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Appeal request form complaint form fair hearing request form prenatal incentive options (car seat or pack and play) form. Complaint and appeal department p.o. Blue cross and blue shield of texas attn: Web provider appeal request form please complete one form per member to request an appeal of an adjudicated/paid claim. Web mail or fax the completed form to: You can ask for an appeal if coverage or payment for an item or medical service is denied that you think should be. Web the claim reconsideration request option allows providers to electronically submit claim reconsiderations for situational.