How to Fill Out and Submit the BCBS Arkansas Prior Authorization Form

The BCBS Arkansas prior authorization form comes in two versions: the Authorization/Organizational Determination Request Form for medical services, and the Pharmacy Formulary Exception/Prior Approval Request Form for prescription drugs. Both are fillable PDFs on the Arkansas Blue Cross provider forms page.¹ You complete the form, attach clinical documentation, and either fax it to the number that matches your plan and urgency level or submit it electronically through the Availity provider portal.

Pick the Right Form First

Grabbing the wrong form is one of the fastest ways to delay a decision. Arkansas Blue Cross separates medical and pharmacy requests completely.

For inpatient admissions, outpatient procedures, and any service on the medical prior authorization list, use the Authorization/Organizational Determination Request Form.²
For medications on the pharmacy benefit, including step-therapy overrides and formulary exceptions, use the Pharmacy Formulary Exception/Prior Approval Request Form.³

Both are fillable PDFs. Type into the on-screen fields, then print and sign before you submit.

If you aren’t sure whether the specific service or drug needs authorization at all, check the published medical prior authorization list before scheduling. Every insurer in Arkansas is required to publish that list, along with the written clinical criteria used to evaluate requests, in plain language.⁴

Gather Your Documentation Before You Start

The insurer’s decision clock does not begin until it has everything it needs to review the request. A form missing a lab result or a diagnosis code effectively resets your timeline. Have the following ready before you open the medical form:

Patient’s full name, date of birth, and Arkansas Blue Cross member ID exactly as they appear on the card.
Treating provider’s name, office address, phone, and fax number.
The CPT code for the requested service and the ICD-10 diagnosis code that supports it. The published PA list pairs specific CPT codes with qualifying diagnosis codes, so match them exactly.⁵
Clinical documentation: office notes, lab results, imaging reports, and any other records showing why this service is the appropriate next step. If the request is for out-of-network care, add a written explanation of why an in-network option won’t work.²

For the pharmacy form, the focus shifts. You’ll need the patient’s diagnosis and ICD code, a full list of every medication already tried for the same condition (how long each was used and why it failed), and whether any contraindications rule out formulary alternatives.³ Attach all supporting clinical records. Skipping the medication history almost guarantees a denial when step therapy applies, because the insurer expects proof that a lower-cost alternative was tried first or is medically inappropriate.⁶

Filling Out the Medical Authorization Form

The medical form is a multi-page PDF, and its own instructions say to complete every applicable section on every page, legibly, before faxing.²

Member information. Enter the patient’s name, date of birth, and member ID exactly as they appear on the insurance card. A single transposed digit in the member ID will bounce the form back before anyone reads the clinical question.

Provider information. Enter the treating provider’s name, office address, phone, and fax number. The fax number here is where the insurer sends the decision back, so verify it before submitting.

Service request. Enter the CPT code, ICD-10 diagnosis code, and a description of what’s being requested. For an inpatient admission, note the expected admission date and length of stay. For an outpatient procedure, note the planned date of service and facility.

Urgency. Check the urgent request box only when a delay could seriously jeopardize the patient’s health or ability to recover. Marking urgent routes the form to a separate fax line and triggers a faster review timeline, so use it when the clinical situation genuinely warrants it.

Attachments. Add chart notes, lab data, and imaging reports as pages behind the completed form. This is where requests succeed or fail. A bare form with no clinical backup gives the reviewer nothing to approve.

How to Submit the Form

By Fax

Fax remains the most common submission method for the medical form. Arkansas Blue Cross uses three numbers depending on plan type and urgency:

Standard (non-urgent) requests: 501-301-1994
Urgent requests: 501-301-1986
FEP, Exchange, and Octave plans: 501-301-1996

Send the completed form and all clinical attachments as a single transmission.² Keep the fax confirmation page. If there’s ever a dispute about whether the request was filed on time, that confirmation is your proof.

