Provider initiated – Pre-service/Formal Benefit coverage information

The Formal Benefit Inquiry Process allows providers to ask for pre-service review of, and approval of coverage for, services with billed charges exceeding $1,500.00 not yet provided to a specific Arkansas Blue Cross and Blue Shield or Health Advantage member. This "Benefit Inquiry" process only applies to provider-initiated inquiries and only applies to services that are not already subject to Prior Authorization requirements under the terms of the member's health plan. For services that the member's health plan requires Prior Approval, select the Prior Approval Request Form. Providers who are requesting a Prior Approval for an ASE/PSP member should direct the request to the utilization review entity for ASE/PSP.

These Benefit Inquiries are only available for Arkansas Blue Cross Blue Shield and Health Advantage Members. They are not available for members of self-funded employer group health plans, even if the plans are administered by Arkansas Blue Cross, d/b/a Blue Advantage Administrators, or by Health Advantage. Also, supplemental plans like Medi-Pak are not included. These Benefit Inquires are also not available for members covered by the Federal Employee Program.

Completed forms received after 12 p.m. will be considered received on the next business day.

You must complete and submit a Provider Initiated – Pre-Service/Formal Benefit Coverage Information form [pdf]

What to include on a voluntary request for prior approval:

• Member Information
• Requested service(s)
• Estimated billed charge must exceed $1,500.00*
• 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
• Diagnosis coding must be detailed and complete on the request form and the subsequent claim for services. If the Benefit Inquiry is approved and the member’s coverage was effective on the date the service is actually provided, payment of the claim is guaranteed only if the information on the Benefit Inquiry Request form matches exactly the post service claim submission.

If a Benefit Inquiry is approved, it is not a guarantee that the claim for the service, if provided, will be paid when the claim for that service is submitted. The claim may be denied if the member’s coverage has lapsed after the approval but before the service is provided due to nonpayment of premium. Please check the member’s coverage status at the time the service is performed. Providers using Availity Essentials portal may check the status of the member’s coverage prior to performing the service in several ways:

• Availity Essentials portal will display the Individual's policy status as Active, Termed or in a Grace Period
• For Members with Arkansas Blue Cross or Health Advantage coverage through ARHOME and Group Employer Policies, Availity Essentials portal displays the most current information that has been received from the State of Arkansas or from the Member's Group Employer.
• Availity Essentials portal also displays information on the status of a member’s coverage limits. However, if multiple providers filing claims for similar services on the same member and depending on the sequence/timely filing of claims, the status of these limits would be updated.

*If less than $1500 billed charges, an informal pre-service review is available, please check Availity Essentials portal for member information or call the Customer Service phone number on the member’s identification card.