Submitting an Appeal

External UsersExternal Last updated:

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

  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).

Completing the Appeal Form

The appeal form has two sections:

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)

You may attach documents to support your appeal — for example, journal articles, clinical notes, or lab results.

  1. Select Upload File to open the file chooser.
  2. Choose a PDF, Word document, or image file (TIFF, JPG, PNG are also accepted).
  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.

Submitting the Appeal

Once you have entered your clinical rationale and attached any supporting 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. The appeal has been sent to the reviewer. 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.