processing an IME request when the following information is needed on Form H1263-A, Certification of Medical Necessity – Durable Medical Equipment, or on Form H1263-B, Certification of No Medical Contraindication - Dental:
- the written signature of the recipient or authorized representative; or
- a description of the authority to sign for the recipient.
- Notify the IME provider of a delay in processing an IME request when the following information is needed:
- current dental terminology (CDT) or health care common procedural coding system (HCPCS) codes;
- the written signature of the attending practitioner on Form H1263-A or Form H1263-B; or
- other information.