- Arkansas formulary exception/Prior authorization request form
- Claim reconsideration request form
- Continuation of care election form
- Designation of authorized appeal representative
- Medicare Supplement USA Senior Care Network claims dispute form
- Other Insurance/Coordination of Benefits (COB)
Providers should submit completed COB (coordination of benefits) questionnaires independently to Arkansas Blue Cross and Blue Shield when received from the member/patient. Questionnaire responses should not be sent as an attachment to a claim. Arkansas Blue Cross will forward the COB questionnaire responses to the member's Blue Cross and Blue Shield Plan on the provider's behalf.
- Open negotiation notice
Use to submit an Open Negotiation Request to dispute the amount or denial of payment.
- Open negotiation notice instructions
Instructions on how to complete and return the Open Negotiation Notice.
- Patient waiver form
Use to educate members on services that may not meet the Primary Coverage Criteria of the member’s policy. Waivers allows 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.
- Timely filing review
- Authorization | Organizational determination request form
You may use this form in following cases:
- When a prior authorization is required.
- 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.
- To notify us of an inpatient admission.
- Exception form
Use the exception form when you need to request either a network or benefit exception.
- Transplant prior authorization/Organizational determination form
Use for transplant services.
- Provider refund form
Use this form to submit a claim refund.
- Statistical questionnaire - bed complement form
- Provider BlueCard claim appeal form
Please submit Provider BlueCard Claim Appeals to:
Appeals Department
PO Box 2181
Little Rock, AR 72203
Email: appealscoordinator@arkbluecross.com
Fax: 501-378-3366
Use these forms for Medicare Advantage and Medicare Advantage Rx plan members only.
- Appointment of representative
- Medicare Advantage provider claim review request form
- Guidelines for bundling admissions
- Medical records routing form – BlueMedicare
- Medicare outpatient observation notice (MOON)
- Waiver of liability
- Arkansas BlueMedicare organizational determination form
- Medicare out of network exception form
- Medicare Advantage single case agreement form
- Important message from Medicare
- Detailed explanation of non-coverage
Medicare Advantage Part D
For more information about Medicare Part D (Pharmacy covered medications) plan formularies, utilization management criteria, and coverage determination requests:
Medicare Advantage prior authorization
- Arkansas Blue Cross Medicare Advantage prior authorization request form
- Prior authorization list
Access the full list of codes requiring Prior Authorization as well as Notification Authorization requirements.
General forms
- New dental provider application
- Adding a network
- Adding or changing par provider or practice
- New practice acquisition
- Change of data form
- DEA Waiver
- Termination request
- NPI or TIN change