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Click ‘Get Form’ to open the amerigroup appeal form in the editor.
Begin by filling out the Member Information section. Enter the member's first and last name, date of birth, coverage type (Medicaid), and Member ID.
Next, complete the Provider/Provider Representative Information. Input your first and last name, NPI number, street address, city, state, ZIP code, and indicate whether you are a participating or nonparticipating provider.
Specify your representative status by selecting from options such as Self, Billing Agency, Law Firm, or Other. Provide the representative contact name and phone number.
In the Claim Information section, enter the claim number, billed amount, amount received, start and end dates of service, and authorization number.
Select the appropriate payment appeal level (First-level or Second-level) and check any applicable reasons for your appeal based on Amerigroup’s determination letter.
Finally, review all entered information for accuracy before submitting. You can easily save or share your completed form directly from our platform.

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