Amerigroup Provider Return Form PDF Details

If you are an Amerigroup member and have received services from a provider, you will need to complete and return the Amerigroup Provider Return Form. This form is used to provide information about the providers who have provided you with services, as well as to request reimbursement for those services. Completing and returning this form is important, as it helps ensure that your benefits are accurately processed. Make sure to include all necessary information on the form, and submit it promptly so that you can receive reimbursement for the services you have received. Thank you for choosing Amerigroup!

QuestionAnswer
Form NameAmerigroup Provider Return Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesamerigroup provider sheet, AMERIGROUP, Outpt, Inpt

Form Preview Example

AUTHORIZATION REQUEST

 

Phone: 1-800-454-3730

Fax: 1-800-964-3627

 

 

 

 

 

** To avoid delay, please print clearly **

 

 

 

 

 

TODAY’S DATE:

PROVIDER RETURN FAX #:

 

 

 

 

 

 

 

 

 

MEMBER INFORMATION (Please verify eligibility prior to rendering service)

 

 

 

 

 

 

 

 

 

 

 

NAME:(Last Name, First Name)

 

 

AMERIGROUP#:

DOB:

 

 

 

 

 

 

 

 

 

 

ADDRESS:

 

 

CITY,STATE,ZIP:

 

 

 

 

 

 

 

 

 

 

MEDICAID#:

OTHERINSURANCE/WORKER’SCOMP:

 

 

 

 

 

 

 

 

 

 

REFERRING PROVIDER INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME:

 

 

OFFICECONTACTNAME:

 

 

 

 

 

 

 

 

 

 

 

MEDICAIDPROVIDER#:

AMERIGROUP#:

GROUPPRACTICE#:

NPI#:

 

 

 

 

 

 

 

 

 

PHONE#:

 

❑ Check the box where the OTHERPHONE#:

❑ Fax back

 

 

 

 

 

 

 

 

 

PHONE#:

 

❑ referral should be faxed back OTHERPHONE#:

 

 

 

 

 

 

 

 

 

 

SPECIALIST CONSULT

CONSULTANT:(Last Name, First Name, Provider Specialty)

AMERIGROUPPROVIDER#: NPI#: PHONE#: FAX#:

ADDRESS:CITY,STATE,ZIP:

ICD-9CODE/DIAGNOSIS/REASONFORREFERRAL:

PMH/PREVIOUSSTUDIES/TREATMENT:

#OFVISITSREQUIRED:

MATERNITY CARE

For initial notification of pregnancy, please use the Maternity Notification form.

For all other services related to pregnancy, please use this form (e.g. ultrasound, fetal non-stress test).

DIAGNOSTIC STUDY

FACILITYNAME:DOS:

DIAGNOSIS/REASONFORREFERRAL:

PROCEDURE/CPT-4CODE:

PMH/PREVIOUSSTUDIES/TREATMENTS:

SURGERY REQUEST

SURGEON’SFULLNAME:(Last Name, First Name)

DOS:

❑Inpt ❑Outpt ❑Ext Stay

FACILITYNAME:

DIAGNOSIS/REASONFORSURGERY:

PROCEDURE/CPT-4CODE:

PMH/PREVIOUSSTUDIES/TREATMENTS:

OTHER - Clinical Information Needed

❑DME ❑ Home Health ❑ Hospice ❑ Other

REFERREDTOPROVIDER:(Last Name, First Name)

AMERIGROUPPROVIDER#:

NPI#:

DIAGNOSIS/REASONFORREFERRAL:

PROCEDURE/CPT-4CODE:

PMH/PREVIOUSSTUDIES/TREATMENTS:

** PLEASE ATTACH CLINICAL INFORMATION TO SUPPORT MEDICAL NECESSITY **

This referral is valid only for services authorized by this form. Only completed referrals will be processed. If hte consultant/provider recommends another service or surgery, additional authorization is required. Certification does not guarantee that benefits will be paid. Payment of claims is subject to eligibility, contractual limitations, provisions, and exclusions.

To be completed by AMERIGROUP: DATEAPPROVED:

DATESPAN:REFERENCE#: INITIALSOFAPPROVER:

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