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Prior approval for requested services

The primary coverage criteria of certain services must be established through a prior Approval or pre-authorization process before they can be performed. Please refer to Availity Essentials portal, Arkansas Blue Cross Coverage Policy or the member’s benefit certificate to determine which services need prior authorization.

What to include with the completed Prior Authorization form [pdf]

  • Member Information
  • Requested service(s)
  • Name and telephone number of contact person
  • Fax number to send determination
  • Requesting / Performing Provider’s NPI or Provider ID
  • Copy of member’s insurance card (front/back)
  • Other Insurance Information
  • CPT Code(s), ICD 10/HCPCS Code(s), Modifiers that are applicable
  • Please use the most descriptive procedure and diagnosis codes
  • Medical records to support requested services