Get Amerigroup Reimbursement Request Form

Filling out the Amerigroup Reimbursement Request Form online is a straightforward process designed to facilitate the reimbursement of your prescription claims. This guide will provide you with step-by-step instructions to ensure that you complete the form accurately and efficiently.

Follow the steps to fill out your reimbursement request form correctly.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In the Card Holder/Patient Information section, enter the identification number from your prescription card and the group number or group name. Fill in the names, address, and contact information accurately to ensure proper reimbursement.
3. Complete the Patient Information, making sure to use a separate claim form for each patient. Include the patient's date of birth and their relationship to the primary member.
4. Fill out the Other Insurance Information section, indicating if the medicine is related to an on-the-job injury and if it is covered under any other group insurance. Provide the name of the insurance company and the ID number if applicable.
5. Ensure you provide a signature and date in the certification area, affirming that the information submitted is accurate and true.
6. Gather all required receipts and documentation as specified. Ensure that the receipts include patient name, date filled, total charge, prescription number, medicine NDC number, metric quantity, days supply, and the pharmacy name and address.
7. Follow the mailing instructions based on your RXBIN number to submit the claim. Match your RXBIN with the correct address provided for processing your claim.
8. After completing the form and gathering all necessary documents, save any changes you've made. You may then choose to download, print, or share the form as needed.

Complete your Amerigroup Reimbursement Request Form online today for a seamless reimbursement experience.