Loading...Loading...We are currently experiencing an unprecedented volume of appeals, resulting in responses taking more than 30 days from receipt. We require all pre-authorization determination and post-service provider appeals to be submitted via the Appeals application on Availity Essentials.
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.
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.
Please wait up to 60 days after submitting an appeal or administrative denial before requesting a status check or tracer. Duplicate submissions and status checks compound the backlog issue and create extra volume for us. If the appeal was submitted through Availity Essentials, please use the Appeals dashboard to view the status and history of submitted appeals. If the appeal is not in a finalized status, it is still under review.
- Submit all provider appeals through the Appeals application on Availity Essentials.
- Research your denials and only appeal items you feel we did not process correctly according to our reimbursement and medical policies as well as coding and billing rules.
- Use the Clear Claim Connection to research procedure code edits. This will also help you identify if simply appending a modifier (when appropriate ) will resolve the issue.
Allow at least 60 days for the appeal review and outcome.
- Resubmitting the same appeal
- Missing or inconsistent basis for the appeal
- Submitting pricing disputes as provider appeals
- Submitting multiple appeal status checks or tracers
- Appeals comingled with protected health information (PHI)
- Submitting an appeal via multiple channels (e.g., by fax and mail)
- Contacting the Appeals team for questions and general correspondence
Invalid or incomplete appeals (e.g., lack of supporting documentation or records)
The Appeals application is accessed from Availity Essentials: Claims & Payments>Appeals. If you do not have access to the Appeals application, please contact your Availity Essentials administrator and request the Claim Status role.
Appeals can be initiated from the Claim Status screen by selecting Dispute Claim.
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.