Through Availity

Providers registered with Availity Essentials can submit prior authorization requests electronically. The portal has a dedicated “Prior Auth/Pre-Service Review” feature. To register, go to availity.com/arkansasbluecross or call Availity Client Services at 800-282-4548, Monday through Friday, 8:00 a.m. to 8:00 p.m. Eastern.⁷ Electronic submission gives you immediate delivery confirmation and online status tracking.

How Long the Decision Takes

Arkansas law sets maximum response times measured from when the insurer has received all necessary information, not from when you first send the form. If the insurer asks for more records, the clock pauses until those records arrive.

Non-urgent requests: the insurer must decide and notify both the provider and the member within two business days of receiving all necessary information.⁸
Urgent requests: the decision and notification must happen no later than one business day after all information is received.⁹

The form itself notes that turnaround for most organizational determination and benefit inquiry requests is ten business days.² The gap between the statutory deadlines and that longer estimate comes down to information gathering. Submit a complete package up front and the statutory clock is the one that runs.

If the Request Is Denied

The denial notice must include the name and phone number of the physician who made the decision, the clinical criteria the reviewer relied on, and instructions for appealing.¹⁰ Read the clinical criteria section carefully. It tells you exactly what evidence the reviewer found missing, which is your roadmap for the next step.

Peer-to-Peer Review

Before filing anything in writing, the treating physician can request a peer-to-peer conversation with the insurer’s medical director. The denial notice must include a phone number for this contact. The calls are usually brief, around five to ten minutes, and let the treating doctor explain the clinical reasoning directly. When the reviewer was working from incomplete information, this often resolves the issue faster than a formal appeal.

Step-Therapy Override

When the denial is based on a fail-first or step-therapy protocol, the treating provider can request an expeditious override. On request, the insurer must provide contact information for a person who can start that process.¹⁰

Internal Appeal

You have 180 days from the date you receive the denial to file a written internal appeal. Include the member’s name, plan ID number, the claim or authorization number being appealed, and the date and provider of service. Mail it to:

Appeals Coordinator
Arkansas Blue Cross and Blue Shield
PO Box 2181
Little Rock, AR 72203-2181

Write “Internal Review Request” on the envelope.¹¹ Attach any new clinical documentation that addresses the reason for the original denial. If the reason cited was insufficient evidence of medical necessity, this is where you fill the gap.

Under Arkansas law, an appeal of a non-urgent denial must be decided within four business days of receiving all necessary information. Appeals of urgent denials must be decided within two business days.⁸⁹

External Review

If the internal appeal fails, you can request an external review by an independent third party. External review is available for denials involving medical judgment or a determination that a treatment is experimental. The written request must be filed within four months of receiving the final internal denial notice.¹² A provider or other authorized representative can file on your behalf.

Emergency Care Is Different

Prior authorization is not required for emergency department visits. Federal law under the No Surprises Act prohibits health plans from requiring advance approval for emergency services.¹³ Once the patient is stabilized, though, continued inpatient care or follow-up procedures may fall back under normal prior authorization rules, and the treating provider should submit a request for the post-stabilization care as soon as the clinical picture allows.

1
Arkansas Blue Cross and Blue Shield. Arkansas Blue Cross and Blue Shield – Provider Forms
2
Arkansas Blue Cross and Blue Shield. Authorization – Organizational Determination Request Form
3
Arkansas Blue Cross and Blue Shield. Arkansas Pharmacy Formulary Exception/Prior Approval Request Form
4
FindLaw. Arkansas Code Title 23 – Section 23-99-1104
5
Arkansas Blue Cross and Blue Shield. Medical Prior Authorization List – Arkansas
6
Arkansas Blue Cross and Blue Shield. Prior Authorization Process for Prescriptions
7
Arkansas Blue Cross and Blue Shield. Provider Portal
8
FindLaw. Arkansas Code Title 23 – Section 23-99-1105
9
FindLaw. Arkansas Code Title 23 – Section 23-99-1106
10
Justia. Arkansas Code 23-99-1115 – Notice Requirements – Process for Appealing Adverse Determination and Restriction or Denial of Healthcare Service
11
Arkansas Blue Cross and Blue Shield. How to File an Appeal
12
HealthCare.gov. External Review
13
UCSF Health. Patient Protections Against Surprise Medical Bills