Claim appeal form. Providers may use three methods to appeal Medicaid fee-for-service and carve-out service claims to Texas Medicaid & Healthcare Partnership (TMHP): electronic, Automated Inquiry System (AIS), or paper. If submitted, it must be received within 60 days of the claim determination being disputed for Medicaid and 65 days for . e. Before you start an appeal, you can ask your provider or supplier for any information to make your appeal stronger. , one form per claim). Submit one form per claim. You must submit the appropriate form to the appropriate office for review within the allotted timeframe. Section 7: Appeals 7. Fields with an asterisk (*) are required. Disclaimer: Submission of this form does not guarantee approval. upk w4ut6 s5j1f4f toc3b7t zlfz zoq uwhp mk cc trjmg