Most doctors or hospitals will file your claim for you. Discuss filing arrangements
with your health care provider. Be sure the health care provider has your most current
insurance information. Showing a copy of your ID card, while not a guarantee of
benefits, will assist the health care provider in completing the claim form properly.
The Schedule of Benefits mailed to you with your ID card has helpful general information.
You can file a claim when a health care provider is not filing the claim for you.
Links to forms are provided below or contact your local Arkansas Blue Cross office
for a claim form or call the number on the back of your ID Card. Instructions for
filing are on the back of the claim form. All bills should be itemized, submitted
on the health care provider's invoice or stationary and attached to the claim form.
A separate form must be submitted for each patient.
Coinsurance — All charges will be subject to your yearly deductible
and coinsurance. Both the doctor and hospital will prepare an estimate and ask you
to pay a specified amount, based on that estimate. All financial arrangements are
made between the health care providers and insured, so please discuss this with
your doctor and hospital. They will want to help you.
Deductible — Deductibles are applied on a calendar-year basis and will
be applied on eligible services (including maternity care and delivery) until the
deductible has been met.
If a claim for payment is denied, the member must ask for an appeal in writing within
180 days after notification of the denial of benefits. Please send your request
Submit issues and comments as well as any additional information relevant to your
claim with your request for appeal. A complete review will be made of all information.
You will receive a final decision in writing within 60 days after your request is
received unless special circumstances require extensive review. For any assistance,
please call the Customer Service number that appears on your ID card.
If you have additional health insurance coverage, a decision must be made as to
which coverage is responsible for primary payment. Please complete the coordination
of benefits questionnaire or call the Customer Service number that appears on your
If the family member is not on the policy, information cannot be obtained. If you
would like someone else to obtain information on your policy or speak on your behalf,
you can complete an Authorization for Release Form (PDF).
Since you have Medicaid, you no longer need Medi-Pak because Medicaid covers what
Medi-Pak covers. You have the option of suspending your Medi-Pak policy for 24 months
if certain criteria are met. You have up to 90 days from the date of notification
of Medicaid eligibility to contact Arkansas Blue Cross requesting to suspend your
Medi-Pak policy. You must also put this request in writing including your policy
number, your signature and the date you sign the request.
If 90 days has passed since you were notified of Medicaid eligibility, your only
option is to cancel the policy in writing or by non-payment of premium.
Gastric Bypass and Organ Transplants
Gastric bypass procedures and organ transplants (except for cornea or kidney transplant
procedures) require prior approval. Prior Approval is a request from a physician
for the approval of a proposed hospitalization, a surgical procedure or a medical
treatment. To obtain prior approval, please have your health care provider send
a written request to:
Consult your benefit booklet or contact the Customer Service number on your ID card
to determine if you are subject to precertification or pre-notification prior to
certain medical services.
Preadmission certification or precertification is a process where a member
must call and receive prior approval for an admission into any hospital. Arkansas
Blue Cross no longer requires preadmission certification.
Pre-notification is a process where a member should call in prior to admission
to an out-of-network hospital facility or a hospital outside the state of Arkansas
to alert us of the admission. Pre-notification provides information helping to determine
if case management would be an appropriate option for the member.
Pre-notification is not required for outpatient treatment or any in-state, in-network
If your inpatient admission does not fall within the described exceptions previously
mentioned, your policy may require pre-notification. If you are an FEP or BlueAdvantage
Administrators of Arkansas member, your admitting physician, or the hospital would
need to contact Integrated Health, the Arkansas Blue Cross and Blue Shield pre-notification
vendor, by calling 1-800-451-7302. All other members should contact
Prior authorization is a review prior to the time a specified procedure is
scheduled. This review consists of checking clinical documentation to verify the
medical necessity for the procedure. National Imaging Associates (NIA) and New Directions
based on medical guidelines from Arkansas Blue Cross conduct the review. A prior
authorization is required for each different procedure, even if those procedures
are performed on the same day. Failure to obtain prior authorization will result
in denial of the claim.
Procedures requiring prior authorization:
NIA — Specified high tech radiology procedures, MRIs, CTs, PET scans,
and nuclear cardiology, must have prior authorization. Inpatient services, emergency
room services and observation room services are not subject to this review.
New Directions (Still applies if insurance is secondary payor) —
For any assistance, call the Customer Service number that appears on your ID card.
Arkansas Blue Cross and Blue Shield is an Independent Licensee of the Blue Cross
and Blue Shield Association and is licensed to offer health plans in all 75 counties
of Arkansas. Copyright © 2001-2014 Arkansas Blue Cross and Blue Shield