Get Claim Correspondence Submission Form - Amerigroup

Filling out the Claim Correspondence Submission Form - Amerigroup online is a crucial step for providers seeking to address claims matters effectively. This guide will walk you through each section of the form, ensuring clarity and accuracy in your submissions.

Follow the steps to complete the submission form with ease.

1. Press the ‘Get Form’ button to access the form and open it in your preferred document editor.
2. Begin by filling in the Member Information section. Input the member's first and last name, coverage, date of birth, and ID number if applicable.
3. Next, complete the Provider/Provider Representative Information. Enter the provider's first and last name, street address, city, state, and ZIP code. Include the provider's phone number and their National Provider Identification Number.
4. Indicate whether you are a participating or nonparticipating provider by checking the appropriate box. Specify the representative type by selecting from options such as 'Self,' 'Billing Agency,' 'Law Firm,' or 'Other.'
5. Input the Representative Contact Name, their contact phone number, and the representative's street address, city, state, and ZIP code.
6. Proceed to the Claim Information section. Enter the claim number, billed amount, amount received, start and end dates of service, and the authorization number.
7. If you have multiple claims linked to the same issue, you can utilize this form to include a single listing of claims along with all supporting documents attached afterward.
8. Complete the Claim Correspondence section by selecting the applicable category for your request by checking the corresponding box.
9. Finally, review your entries for accuracy. Once completed, you can save changes, download, print, or share the form as required.

Start filling out your Claim Correspondence Submission Form online today for efficient claim processing.