Providers
Provider forms
Contact your Network Development Representative at the ArkansasBlue welcome center nearest you for assistance.
Medical forms for Arkansas Blue Cross and Blue Shield plans
Use these forms for Arkansas Blue Cross metallic and non-metallic medical plans members only.
- Arkansas Formulary Exception/Prior Approval Request Form [pdf]
- Authorization Form for Clinic/Group
Billing [pdf]
Use for notification that a practitioner is joining a clinic or group. - Claim Reconsideration Request Form [pdf]
- Continuation of Care Election Form [pdf]
- Designation of Authorized Appeal Representative [pdf]
- Expedited Appeal Request Form [pdf]
- Medi-Pak Supplement USA Senior Care Network Claims Dispute Form [pdf]
- Network Exception Form [pdf]
- New Clinic/Group Application [pdf]
Use for NEW clinic or NEW billing group only. Not for current providers. - 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 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. - Physician/Supplier Corrected Bill
Submission Form [pdf]
Use when submitting previously finalized (corrected) bills. - Prior Approval Request Form
[pdf]
Use for services that require prior authorization. - 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
Initiated-Pre-Service/Formal Benefit Coverage Information Form [pdf]
Use for voluntary benefit inquiry requests. - Provider
Refund Form [pdf]
Use this form to submit a claim refund. - Statistical Questionnaire - Bed Complement Form [pdf]
- 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]
- Medical Records Routing Form - BlueMedicare [pdf]
- Medical Records Routing Form – HA MA [pdf]
- Medicare Outpatient Observation Notice (MOON) [pdf]
- Notice of Medicare Non-Coverage [pdf]
- Waiver of Liability [pdf]
- Arkansas Blue Medicare Organizational Determination Form [pdf]
- Medicare Out of Network Exception Form [pdf]
- Medicare Advantage Single Case Agreement Form [pdf]
Medicare Advantage Part D
For more information about Medicare Part D (Pharmacy covered medications) plan formularies, utilization management criteria, and coverage determination requests: