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]
• 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 
  This form is no longer valid. Corrected Claims should be submitted electronically through Availity. Timely Review is now its own form.Timely Filing Review
• Provider Application/Contract Request [pdf]
  
• Use to request application packet for new providers.
• Authorization | Organizational Determination Request Form
  You may use this form in two cases:
  
  1. When a prior authorization is required.
  2. When a prior authorization is not required but a decision is needed. In this case, you can use the "Org Determination/Benefit Inquiry Only" option on the "Request Type" field.
• 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