Amerigroup Provider Appeal Form 2019 Details

Amerigroup Medicaid is a state-sponsored health care program that provides long-term and short-term medical coverage for low income individuals and families. The company offers a variety of plans to fit the needs of their customers, including MediConnect Plus, HCS Basic, and Amerigroup Advantage. All premiums are paid by the individual's employer or family member's employer if eligible. Maintaining health coverage is crucial in today's society because it not only ensures continued access to necessary healthcare services but it also helps with managing chronic diseases such as diabetes, hypertension, asthma and other serious illnesses that can be life threatening without proper treatment.

You will find info about the type of form you would like to submit in the table. It will tell you how much time it will need to complete amerigroup medicaid, what fields you need to fill in, and so forth.

Form NameAmerigroup Medicaid
Form Length1 pages
Fillable fields0
Avg. time to fill out15 sec
Other namesamerigroup reconsideration form texas, amerigroup medicare appeal form, amerigroup reconsideration form, amerigroup reconsideration 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


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