Provider forms

Contact your network development representative at the ArkansasBlue Welcome Center nearest you for assistance.

For medical providers

• Arkansas Blue Cross Employees/Dependents/Retirees- Designation for Authorized Appeal Representative Form
• Arkansas Formulary Exception/Prior Authorization Request Form
• Authorization Form for Clinic/Group Billing Use for notification that a practitioner is joining a clinic or group.
• Claim Reconsideration Request Form
• Designation for authorized appeal representative form
• Request for Application (Organization) Organizations should use this link to request an application to enroll in the network.
• Request for Application (Provider) Providers should use this link to request an application to join the network.
• Notice of Payer Policies and Procedures and Terms and Conditions Applicable to all individual network participants and applicants.
• Other Insurance/Coordination of Benefits (COB)
• Open Negotiation Notice Use to submit an open negotiation request to dispute the amount or denial of payment.
• Patient Waiver Form Use to educate members on services that may not meet the Primary Coverage Criteria of the member’s policy. Waivers allow 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• Physician/Supplier Corrected Bill Submission Form This form is no longer valid. Corrected Claims should be submitted electronically through Availity. Timely Review is now its own form.
• Timely Filing Review
• Authorization | Organizational Determination Request FormYou may use this form in two cases:
  1. When a prior authorization is required.
  2. 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.
• Exception formUse the exception form when you need to request either a network or benefit exception.
• 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 Form Use this form to submit a claim refund.
• Specialty Referral Participating Primary Care Physicians - for referrals to participating in-network specialist providers.
• Termination Form for Clinic/Group Billing Use for notification that a practitioner is leaving a clinic.
• Provider BlueCard Claim Appeal FormPlease submit Provider BlueCard Claim Appeals to:
  Appeals Department
  P.O. Box 2181
  Little Rock, AR 72203
  Email: [email protected]
  Fax: 501-378-3366

Provider dental forms

Access forms for dental providers.

View dental forms