Availity Essentials Appeals application

The Appeals Application:

Streamlines the appeals process by making it easy to submit appeals directly from the Claim Status screen
Gathers all required information about the claim being disputed
Prevents duplicate appeal submissions

The Appeals dashboard shows the status and history of submitted appeals, eliminating the need to contact us for status information. For the Appeals Application:

The maximum number of files to upload is 10.
Files must be larger than 3 KB.
Maximum individual file size is 60 MB with a total of 150 MB across all files.
Supported file types include: .csv, .doc, .docx, .gif, .html, .jpg, .jpeg, .msg, .pdf, .png, .ppt, .pptx, .rtf, .tif, .tiff, .txt, .xls, and xlsx.

Pre-authorization determination appeals

Pre-authorization determinations appearing on the Availity Essentials Authorization dashboard can be appealed using the appeals application. Pre-authorizations appear on the dashboard when they are submitted using the Authorization application or by submitting an inquiry and pinning the authorization to the Authorization dashboard.

The following pre-authorization determinations appeals cannot be submitted via Availity Essentials:

Pharmacy pre-authorization
Specialty medication pre-authorization 
Pre-authorizations submitted via eviCore healthcare (physical medicine) or Carelon  Medcial Benefits Management (radiology, sleep medicine or cardiology)

Post-service claims appeals

All post-service provider claims appeals must be submitted via the Appeals Application on Availity Essentials.

Note: The only disputes and appeals that should not be submitted via Availity Essentials are:

Pricing disputes, which are not appeals and are subject to a separate pricing dispute process
Disputes that meet our Extenuating Circumstances exception criteria which must be submitted via fax
Appeals that Availity cannot process because of file size limits (see above), which may be submitted via secure file transfer protocol (SFTP)

Accessing the Appeals application

Access the application from Availity Essentials: Claims & Payments>Appeals. If you do not have access to the application, contact your Availity Essentials administrator and request the Claim Status role.

Appeals can be initiated from the Claim Status screen by selecting Dispute Claim.

Get trained for free

View the training options available by clicking the Help & Training link in the Availity Essentials menu. View user guides on Availity Essentials: Help & Training>Find Help>Appeals. A recorded training demonstration is also available by searching for Appeals: Help & Training>Get Trained.

Availity Essentials Appeals application messaging

If you receive one of the following messages when trying to dispute a claim using the Appeals application, review the explanation for alternative options for submitting your dispute.

Appeals tool message	Explanation
This is not an appealable denial. If you have questions, please refer to the "Contact Us" page of our provider website.	Out-of-network provider Your dispute may be eligible through the member appeal process. Please review the Appeals for Members (PDF) section of our Administrative Manual and the Member Appeal Form (PDF) for help with submitting the appeal through alternative channels. Contracted providers Your disputed claim does not contain a denial. Pricing disputes: If your dispute is regarding pricing, please follow the process to submit a pricing dispute relating to how a claim or claim line was processed. Benefit disputes: If your dispute is regarding benefit categories (e.g., preventive vs. medical, dental vs. medical, behavioral health vs. medical), copays, deductibles or other benefit issues, review the Appeals for Members (PDF) section of our Administrative Manual and the Member Appeal Form (PDF) for help with submitting the appeal through alternative channels. All other disputes: Review the denial message on the remittance advice to determine appropriate action.
This claim is not eligible for an appeal at this time. Information has been requested for further processing of this claim.	Your disputed claim contains a “soft” denial. This means there is an internal review available before utilizing an appeal to resolve the issue. Review the denial message on the remittance advice or the letter requesting information to determine appropriate action. Additional appeals options are available on our Self-Service Tool.
We require all professional services rendered by the same provider for the same date of service to be submitted on one claim form. Please submit corrected claim.	For claim submission help, please review claim submission and fragmented/split professional billings.
This is a joint administrated or shared administrated plan, please refer to the Appeals for Members process within the Administrative Manual on our provider website.	There is a denial associated with this claim indicating member liability for the denied service. Member appeals for these joint- or shared-administrated plans must be submitted to the appropriate party. Please review the Appeals for Members (PDF) section of our Administrative Manual for help with submitting joint- or shared-administration member appeals.
This member is enrolled in hospice. Please resubmit claim with Medicare EOB or contact CMS.	The denial on this claim is identified as Medicare Primary. Resubmit the claim along with the Medicare explanation of benefits for further processing.