Effective Date
Instructions
Updated: 3/2026
Purpose
To notify a dental provider, durable medical equipment provider, or insurance provider that an incurred medical expense (IME) deduction request is approved or denied.
Procedure
When to Prepare
Complete this form when a request for an IME deduction was approved or denied.
Number of Copies
An original and one copy.
Transmittal
The form is only sent to the provider.
Detailed Instructions
Provider Name and Address — Enter the name of the provider and the provider’s full mailing address.
Date — Enter the date of the notice.
Case No.— Enter the TIERS case number.
Section 1 – Recipient Information
Name of Recipient — Enter the full name of the Medicaid recipient.
Recipient Individual No. — Enter the individual number of the Medicaid recipient.
Facility Name — Enter the name of the facility where the recipient lives.
Facility Address — Enter the full address of the facility where the recipient lives.
Provider Name — Enter the name of the dental provider, durable medical equipment provider or insurance provider.
Provider Address — Enter the full address for the provider.
Section 2 – Approval of Incurred Medical Expense
The request for _________ is approved. — Enter the approved item or items based on case information.
Total amount approved _________. — Enter the monthly expense for open-ended IMEs or the total expense for one-time IMEs. If the expense is open-ended, select Monthly checkbox.
The recipient’s co-payment amount is adjusted effective _________ and is ongoing. _________ ending _________. — Enter the first month of the co-payment adjustment. Select ongoing If the IME is an open-ended expense. Select ending if the IME is a one-time expense and enter the last month of the co-payment adjustment.
Section 3 – Denial of Incurred Medical Expense
The request for _________ is not approved. — Enter the denied item or items based on case information.
Comments — Enter the reason for denial. Enter more comments if necessary.