Submitting an Appeal

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If a prior authorization for your patient was not approved, you may have the option to file a formal appeal. This article explains who can submit an appeal and how the process works.

Who Can Submit an Appeal

Appeals are submitted by the prescribing provider through the same unique link sent in the determination letter. You must first complete the identity verification step (see Prescriber Data Collection Form) before the appeal option becomes available.

The option to submit an appeal only appears when the health plan has enabled appeals for the case. If you do not see an appeal option, contact the health plan for guidance.

Accessing the Appeal Form

From your determination letter

  1. Open the unique link from your determination letter.
  2. Complete Step 1: Identity Verification by entering the patient’s date of birth and your NPI number, then select Verify Identity.
  3. If the authorization was not approved, you will see two options:
    • Provide Additional Clinical Data — returns to the clinical data form.
    • Submit Appeal — opens the appeal form.
  4. Select Submit Appeal (or Submit External Appeal if the plan offers a second-level external appeal).

From the Provider Portal

On your plan’s Provider Portal, choose the Appeal tab, enter the case reference, your NPI, the patient’s date of birth, and the member number, pick an Appeal Type, and select Start Appeal. See Provider Portal.

You still verify the patient’s date of birth and your NPI when the case opens. Because you already chose to appeal, the page opens straight away under the title Appeal Response Form in the two-column response layout, rather than asking again how you want to proceed, and the appeal type you picked on the portal is shown as a read-only chip. If the case turns out not to be appealable — for example the plan has appeals switched off, or the only remaining option is an external appeal the plan does not offer — you see the case status screen instead.

Complete the appeal in the same browser tab you started it in. If you close the tab first, the case still opens normally but the appeal form asks you how you want to proceed and lets you choose the turnaround again.

Completing the Appeal Form

The appeal form has four sections:

Appeal Type

Choose the turnaround you are requesting:

  • Standard (30 days)
  • Expedited (72 hours)

Choose expedited only when a delay would seriously jeopardize the patient’s health. If you started the appeal on the Provider Portal in this browser tab, your earlier choice appears as a read-only chip — you cannot change it on this screen, and the plan files the appeal under the turnaround you picked there. Contact the health plan if you need a different one. If you opened the appeal from a determination letter instead, you choose the turnaround here before submitting. This choice is separate from whether the appeal is internal or external — the plan determines that automatically.

Clinical Rationale

Enter your reasoning in the Clinical Rationale text box. Explain clearly why you believe this authorization should be approved. You may reference clinical guidelines, journal articles, or other supporting evidence. This field is required.

Supporting Documents (Optional)

Attach records for this patient — clinical notes, lab results, or imaging.

  1. Select Upload File to open the file chooser.
  2. Choose a PDF, Word document, or image file (TIFF, JPG, PNG are also accepted). Files up to 50 MB are supported.
  3. The uploaded file appears as a card in the form. You can remove it by selecting the X on the card.
  4. Select Upload Another File to add more documents if needed.

Academic Studies & Clinical Literature (Optional)

Use this second uploader for published evidence rather than patient records — peer-reviewed studies, published guidelines, or compendia entries that support the requested therapy.

It works exactly like the section above: select Upload Literature, choose a file, and select Upload Another File to add more. Uploads in either section are sent to the reviewer together; keeping them separate simply makes clear which files are patient records and which are published evidence. If an upload fails, the error appears under the section you were uploading to and does not affect the other one.

Submitting the Appeal

Once you have chosen an appeal type, entered your clinical rationale, and attached any documents, select Submit Appeal at the bottom of the form.

If there is an error during submission, an error message will appear. Review the message and try again, or contact the health plan if the problem persists.

What Happens Next

After you submit, you will see a confirmation screen with the message Appeal Submitted. It confirms whether the appeal was filed as internal or external and the turnaround it was filed under. The appeal has been sent to the reviewer, and you will be notified of the outcome through the health plan’s normal communication channels.

While an appeal is under review, if you open the original link again you will see the message Appeal Under Review. No further action is needed unless you receive additional correspondence.