Provider appeal rights
Summary: As a provider, you have the right to appeal any denied claims. There are
two types of appeals: (1) a medical necessity appeal or (2) an administrative appeal.
You may file either type of appeal through the Amerigroup Community Care internal
appeals process online at https://providers.amerigroup.com/NV or by contacting
Provider Services at 1-800-454-3730.
 What this means to you: For your information.
Medical necessity appeal
A medical necessity appeal involves an Amerigroup decision where a service does not
meet the health plan’s medical necessity criteria. This type of appeal will be reviewed by
a similarly credentialed physician who would normally treat the condition that is being
appealed. The physician reviewing the appeal has no involvement in the initial denial. If
you are appealing a medical necessity decision on behalf of a member, unless it is a
request for an expedited appeal, you must first obtain the member’s written
permission.
*There is only one level of review for medical necessity appeals.
You may appeal our Utilization Management (UM) decision within 30 calendar days of
receipt of the denial by using the Provider Appeal Request Form for Utilization
Management Denials (sample attached). Mail your appeal to the following address:
Appeals Department
Amerigroup Community Care
P.O. Box 62429
Virginia Beach, VA 23466-2429
Administrative appeal
An administrative appeal involves an Amerigroup determination based on
noncompliance with a contractual arrangement. This decision is NOT based on medical
necessity. Administrative appeals are reviewed by an Amerigroup associate who was not
involved in the initial decision.
*There are two levels of review for this type of dispute.
NVPEC-0744-16
June 2016
Provider payment disputes
If you are dissatisfied with the way that Amerigroup paid your claim, you may appeal the
decision within 90 calendar days of receipt of the explanation of payment (EOP) by using
the Provider Dispute and Correspondence Submission Form (sample attached). Mail your
appeal to the following:
Payment Dispute Unit
Amerigroup Community Care
P.O. Box 61599
Virginia Beach, VA 23466-1599
What should I include with my appeal?
Member’s name, ID/subscriber number, date of service, description of services and an
explanation of why you believe the decision should be reversed.
If you are appealing inpatient days, also include the appropriate medical records with
your request in order to prevent a delay in processing your appeal.
When will I receive a decision about my medical necessity or administrative appeal?
Standard appeal: You will be notified of Amerigroup’s decision within 30 calendar days
of receipt of your appeal.
Expedited appeal: If your requested service involves an emergent or life-threatening
situation, you can request an expedited appeal. A decision will be made no later than 72
hours after we receive your appeal request. If you submit an urgent request that does
not qualify, the Appeals Department will contact you to notify you that the request will
be processed using the standard appeal time frame.
Are there additional levels of appeals?
If you do not agree with the decision made by Amerigroup, you may qualify to request a
State Fair Hearing. State Fair Hearing information will be sent to you if your appeal is not
decided in your favor and you qualify for the State Fair Hearing.
Resource for a complete statement of appeal rights
Refer to your Amerigroup provider manual located online at
providers.amerigroup.com/NV or within your provider contract agreement.
What if I need assistance?
If you have questions about this communication, received this fax in error or need
assistance in general, contact your local Provider Relations representative or call
Provider Services at 1-800-454-3730.
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PROVIDER APPEAL REQUEST FORM FOR UTILIZATION MANAGEMENT DENIALS
If Amerigroup has rendered an adverse determination for either an administrative or medical necessity
reason, you can appeal the decision. You must file an appeal within 90 calendar days from the date on the
denial letter. We will send you an acknowledgement letter within five calendar days of receipt of your
appeal request. If you have already called to file an appeal over the phone, we need you to send us this
form or a letter outlining your appeal request within 10 calendar days of your call. We will respond to you
within 30 calendar days with our decision.
If you need assistance, please call Provider Services toll free at 1-800-454-3730. You can call Monday
through Friday from 8:00 a.m. to 5:00 p.m. Pacific Time.
Date: ___________________________________
Member Name: _____________________________________________________________________
Member ID Number: _________________________________________________________________
Reference Number: ___________________________ Date of Service: _________________________
Provider Name: __________________________________ NPI: _______________________________
Address: _________________________ City: ___________________ State: _______ ZIP: __________
Contact Name: __________________________________ Phone: ______________________________
Services that were denied: _____________________________________________________________
Provide explanation as to why the denial should be overturned. Attach relevant medical documentation
to support your case: __________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Send this form to:
Appeals Department
Amerigroup Community Care
P.O. Box 62429
Virginia Beach, VA 23466-2429
NVPEC-0075-10
December 2010
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Provider Payment Dispute and Correspondence Submission Form
If you are dissatisfied with the way Amerigroup Community Care paid your claim, you can appeal the
decision within 90 calendar days from the date on the Explanation Of Payment (EOP). If you have already
called to file an appeal over the phone, send us this form or a letter outlining your appeal request within
10 calendar days of your call. We will respond to you within 30 calendar days with our decision. Do not
use this form for Medical Necessity Appeals.
Date ____________________________
Member Name __________________________________ Member Date of Birth __________________
Member Amerigroup or Medicaid ID Number (circle one) _____________________________________
Provider Name ____________________________________ NPI ________________________________
Provider Address ______________________________________________________________________
City _____________________________________ State ___________________ ZIP_________________
Contact Name_________________________________ Contact Phone (____) _____________________
Claim Number____________________ Billed Amount $_____________ Amount Paid $ _____________
Date of Service ____________________________ Authorization Number ________________________
Check the applicable reason for your submission with a copy of your EOP.
Payment Dispute: Check (√) one →
First Level Dispute
Second Level Dispute
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 follow the applicable appeals process. Please refer to the EOP to ensure you are following the
correct process. Completely indicate the payment dispute reason(s). You may attach an additional sheet if
necessary. Please include appropriate medical records if applicable.
______________________________________________________________________________________
______________________________________________________________________________________
Claim Correspondence: Check (√) the appropriate box below.
Claim correspondence is defined as a request for additional/needed information 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 an Amerigroup claim denial or request)
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:
Amerigroup Community Care
Payment Disputes
P.O. Box 61599
Virginia Beach, VA 23466-1599
NVPEC-0074-10
December 2010
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