Amerigroup claim dispute form

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For additional information, please reference the IntegraNet Provider Manual. To begin the credentialing process, please contact our credentialing department at:. To begin the credentialing process for ancillary providers, please contact us at:. AncillaryContracting integranethealth.

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In this post, we'll discuss what types of disputes can be addressed through a Payment Dispute Form, how to correctly fill out such a form, and other important information about when or why to use such forms in payment disputes. This form should be completed by providers for payment disputes and claim correspondence only. To ensure timely and accurate processing of your request, please complete the Payment Dispute or Claim Correspondence section below by checking the applicable determination or request reason that was provided on the Amerigroup determination letter or Explanation of Payment EOP.

A payment dispute is defined as a dispute between the provider and Amerigroup in reference to a claim determination where the member cannot be held financially liable. All disputes with member liability must. Please refer to the EOP to ensure you are following the correct process. Clearly and completely indicate the payment dispute reason s in the space provided. You may attach an additional sheet if necessary. Please include appropriate medical records. Clearly and completely indicate the reason s for your correspondence.

No Fillable fields 0 Avg. Provider Payment Dispute and Correspondence — Submission Form This form should be completed by providers for payment disputes and claim correspondence only.