Provider forms

Providers should submit completed COB (coordination of benefits) questionnaires independently to BlueAdvantage Administrators of Arkansas when received from the member/patient. Questionnaire responses should not be sent as an attachment to a claim. BlueAdvantage will forward the COB questionnaire responses to the member's Blue Cross and Blue Shield Plan on the provider's behalf.

Use to submit an Open Negotiation Request to dispute the amount or denial of payment.

Instructions on how to complete and return the Open Negotiation Notice.

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.

You may use this form in following 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. 
3. To notify us of an inpatient admission.

Use the exception form when you need to request either a network or benefit exception.

Use for transplant services.

Use this form to submit a claim refund.

Please submit Provider BlueCard Claim Appeals to:

Appeals Department
PO Box 2181
Little Rock, AR 72203
Email: appealscoordinator@arkbluecross.com
Fax: 501-378-3366