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I
CLAIM RECONSIDERATION REQUEST COVER SHEET – PROVIDER REQUESTS
ATTACH EXPLANATION FOR REQUEST AND SUPPORTING DOCUMENTATION TO COVERSHEET
INSTRUCTIONS: Submit a separate form for each member. This cover sheet is to be completed by physicians, hospitals, or other health care
professionals to request a claim reconsideration or appeal on members enrolled in Arkansas Blue Cross or Health Advantage Plans. There are two
stages available; 1) Claim Reconsideration and 2) Formal Provider Appeal. If you disagree with the processing of a claim, the first step is the
submission of a 1
st
Level‐ Claim Reconsideration Request to Medical Re‐review. If you disagree with the claim reconsideration decision, you may
then submit a 2
nd
Level ‐ Formal Provider Appeal. Do NOT use this form for submitting new or corrected claims, requesting timely filing
exceptions, responding to bar code request letters for medical information, or submitting coordination of benefits information. Please be sure
to attach all pertinent information to support your request. If requesting a 2
nd
Level – Formal Provider Appeal, please be sure to include a copy of
the determination response from the 1
st
Level – Claim Reconsideration Request.
Request Information
Line of Business (Select One): Arkansas Blue Cross and Blue Shield Health Advantage
Request Level (Select One): 1
st
Level – Claim Reconsideration Request 2
nd
Level – Formal Provider Appeal
Reason For Request (attach explanation for request and supporting documentation):
Pricing Issue Fragmented Charge Denial – Fragmented or “bundled claim” issue
Resubmission of “Prior Notification Information” Other:
Provider Information
Type of Provider: Physician Hospital Other health care professional (Lab, DME, etc. )
Date Form Completed:
NPI # or Tax ID: Return Address:
Provider Name (as listed on RA/EOB):
Facility/Group Name: Contact Person: Phone Number:
( )
Member Information
Member ID#
Member’s Name: Denial Reason: CPT Code at Issue:
Claim #: Date of Service: Billed Amount:
Provider Mailing Instruc tions
1
st
Level Reconsiderations 2
nd
Level – Formal Provider Appeals 1
st
Level and 2
nd
Level requests
For Arkansas Blue Cross, For Arkansas Blue Cross, For Health Advantage,
mail request to: mail request to: mail request to:
Arkansas Blue Cross and Blue Shield Arkansas Blue Cross and Blue Shield Health Advantage
Attn: Medical Re‐review Attn: Appeals Coordinator Attn: Member Response Coordinator
PO Box 3688 PO Box 2181 PO Box 8069
Little Rock, AR 72203‐3688 Little Rock, AR 72203‐2181 Little Rock, AR 72203‐8069
Revised: 10/5/2011
