Forms for providers
- Request for Application (Organization)File type: PDF
Organizations should use this link to request an application to enroll in the network.
- Request for Application (Provider)File type:
Providers should use this link to request an application to join the network.
- Notice of Payer Policies and Procedures and Terms and ConditionsFile type: PDF
Applicable to all individual network participants and applicants.
- Authorization | Organizational Determination Request FormFile type: PDFYou may use this form in two cases:
- When a prior authorization is required.
- 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.
- Exception formFile type: PDF
Use the exception form when you need to request either a network or benefit exception.
- Transplant Prior Authorization/Organizational Determination FormFile type: PDF
Use for transplant services.
- Other Insurance/Coordination of Benefits (COB)File type: PDF
- Provider Blue Card Claim Appeal FormFile type: PDF
Please submit Provider BlueCard Claim Appeals to:
Appeals Department
P.O. Box 2181
Little Rock, AR 72203
Email: appealscoordinator@arkbluecross.com
Fax: 501-378-3366