Provider forms

Forms for medical providers

Arkansas Formulary Exception/Prior Approval Request Form

Prior Authorization Request Form Use when 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.