WAPEC-2737-20 December 2020
Claim Payment Appeal Submission Form
Member information
Member first/last name:
Member ID:
Member DOB:
Provider/provider representative information
Provider first/last name:
NPI number:
Provider street address:
ZIP code:
I am a participating provider.
I am not a participating provider.
Provider representative: Self Billing agency Law firm Other: ______________________________
Representative contact name:
Contact phone:
Street address:
ZIP code:
Claim information*
Claim number:
Billed amount: $
Amount received: $
Start date of service:
End date of service:
Authorization number:
* For multiple claims related to the same issue, providers can use one form and attach a listing of the claims with each
supporting document. This form is a required attachment for all Claim Payment Appeals.
Claim Payment Appeal
All Claim Payment Appeals must be submitted in writing or via our provider website. We accept web and written
payment Claim Payment Appeals within 60 calendar days of the date the Reconsideration Determination letter was
mailed. A Claim Payment Appeal is defined as a request from a health care provider to change a decision made by
Amerigroup Washington, Inc., related to a claim payment for services already provided. A provider Claim 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.
Claim Payment Reconsideration reference number:
Page 2 of 2
Reason for Claim Payment Appeal
To ensure timely and accurate processing of your request, please check the applicable determination provided on the
Untimely filing
No authorization
Denied for other health insurance
(OHI) but member does not have
procedure denial
Denied as duplicate
Denial related to provider date
Member retro-eligibility issues
ER level of payment review
Mail this form (or upload if filing a web Claim Payment Appeal), a listing of claims (if applicable) and supporting
documentation to:
Claim Payment Appeals
Amerigroup Washington, Inc.
P.O. Box 61599
Virginia Beach, VA 23466-1599