Get Amerigroup Recoupment Form

Filling out the Amerigroup Recoupment Form online is a crucial step for providers seeking to adjust claims effectively. This guide will walk you through each section of the form to ensure your request is processed smoothly.

Follow the steps to complete the Amerigroup Recoupment Form online.

1. Click 'Get Form' button to obtain the form and open it in the editing environment.
2. Enter your provider name in the designated field. This should reflect the name associated with your practice.
3. Input your provider NPI (National Provider Identifier) number to verify your identity.
4. Provide your tax identification number. Ensure that this number is accurate to avoid processing delays.
5. Fill in your contact information, including your phone number and email address, to facilitate communication.
6. If applicable, include the cost containment project number related to your claims adjustments.
7. Add the document identification number if there is one associated with your request.
8. Clearly state the total recoupment dollar amount you are requesting for adjustments.
9. List claim information in the specified fields. Include each claim number along with corresponding member numbers, service dates, and recoupment amounts.
10. Elaborate on the recoupment reason for each claim. This is essential for processing your request.
11. If your claims exceed the space provided, attach an Excel file containing the necessary data.
12. Authorize the adjustments by printing your name and signing the form.
13. Return the form via mail to the designated address or fax it to the given number.
14. After completing the form, you can save changes, download, print, or share the document as needed.

Get started by filling out the Amerigroup Recoupment Form online to expedite your claims adjustments.