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 Authorization Request Form
- Authorization Form for Clinic/Group BillingUse for notification that a practitioner is joining a clinic or group.
- Claim Reconsideration Request Form
- Continuation of Care Election Form
- Designation of Authorized Appeal Representative
- Expedited Appeal Request Form
- Medicare Supplement USA Senior Care Network Claims Dispute Form
- New Clinic/Group Application Use for NEW clinic or NEW billing group only. Not for current providers.
- Notice of Payer Policies and Procedures and Terms and ConditionsApplicable to all individual network participants and applicants.
- 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 NoticeUse 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 FormUse 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- Physician/Supplier Corrected Bill Submission FormThis form is no longer valid. Corrected Claims should be submitted electronically through Availity. Timely Filing Review is now its own form.
- Timely Filing Review
- Provider Application/Contract Request Use to request application packet for new provider.
- Authorization
| Organizational Determination Request FormYou may use this form in three 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.
- Please select exception under request type on the form and place exception related comments in the "other clinical information" section on the form. Once reviewed by the organization, the decision will be communicated promptly to the provider.
- Transplant Prior Authorization/Organizational Determination Form Use for transplant services.
- Provider Change of Data Form Use to report a change of address or other data. Completion of this form DOES NOT create any network participation.
- Provider Refund FormUse this form to submit a claim refund.
- Statistical Questionnaire - Bed Complement Form
- Termination Form for Clinic/Group BillingUse 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]
- 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:
Medicare Advantage Prior Authorization
Medicare Advantage Prior Authorization List
Access the full list of codes requiring Prior Authorization as well as Notification Authorization requirements.