Providers
Provider forms
Contact your Network Development Representative at the Office Location 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.
- 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]
- 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. - Arkansas Formulary Exception/Prior Approval Request Form [pdf]
Medical forms for Medi-Pak Advantage and Medi-Pak Rx plans
Use these forms for Medi-Pak Advantage and Medi-Pak Rx plan members only.
- Appointment of Representative [pdf]
- Claim Reconsideration Request [pdf]
- Guidelines for Bundling Admissions[pdf]
- Inpatient Hospital Assessment Form and Checklist [pdf]
- LTAC Post-Acute Admission [pdf]
- Medical Records Routing Form - MA [pdf]
- Medical Records Routing Form – HMO MA [pdf]
- Medicare Outpatient Observation Notice (MOON) [pdf]
- Notice of Medicare Non-Coverage [pdf]
- Organization Determination/Prior Authorization Form [pdf]
- Out-of-Network Exception Request [pdf]
- Rehab and SNF Post-Acute Admission [pdf]
- Waiver of Liability [pdf]
Medi-Pak Advantage
For more information about Medicare Part D plan formularies, utilization management criteria, and coverage determination requests:
Dental forms for all plans
Use these forms for all members who have dental plans.
- Dental Provider Application [pdf]
If joining a clinic, also complete the Dental Authorization Form for Clinic/Group Billing. - Dental Authorization Form for Clinic/Group Billing [pdf]
Use for notification that a practitioner is joining a clinic or group. - Dental 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. - Member Dental claim form [pdf]
- Termination Form for Clinic/Group Billing [pdf]
- New Clinic/Group Application [pdf]
Use for NEW clinic or NEW billing group only. Not for current providers. - Accident Form for Dental Injury [pdf]
Please use this form to file a claim with your medical plan. Accidents are not covered under your dental policy.