Claims, Appeals & Provider Complaints 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the personal details of the person appealing. Fill in their full name, date of birth, Social Security Number or TennCare card number, and current mailing address.
3. Indicate who is filling out the form. If it's not the person appealing, provide your name and select your relationship to the individual (e.g., parent, advocate).
4. Specify the reason for the appeal by placing an X next to one of the options: changing health plans, needing care or medicine, or disputing bills.
5. If applicable, indicate whether you believe there is an emergency situation that requires an expedited appeal. Follow instructions for obtaining necessary permissions if a doctor is involved.
6. In the provided sections (Parts A, B, C), detail your specific appeal reasons and include any relevant documentation that supports your case.
7. Once completed, make a copy of all pages for your records before submitting them via mail or fax as instructed.

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