Get Amerigroup Apply Online

Filling out the Amerigroup Apply Online is a straightforward process that provides an essential pathway for facilities and providers looking to participate in the Amerigroup network. This comprehensive guide will walk you through each section of the application, ensuring that you provide all necessary information correctly and efficiently.

Follow the steps to complete your application successfully.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Begin by selecting the applicable health plans for your location, which include states like GA, KS, LA, and others. Ensure you check all that apply.
3. In the provider identification section, enter the legal business name and any doing business as (DBA) name if applicable. Provide the contact person's information, including their email address and relevant tax IDs.
4. Specify the type of provider by checking the appropriate boxes under facility, ancillary, or long-term care provider categories. Be as detailed as possible to ensure clarity.
5. Complete the primary office/service address section with the practice location name, full address, city, state, zip, county, and contact information. Confirm whether this address is utilized for billing.
6. If applicable, include information for any secondary office/service addresses by following the same format as step 5.
7. Enter your national provider identifier (NPI) and taxonomy codes, ensuring you attach separate sheets for additional provider locations if required.
8. Provide details on licensure, including state, date of license, license number, expiration date, and any relevant CLIA certificate numbers.
9. Complete the accreditation/certification section by attaching necessary documentation and providing details of initial accreditations and surveys.
10. Fill out the general and professional liability insurance information, including carrier names and policy numbers for both general and professional liability coverage.
11. Complete the Amerigroup disclosure form for provider entities by providing identifying information and details about owners, control interests, and managing employees.
12. End with the signature section, ensuring that the individual completing the form has the authority to bind the organization. Include printed names, titles, and contact information.
13. Review and save your changes, then decide whether to download, print, or share the completed form.

Complete your Amerigroup Apply Online today to begin the process of becoming a participating provider.