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.
• Exception Letter [pdf]
  Request a pre-service exception to receive network benefit reimbursement for non-network provider services. All requests are subject to medical necessity and coverage guidelines. For Tyson or Walmart members, please use the Network Exception Form.
• 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 Approval Form- Medications – BlueAdvantage [pdf]
• Prior Authorization Form for Requested Services [pdf]
  For Tyson or Walmart members, please use the Courtesy Review Form.
• 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]

Forms for Tyson

• Courtesy Review Form [pdf]
• Network Exception Form [pdf]
  Request a pre-service exception to receive network benefit reimbursement for non-network provider services. All requests are subject to medical necessity and coverage guidelines.
• Prior Approval Form – Medications – Tyson [pdf]

Forms for Walmart

• Courtesy Review Form [pdf]
• Network Exception Form [pdf]
  Request a pre-service exception to receive network benefit reimbursement for non-network provider services. All requests are subject to medical necessity and coverage guidelines.
• Prior Approval Form – Medications – Walmart [pdf]