Amerigroup Appeal Form

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Get your Amerigroup Appeal Form in 3 easy steps

  • 01 Fill and edit template
  • 02 Sign it online
  • 03 Export or print immediately

What is Amerigroup Appeal Form?

This Amerigroup appeal form was created for healthcare providers. The template was produced by Amerigroup Real Solutions for everyone who works with Amerigroup healthcare. Yet, this form is made just for payment appeals, if you want to make the member appeal you have to use another document.

Using this template you can only ask for payment for services that your company has provided already. You can’t fill the document if you have a client who is a member of Amerigroup and ask you to act on his/her behalf. To prove your claim, you need to specify facts and provide evidence that the payment was made and services provided.

The document is simple to fill. However, without specific information only the healthcare provider can have, you will not be able to create the appeal. The document requires time to be considered by Amerigroup. If you have questions about it, you can contact the company and consult with them.

Amerigroup Appeal Form on PDFLiner

What I need the Amerigroup Appeal Form for?

  • You need Amerigroup claim appeal form to ask for compensation for the expenses. It can be used only for claims of the same issue. If you have different types of claims you have to file forms for each of them. Add the documents that support your point of view to every form;
  • If you represent the healthcare provider and you need to change your decision about the issue related to Amerigroup payment for the services you have provided, you need to fill out the document and prove that the services were provided already;
  • Amerigroup requires the form to start the investigation of the problem that occurred.

How to Fill Out Amerigroup Appeal Form?

You will easily find the claim appeal form on the official website of Amerigroup. There are numerous templates in their library so you have to spend some time searching for the one you need. If you don’t want to do this, you can always open PDFLiner. There you will see the template. Open it and you will be able to fill out the document right away.

Since PDFLiner is an online editor of PDF documents you can simply find the paper and start filling in sections using the tools that are on the panel in front of you. Once you are done, you have to save the file on your device and make sure it will not be lost among other papers. Send the copy to Amerigroup online. You can also print it and send it by regular mail. The company offers the number of the PO Box in VA. Here is what you need to include in the document:

  1. Provide information about the member, including the name, date of birth, coverage, and ID;
  2. Share the information about the provider, including the name, and address. If you are a representative of the provider, you have to include your name and address. Share the phone number and email you can be reached at;
  3. Provide the information about the claim, including the number, billed amount, the one that was received, date of service, and authorization number;
  4. Put the tick in the appropriate box that matches your payment appeal option;
  5. Pick the matching box in the Payment Dispute section.

Amerigroup Appeal Form on PDFLiner

Organizations that work with Amerigroup Appeal Form

  • Amerigroup Real Solutions in Healthcare providers.

Fillable online Amerigroup Appeal Form
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