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 [pdf]
• Authorization Form for Clinic/Group Billing [pdf]
  Use for notification that a practitioner is joining a clinic or group.
• Baptist Health employees/dependents/retirees: Designation for authorized appeal representative form [pdf]
• Claim Reconsideration Request Form [pdf]
• Designation for authorized appeal representative form [pdf]
• Expedited Appeal Request Form [pdf]
• New Clinic/Group Application [pdf]
• 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]
• Network Exception Form [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 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 [pdf]
  Use when submitting previously finalized (corrected) bills.
• Prior Approval Request Form (for Services that Member’s policy requires 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 (for voluntary benefit inquiry requests)
• Provider Refund Form [pdf]
  Use this form to submit a claim refund.
• Specialty Referral [pdf]
  Participating Primary Care Physicians - for referrals to participating in-network specialist providers.
• Termination Form for Clinic/Group Billing [pdf]
  Use for notification that a practitioner is leaving a clinic.
• Arkansas Formulary Exception/Prior Approval Request Form

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 – HA MA [pdf]
• Medicare Outpatient Observation Notice (MOON) [pdf]
• Notice of Medicare Non-Coverage [pdf]
• Waiver of Liability [pdf]

Medicare Advantage Part D

For more information about Medicare Part D (Pharmacy covered medications) plan formularies, utilization management criteria, and coverage determination requests:

• Advantage PFFS (MA-PD)
• Advantage HMO
• Rx (PDP) Basic
• Rx (PDP) Premier

2021 Medicare Advantage Prior Authorization

• 2021 Medicare Advantage Prior Authorization Guide
• 2021 Health Advantage Medicare Advantage Prior Authorization Request Form
  

For dental providers

• Authorization Form for Clinic/Group Billing [pdf]
  Use for notification that a practitioner is joining a clinic or group.
• New Clinic/Group Application [pdf]
  Use for NEW clinic or NEW billing group only. Not for current providers.
• 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.
• Termination Form for Clinic/Group Billing [pdf]
  Use for notification that a practitioner is leaving a clinic.
• 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.