Provider forms

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.
• 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• Physician/Supplier Corrected Bill Submission FormThis form is no longer valid. Corrected Claims should be submitted electronically through Availity. Timely Filing Review is now its own form. Timely-Filing-Review

• Authorization | Organizational Determination Request Form
  You 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.
• 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.

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]