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Web please complete this form if you are seeking reconsideration of a previous billing determination. Original claims should not be attached to a review form. Web arkansas formulary exception/prior authorization request form [pdf] authorization form for clinic/group billing [pdf] use for notification that a practitioner. Web use this form to submit reconsideration requests for their commercial and bluecare patients. Do.
Be specific when completing the description of dispute and. Do not use this form to. Original claims should not be attached to a review form. Web for more details, refer to the claim reconsideration requests page and instructional user guide in the provider tools section of our website. This form is only to be used for review of a previously adjudicated claim. Web use this form to submit reconsideration requests for their commercial and bluecare patients. Web arkansas formulary exception/prior authorization request form [pdf] authorization form for clinic/group billing [pdf] use for notification that a practitioner. Web please complete this form if you are seeking reconsideration of a previous billing determination.