Payment Dispute Form PDF Details

Are you currently dealing with a payment dispute? If so, navigating the steps to resolve it can be incredibly confusing and time consuming. Fortunately, there are resources available that can help streamline this process for you – one of them being the Payment Dispute Form. This form will simplify the process of dispute resolution and allow you to ensure your rights as both buyer and seller are protected. In this post, we'll discuss what types of disputes can be addressed through a Payment Dispute Form, how to correctly fill out such a form, and other important information about when or why to use such forms in payment disputes.

Form NamePayment Dispute Form
Form Length1 pages
Fillable fields0
Avg. time to fill out15 sec
Other namesamerigroup form medicare, provider payment dispute form, dispute form medicare, claim dispute amerigroup

Form Preview Example

Provider Payment Dispute and Correspondence – Submission Form

This form should be completed by providers for payment disputes and claim correspondence only.

Member First/Last Name_________________________________________ Member Date of Birth __________________

Member Amerigroup, Medicaid or Medicare ID # (circle one) ________________________________________________

Provider First/Last Name________________________ National Provider Identification (NPI) #______________________

I am a participating provider.

I am a nonparticipating* provider.

*If filing for a Medicare member and the member has potential financial liability, you must include a completed Centers for Medicare & Medicaid Services (CMS) Waiver of Liability form.

Provider Contact First/Last Name________________________________ Contact Phone (____) ______ _______

Provider Street Address_________________________________________________________________________

City___________________________ State______ ZIP_____________ Phone (_______) _____________________

Claim #________________________ Billed Amount $____________ Amount Received $__________________

Start Date of Service _________________ End Date of Service ________________ Authorization Number_____________

To ensure timely and accurate processing of your request, please complete the Payment Dispute or Claim Correspondence section below by checking the applicable determination or request reason that was provided on the Amerigroup determination letter or Explanation of Payment (EOP).


A payment dispute is defined as a dispute between the provider and Amerigroup in reference to a claim determination where the member cannot be held financially liable. All disputes with member liability must

follow the applicable appeals process. Please refer to the EOP to ensure you are following the correct process.

Check the appropriate dispute type below: () First-level dispute

()Second-level dispute

Clearly and completely indicate the payment dispute reason(s) in the space provided. You may attach an additional sheet if necessary. Please include appropriate medical records.




Claim correspondence is defined as a request for additional/needed information in order for a claim to be considered clean, to be processed correctly or for a payment determination to be made.

Check the appropriate box below.

() Itemized Bill/Medical Records (in response to an Amerigroup claim denial or request)

() Corrected Claim Other Insurance/Third-Party Liability Information/Other Correspondence

Clearly and completely indicate the reason(s) for your correspondence. You may attach an additional sheet if necessary.


Mail this form and supporting documentation to:

Payment Disputes


P.O. Box 61599

Virginia Beach, VA 23466-1599