Follow the steps to complete the appeal form accurately.

1. Press the ‘Get Form’ button to access the PCS/PDN Claim Appeal Submission Form. This form must be filled out completely, using one form per client and authorization period.
2. Begin by entering the provider information. Include the provider name, contact name, TPI, NPI, taxonomy, address, city, state, telephone number, ZIP, extension, and email.
3. Fill in the client information section by entering the client's first name, last name, middle initial, date of birth (DOB), and client Medicaid number.
4. In the authorization information section, input the authorization number, total units authorized, and the date range for the services provided, including the start and end dates.
5. Prepare the required documentation. Attach a spreadsheet that includes details such as dates of service, claim number (ICN), quantity billed, quantity paid, claim status, payment amount, EOB for denied claims or details, and a summary of quantity remaining.
6. Ensure that you have included remittance and status reports for each denied claim, as well as a copy of the Authorization Notification Letter from TMHP.
7. Review the form and all attached documentation to confirm that everything is complete. Incomplete submissions will be returned.
8. Once all fields are filled and documentation is prepared, save your changes to the form. You may then download, print, or share the form as needed.

Complete your appeal submission online today to ensure a timely review.