Providers
Prior authorization 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.
Important information
- This form should only be used for Arkansas Blue Cross and Blue Shield members.
- FEP utilizes Magellan Rx Management for medical specialty pharmacy prior authorization.
- Providers requesting prior authorization for an ASE/PSE member should use the appropriate form on the Health Advantage website.
- Providers who are requesting a prior authorization for Walmart or other BlueAdvantage members should use the appropriate form from the BlueAdvantage website.
- Providers who are requesting a prior authorization for BlueMedicare members should use the appropriate form from Medicare Advantage Prior Authorization Request Form.
- Providers requesting prior authorization for Part B drugs for BlueMedicare should use the Part B Medication Prior Approval Request Form.
- Medicare Advantage - eviCore Innovative Solutions - Durable Medical Equipment, High-Tech Radiology and Radiation Oncology Guidelines.
- Medicare Advantage 2023 Prior Authorization List - Access the full list of codes requiring Prior Authorization as well as Notification Authorization requirements.
What to include with the completed Prior Authorization form [pdf] "Use when a PA is required"
Please 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.
- 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