Amerigroup Medicaid PDF Details

The Amerigroup Medicaid form is an essential tool for healthcare providers seeking to appeal decisions related to payment for services rendered. This comprehensive form requires providers to fill in detailed member information, including the member's name, date of birth, coverage type, and Medicaid member ID. Providers must also disclose their own information, such as their name, National Provider Identifier (NPI) number, and contact details, and indicate whether they are participating or nonparticipating providers. The form gives options for the identity of the provider representative, which could be the provider themselves, a billing agency, a law firm, or another entity, along with their contact information. Crucially, this form is used specifically for payment appeals, distinguishing it from member appeals regarding service denials or limited authorization. The form guides providers through the process of appealing payment decisions by asking for detailed claim information, including the claim number, billed and received amounts, service dates, and any authorization numbers. Providers can appeal various determinations, such as untimely filing or denials due to issues with provider data. Finally, the form outlines the steps for submitting both the appeal and any supporting documentation, emphasizing the need for accuracy and completeness to ensure efficient processing. This introduction to the Amerigroup Medicaid form aims to provide healthcare providers with a clear and concise overview of its purpose, the required information, and the submission process, facilitating smoother appeals of payment decisions.

Form NameAmerigroup Medicaid
Form Length1 pages
Fillable fields0
Avg. time to fill out15 sec
Other namesamerigroup texas provider appeal form, amerigroup appeal form texas, amerigroup appeals address, amerigroup provider appeal form 2019

Form Preview Example




Claim Payment Appeal – Submission Form






This form should be completed by providers for payment appeals only.

Member Information:

















































Member First/Last Name:











Member Date of Birth:

Member Coverage:


Member ID:








































Provider/Provider Representative Information:








































Provider First/Last Name:











NPI Number:










Provider Street Address:








































ZIP Code:



I am a participating provider.

I am a nonparticipating provider.










Provider Representative: Self Billing Agency Law Firm Other:











Representative Contact Name:






Contact Phone: (








Representative Street Address:



































ZIP Code:




























Claim Information**:























Claim Number:





Billed Amount: $

Amount Received: $














Start Date of Service:




End Date of Service:

Authorization Number:




























**If you have multiple claims related to the same issue, you can use one form and attach a listing of the claims with each supporting document following behind.

Payment Appeal

A payment appeal is defined as a request from a health care provider to change a decision made by Amerigroup related to claim payment for services already provided. A provider payment appeal is not a member appeal (or a provider appeal on behalf of a member) of a denial or limited authorization as communicated to a member in a notice of action.

First-level Appeal Second-level Appeal (Not available in Ohio)

To ensure timely and accurate processing of your request, please complete the Payment Dispute section below by checking the applicable determination provided on the Amerigroup determination letter or Explanation of Payment.

Untimely filing

Claim code editing denial

Denied as duplicate

No authorization

Retrospective authorization issue

Denial related to provider data issue

Denied for Other Health Insurance

Disagree that you were paid according

Member retro-eligibility issue

(OHI), but member doesn’t have OHI

to your contract



Data elements on the claim on file does


procedure denial

not match the claim originally submitted


Mail this form, a listing of claims (if applicable) and supporting documentation to:

Payment Appeals


P.O. Box 61599

Virginia Beach, VA 23466-1599


September 2012

Medicaid Only


How to Edit Amerigroup Medicaid Online for Free

The PDF editor that you can go with was designed by our leading computer programmers. You may submit the amerigroup appeal form file instantly and efficiently with our software. Merely keep up with the procedure to get going.

Step 1: Select the "Get Form Now" button to start out.

Step 2: You're now on the document editing page. You may edit, add content, highlight specific words or phrases, place crosses or checks, and insert images.

The PDF template you decide to fill out will contain the next segments:

example of fields in amerigroup reconsideration form 2019

You should enter the particulars within the box Claim Number, Billed Amount, Amount Received, Start Date of Service, End Date of Service, Authorization Number, If you have multiple claims, Payment Appeal A payment appeal is, Claim code editing denial, Denied as duplicate Denial, OHI but member doesnt have OHI, and to your contract.

Finishing amerigroup reconsideration form 2019 part 2

It's essential to point out the relevant details within the OHI but member doesnt have OHI, to your contract, Experimentalinvestigational, procedure denial, Data elements on the claim on, Other, Mail this form a listing of claims, Payment Appeals Amerigroup PO Box, PFALL Medicaid Only, and September area.

stage 3 to finishing amerigroup reconsideration form 2019

Step 3: Click "Done". You can now export your PDF form.

Step 4: To protect yourself from all of the issues in the long run, you will need to make around several duplicates of your form.

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