Form H1052-IME, Notice of Delay in Decision for Incurred Medical Expense – Action Needed

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Effective Date: 6/2019


Updated: 3/2019


To notify the recipient or authorized representative of a delay in processing the deduction for incurred medical expenses (IME) when the:

  • signature of the recipient or authorized representative is missing on Form H1263-A, Certification of Medical Necessity – Durable Medical Equipment or Other IME, or Form H1263-B, Certification of No Medical Contraindication – Dental;
  • signature of the recipient or authorized representative is not an original signature on Form H1263-A or Form H1263-B; or
  • authority to act for the recipient is not complete on Form H1263-A or Form H1263-B.

To notify providers of a delay in processing the deduction for IME when:

  • Current dental terminology (CDT) codes are needed;
  • Healthcare common procedural coding system (HCPCS) codes are needed;
  • the original signature of the attending practitioner is needed; or
  • other information is needed.


When to Prepare

Complete this form when items are needed and when processing of the IME request is delayed beyond the 10-day time frame.

Number of Copies

An original and one copy.


The form is sent to the recipient at their address or that of the authorized representative. This form is sent to the provider if the information is needed from the provider.

Form Retention

Keep one copy in the case record.

Detailed Instructions

Name and address: — Enter the name of the applicant or recipient and mailing address, or the address of the applicant or recipient's client's authorized representative, or enter the provider's name and address.

Date — Self-explanatory.

Case number — Self-explanatory.

HHSC contact information — Self-explanatory.

Return the item marked below with this letter by — Enter 10 days from the current date. The day the form is sent out is day zero.

For recipients or authorized representatives — Check the box needed.

For authorized representatives — Check the box, if needed.

For providers — Check the box needed. If other, enter the items needed.