Fillable Claim Payment Appeal Submission Form (Amerigroup)

Fill Online, Printable, Fillable, Blank Claim Payment Appeal Submission Form (Amerigroup) Form

Use Fill to complete blank online AMERIGROUP pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Claim Payment Appeal Submission Form (Amerigroup)

On average this form takes 8 minutes to complete

The Claim Payment Appeal Submission Form (Amerigroup) form is 2 pages long and contains:

  • 0 signatures
  • 19 check-boxes
  • 24 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Amerigroup forms online.

BROWSE AMERIGROUP FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
https://providers.amerigroup.com
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:
City:
State:
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:
Email:
Street address:
City:
State:
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
EOP.
☐ Untimely filing
☐ No authorization
☐ Denied for other health insurance
(OHI) but member does not have
OHI
☐ Experimental/investigational
procedure denial
☐ Denied as duplicate
☐ Denial related to provider date
issue
☐ Member retro-eligibility issues
☐ ER level of payment review
☐ Other
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
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Claim Payment Appeal Submission Form (Amerigroup)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 25 March 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document