How to Complete and Submit the TMHP Provider Appeal Form

There is no standalone TMHP provider appeal form. To appeal a denied or underpaid Texas Medicaid claim, you send the Texas Medicaid & Healthcare Partnership a copy of the Remittance and Status (R&S) Report page with the disputed claim circled, a written explanation of what was wrong, and any supporting documentation. You can submit it electronically through TexMedConnect, by phone through the Automated Inquiry System for simple corrections, or by paper mail. TMHP must receive the appeal within 120 days of the R&S Report date on which the denial or payment appears.¹

First Decide Whether You Actually Need an Appeal

Not every problem claim calls for an appeal. If the claim was rejected because of wrong patient demographics, an incorrect procedure code, a missing modifier, or missing coordination-of-benefits information, a corrected claim resubmitted through TexMedConnect or EDI is faster. Electronically rejected claims that show on the 277CA response file can be corrected and resubmitted within 95 days of the date of service.²

An appeal is the right route when TMHP has processed the claim and you believe the result was wrong: medical necessity denials, prior authorization disputes, incorrect eligibility terminations, and wrong reimbursement rates. The appeal is a formal request to reconsider a claim that already received a disposition on the R&S Report.¹

What Goes in the Appeal Packet

Because there is no form to complete, the packet itself is the appeal. Gather these items before you start, no matter which submission method you use:

The R&S Report page showing the specific claim you are disputing. For paper, you will send a copy with the claim circled; for electronic, you will pull the data from it.
The National Provider Identifier for the billing provider, performing provider, referring provider, and any limited provider on the claim. TMHP uses NPI as the primary provider identifier.
The client’s Medicaid number, name, and date of birth.
The exact dates of service tied to the disputed claim.
A written explanation that identifies what was wrong with the original adjudication and states the correction you want.
Supporting documentation: clinical notes, prior authorization letters, proof of timely filing, or other records that back your position. Utilization review appeals must include a completed Business Records Affidavit (available on the TMHP forms page) with the medical record.

Each appeal covers one claim. Disputing five claims means preparing five separate R&S Report copies.³

Submitting Electronically

Electronic submission is the fastest option. File through TexMedConnect, the free web portal from TMHP, or interface directly with the TMHP EDI Gateway using the HIPAA-standard ANSI ASC X12 837 format. TexMedConnect lets you attach the appeal and supporting documents to the electronic record and gives you confirmation that TMHP has the file.¹

If you are appealing an electronically rejected claim, include the batch ID, patient control number, date of service, transaction date range, receipt date, and rejection codes from the 277CA claims response file. For EDI formatting questions, contact the TMHP EDI Help Desk at 888-863-3638.³

Submitting by Phone Through AIS

The Automated Inquiry System handles limited appeal types by phone at 800-925-9126. You can correct up to three fields per claim and submit up to 15 appeals per call. AIS works for client eligibility corrections, provider information corrections (Medicare crossovers cannot be fixed this way), and corrections to fields like patient control number, date of birth, date of onset, X-ray date, place of service, quantity billed, prior authorization number, and the beginning or ending dates of service, provided the corrected date still falls within the filing deadline.

AIS is built for straightforward data-entry fixes. If the appeal involves medical necessity, requires supporting documentation, or disputes a policy decision, use the electronic or paper method.³

Submitting by Paper Mail

Paper is the fallback when the claim cannot be appealed electronically or through AIS. You do not fill out a claim form. Instead:

Copy the R&S Report page showing the denied or underpaid claim. Other official TMHP notification, such as a letter attached to a returned claim, can be used in place of the R&S Report page.
Circle one claim per page. Five appeals, five pages.
Write out the reason for the appeal and the correction you want. Identify any incorrect information and give the corrected data.
Attach supporting documentation on separate pages. Do not copy anything on the back of the R&S Report page; the scanning process may miss it.

Mail first-level appeals to:

Texas Medicaid & Healthcare Partnership
ATTN: Adjustments/Appeals
PO Box 200645
Austin, TX 78720-0645⁴

Send paper appeals by certified mail with return receipt. Keep copies of everything. If a timing dispute comes up later, that receipt is your only protection.⁵

The 120-Day Deadline

TMHP must receive your appeal within 120 days of the R&S Report date on which the disputed claim appears. If day 120 falls on a weekend or holiday, the deadline moves to the next business day. Miss the window and TMHP will not review the appeal on the merits, no matter how strong the case.¹

A separate deadline applies to the original claim: most Texas Medicaid claims must reach TMHP within 95 days of the date of service. A 95-day exception request is not an appeal and does not go to TMHP. Those requests are handled by HHSC Claims Administrator Operations Management.²

One boundary worth flagging: if the claim was processed by a Medicaid managed care plan rather than fee-for-service, the appeal goes to that plan’s internal process first, and MCO deadlines are generally shorter than TMHP’s 120 days. Check the plan’s provider manual.⁶

Mistakes That Sink Appeals

Billing staff who file these regularly see the same errors repeat:

Missing the 120-day deadline. Mark the R&S Report date on your calendar the day it arrives.
Bundling multiple claims on one R&S Report page. TMHP requires one claim circled per page; bundling can result in only one being processed, or the whole submission being returned.
Circling a claim with no written explanation. The reviewer should not have to guess what you are disputing.
Printing documentation on the back of the R&S Report. Put it on separate pages.
Appealing when a corrected claim would work. Wrong codes and missing modifiers are faster to fix by resubmission.
Sending a 95-day exception request to TMHP. TMHP cannot grant it; the request belongs with HHSC Claims Administrator Operations Management.

Appeals that arrive complete, clearly documented, and routed correctly avoid most processing delays.³

If TMHP Denies the First-Level Appeal

You can escalate to HHSC Medicaid/CHIP Administrative Claim and Medical Appeals, but only after exhausting the TMHP process. The second-level packet must include evidence of the TMHP disposition, a written explanation of why you disagree, and all supporting documentation.⁷

HHSC must receive the appeal within 120 days of the TMHP disposition date on the R&S Report.
HHSC will only review appeals received within 18 months of the original date of service.
HHSC has 90 days from receipt of a complete appeal to issue a determination.
If HHSC requests additional information, you have 21 calendar days from the date of the request letter to respond; miss it and the case closes.

Mail second-level appeals to:

Texas Health and Human Services Commission
HHSC Claims Administrator Operations Management
Mail Code 91X
PO Box 204077
Austin, TX 78720-4077⁴

The HHSC determination at this level is the final administrative decision for administrative and medical appeals.⁷

1
Texas Medicaid & Healthcare Partnership. TMHP Provider Manual – Appeals
2
Texas Medicaid & Healthcare Partnership. TMHP Provider Manual – Claims Filing
3
Texas Medicaid & Healthcare Partnership. TMHP Provider Manual – Section 7 Appeals
4
Texas Medicaid & Healthcare Partnership. Texas Medicaid Program Quick Reference Guide
5
Texas Medicaid & Healthcare Partnership. TMHP Appeals and Administrative Review Manual
6
Texas Health and Human Services. Medicaid and CHIP Complaints and Appeals
7
Legal Information Institute. Texas Administrative Code 1-354-2217 – Provider Appeals and Reviews