WAPEC-2737-20 December 2020
Claim Payment Appeal Submission Form
* 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: