Provider forms

The forms listed on the menu below are for use by medical providers. These forms are in portable document format (PDF) and allow you to complete the form online, print, sign and mail to the appropriate address with supporting documents. Contact your Network Development Representative at the Office Location nearest you for assistance.

 

Forms for medical providers

• Arkansas Formulary Exception/Prior Approval Request Form
• Authorization Form for Clinic/Group Billing [pdf]
  Use for notification that a practitioner is joining a clinic or group.
• Electronic Claims Waiver Request Form 
  Use for providers requesting electronic claims waiver and exception to submit paper claims.
• 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]
• Open Negotiation Notice [pdf]
  Use to submit an open negotiation request to dispute the amount or denial of payment.
• 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 Authorization form Use when a PA is required
  Please note: Not all services require prior authorization. You may contact customer service to determine what services require prior authorization. If the service does not require prior authorization, the service may be considered cosmetic, investigational, or may not be a covered benefit. We recommend you submit an Organizational Determination/Benefit Inquiry form. Failure to obtain any necessary authorizations may result in denial or reduction in benefits.
• Organizational Determination/Benefit Inquiry Form Use when PA is not required but a decision is neededPlease Note: If the service or procedure you’re requesting is on the PA list (meaning that it requires a Prior Authorization decision), please fill out the applicable prior authorization request form instead. Failure to obtain any necessary authorizations may result in a denial or reduction in benefits. For all other services or procedures, we don’t require this Organizational Determination/Benefit Inquiry form, but we do strongly recommend it for any procedures or services that may be considered cosmetic, investigational, or those that may not be a covered benefit. This allows us to determine beforehand if they meet medical criteria/guidelines and are covered benefits.
• Transplant Prior Authorization/Organizational Determination Form Use for transplant services.
• Provider Application/Contract Request [pdf]
  Use to request application packet for new 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.
• Provider Refund Form [pdf]
  Use this form to submit a claim refund.
• Referral Form [pdf]
  Primary care physicians should use this form to refer a patient to a specialist when a referral is required by the patient's health plan.
• Termination Form for Clinic/Group Billing [pdf]
  Use for notification that a practitioner is leaving a clinic.
• View Precert FAQ [pdf]

Forms 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]