Provider forms

Contact your network development representative at the ArkansasBlue Welcome Center nearest you for assistance.

For medical providers

• Arkansas Blue Cross Employees/Dependents/Retirees- Designation for Authorized Appeal Representative Form [pdf]
• Arkansas Formulary Exception/Prior Approval Request Form
• Authorization Form for Clinic/Group Billing [pdf]
  Use for notification that a practitioner is joining a clinic or group.
• Claim Reconsideration Request Form [pdf]
• Designation for authorized appeal representative form [pdf]
• Electronic Claims Waiver Request Form 
  Use for providers requesting electronic claims waiver and exception to submit paper claims.
• Expedited Appeal Request Form [pdf]
• New Clinic/Group Application [pdf]
• Notice of Payer Policies and Procedures and Terms and Conditions [pdf]
  Applicable to all individual network participants and applicants.
• Other Insurance/Coordination of Benefits (COB) [pdf]
• Open Negotiation Notice [pdf]
  Use to submit an open negotiation request to dispute the amount or denial of payment.
• Patient Waiver Form [pdf]
  Use to educate members on services that may not meet the Primary Coverage Criteria of the member’s policy. Waivers allow providers to collect for services that may not be deemed as meeting the Primary Coverage Criteria particularly for services designated as experimental/investigational or which are not for the treatment of a medical condition.
• Physician/Supplier Corrected Bill Submission Form [pdf]
  Use when submitting previously finalized (corrected) bills.
• Provider Application/Contract Request [pdf]
  Use to request application packet for new providers.
• Prior Authorization Request Form Use when PA is requiredPlease note: Not all services require prior authorization. You may contact customer service to determine what services require prior authorization. If the service does not require prior authorization, the service may be considered cosmetic, investigational, or may not be a covered benefit. We recommend you submit an Organizational Determination/Benefit Inquiry form. Failure to obtain any necessary authorizations may result in denial or reduction in benefits.
• Organizational Determination/Benefit Inquiry Form Use when PA is not required but a decision is neededPlease Note: If the service or procedure you’re requesting is on the PA list (meaning that it requires a Prior Authorization decision), please fill out the applicable prior authorization request form instead. Failure to obtain any necessary authorizations may result in a denial or reduction in benefits. For all other services or procedures, we don’t require this Organizational Determination/Benefit Inquiry form, but we do strongly recommend it for any procedures or services that may be considered cosmetic, investigational, or those that may not be a covered benefit. This allows us to determine beforehand if they meet medical criteria/guidelines and are covered benefits.
• Transplant Prior Authorization/Organizational Determination Form Use for transplant services.
• Provider Change of Data Form [pdf]
  Use to report a change of address or other data. Completion of this form DOES NOT create any network participation.
• Provider Refund Form [pdf]
  Use this form to submit a claim refund.
• Specialty Referral [pdf]
  Participating Primary Care Physicians - for referrals to participating in-network specialist providers.
• Termination Form for Clinic/Group Billing [pdf]
  Use for notification that a practitioner is leaving a clinic.

Medical forms for Medicare Advantage and Medicare Advantage Rx plans

Use these forms for Medicare Advantage and Medicare Advantage Rx plan members only.

• Appointment of Representative [pdf]
• Medicare Advantage Provider Claim Review Request Form [pdf]
• Guidelines for Bundling Admissions[pdf]
• Medicare Outpatient Observation Notice (MOON) [pdf]
• Notice of Medicare Non-Coverage [pdf]
• Waiver of Liability [pdf]

Medicare Advantage Part D

For more information about Medicare Part D (Pharmacy covered medications) plan formularies, utilization management criteria, and coverage determination requests:

• Advantage PFFS (MA-PD)
• Advantage HMO
• Rx (PDP) Basic
• Rx (PDP) Premier

Medicare Advantage Prior Authorization

• Arkansas Blue Cross Medicare Advantage Prior Authorization Request Form
  

Provider dental forms

Access forms for dental providers.

View dental forms