Get Provider Authorization To Adjust Claims And Create Claim

This guide provides a clear, concise process for completing the Provider Authorization To Adjust Claims And Create Claim online. By following these steps, you will be equipped to accurately fill out the necessary information and submit your authorization request effectively.

Follow the steps to complete your authorization form effectively.

1. Click ‘Get Form’ button to access the form and open it for editing.
2. Begin by entering the provider name in the designated field. Ensure that the name matches your official documentation to avoid any processing delays.
3. Fill in the provider NPI (National Provider Identifier) number to confirm your identity and credentials within the healthcare system.
4. Input the provider tax identification number to document the financial aspect of your claim accurately.
5. Provide your contact information, including a valid phone number and email address, for any necessary follow-ups regarding your request.
6. If applicable, include the cost containment project number. If you do not have one, you may leave this section blank.
7. If there is a document identification number associated with your submission, ensure it is included in the respective field.
8. Clearly state the total recoupment dollar amount that you are requesting to adjust from the future claims payments.
9. List the claim information, including the claim numbers, member numbers, service dates, and recoupment amounts. Repeat this process for each claim as needed.
10. Provide detailed recoupment reasons for each claim listed. Clear explanations will facilitate the review process.
11. If more space is required, attach an excel file containing all the necessary data points.
12. At the end of the form, authorize Amerigroup to proceed with adjusting the claims by printing your name and providing your signature.
13. Finally, return this completed form along with any supporting documentation to the specified mailing address or via fax to ensure proper processing.

Complete your documentation online today to ensure your claims are adjusted accurately and promptly.