Form Txpec-2056-17 - Provider Payment Appeal And Correspondence Submission Form
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1Provider Payment Appeal and Correspondence Submission Form
Use this form for payment appeals and claim correspondence only.
Member first/last name:
Member DOB:
Amerigroup ID:
Medicaid/CHIP ID:
Provider first/last name:
Provider ID:
☐ Participating provider
☐ Nonparticipating provider
Provider contact first/last name:
Contact phone:
Provider street address:
City:
State:
ZIP:
Phone:
Claim number: ____________________ Billed amount: $___________ Amount received: $
Start date of service:
End date of service:
Authorization number:
To ensure timely and accurate processing of your request, please complete the payment appeal or
claim correspondence section below.
Payment appeal (check the appropriate box): ☐ First-level appeal ☐ Second-level appeal
A payment appeal is defined as any claim payment disagreement between Amerigroup and the health
care provider for reasons including but not limited to contractual payment issues, timely filing and
notification/authorization issues.
Clearly and completely indicate the payment appeal reason(s). You may attach an additional sheet if
necessary. Please include any appropriate medical records.
Claim correspondence (check the appropriate box below):
Claim correspondence is defined as additional requested information necessary in order for a claim to
be considered clean, to be processed correctly or for a payment determination to be made.
☐ Itemized bill/medical records (in response to a claim denial or request from Amerigroup)
☐ Corrected claim
☐ Other insurance/third-party liability information
☐ Other correspondence
Clearly and completely indicate the reason(s) for your correspondence. You may attach an additional
sheet if necessary.
Mail this form and supporting documentation to:
Provider Payment Appeals
Amerigroup
P.O. Box 61599
Virginia Beach, VA 23466-1599
Amerigroup members in the Medicaid Rural Service Area and the STAR Kids program are served by Amerigroup Insurance
Company; all other Amerigroup members in Texas are served by Amerigroup Texas, Inc.
TXPEC-2056-17
June 2017
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