H-2900, IME Notices

Revision 26-1; Effective March 1, 2026

Form TF0001, Notice of Case Action, notifies 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, notifies the nursing facility that a co-payment adjustment has been approved.

For approved IME requests, the system automatically generates and mails 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 such as 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, the system automatically generates and mails 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 open-ended and one-time 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 lists the services and total amount of the IME allowed.
• If the IME request is denied, the form lists the services not allowed. Manually add comments to explain why the IME request was denied.

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 authorized representative (AR).

Request for Verification of Delivery

Use the following forms to request verification of receipt of services from the recipient or the recipient’s AR when an IME request does not include proof of delivery or verification of the date services were provided. Do not send the request to the provider. The provider may help the recipient provide the requested information, but the recipient or the recipient’s AR must complete the form.

• Use Form H1051-IME, Receipt of Durable Medical Equipment for durable IME requests
• Use Form H1054-IME, Proof of Dental Services for dental IME requests.

Notice of Delay

Use Form H1052-IME, Notice of Delay in Decision for Incurred Medical Expenses – Action Needed, for both dental and durable IME requests 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 Other IME, 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.

Related Policy

Deduction of Incurred Medical Expenses (IMEs), H-2100
IME Budget Adjustments Due to Death, H-2310
Notices, R-1300