Get Recoupment Notification Form-hawk-i - Providers Amerigroup

Completing the Recoupment Notification Form-hawk-i - Providers Amerigroup is a crucial step for providers to authorize claim adjustments and to manage overpayments effectively. This guide will provide a clear, step-by-step procedure to assist you in accurately filling out the form online.

Follow the steps to successfully complete the form online.

1. Start by clicking the ‘Get Form’ button to access the document and open it in an editing tool.
2. Enter your provider name in the designated field. This should be the official name under which you operate your practice.
3. Input your provider NPI (National Provider Identifier) number. Ensure this is correct as it helps in the identification of your services.
4. Fill in your provider tax identification number. This number is essential for processing payments and claims.
5. Provide your contact information, including phone number and email address, to facilitate communication.
6. If applicable, indicate the cost containment project number to reference the particular initiative related to the recoupment.
7. List the total recoupment dollar amount you are requesting. This is the total amount from which overpayments will be withheld.
8. Document the claim information. If you do not have a cost containment letter or supporting detail, fill out the claim number, member number, service dates, and recoupment amount for each claim.
9. Provide the recoupment reason for each claim listed. Ensure to specify distinct reasons if applicable.
10. If you require additional space for more claims, attach an Excel file containing all the necessary details as specified above.
11. Review your entries for accuracy and completeness before proceeding.
12. Finally, print your name in the authorization section and sign the form to validate your request.
13. Submit the completed form via mail or fax as indicated, ensuring you follow the correct submission instructions.

Don't delay; complete your Recoupment Notification Form online today to ensure timely processing.