CVS Caremark Appeal Submission Guide

Watch the video. 

● Click ‘Open Portal’ on opportunity in Pharmacy Marketplace

● Log into the CVS Caremark Portal

Once on home screen

● Appeals Menu (will send you to another screen)

○ Submit Appeals

CVS Caremark will automatically populate pharmacy’s information

● Chain/Affiliation Code

● Your name (will be your login username)

● Pharmacy phone number

● Email Address

Pharmacy will then input data that is listed on Pharmacy Marketplace

*You will be able to copy and paste listed information.

● Claim Bin (dropdown option)

● Date of Fill

○ The date will need to be entered by using the calendar button on CVS portal.

● RX Number

● NCPDP

● PCN

Upload invoice

● Select the red box ‘Upload Invoice(s)’. This will open an action box for pharmacies to upload the invoice that is available on Pharmacy Marketplace.

● Close action box once upload shows attached.

● Attachment will show as attached in the ‘files’ section.

Complete CAPTCHA code

● The code will populate in a black box at the bottom of the page once an invoice is attached. ● Enter the code (caps lock sensitive)

Submit

● The new page will show the confirmation of appeal submission. Copy and paste the confirmation code (ex:..P_xx..).

Appeal successfully submitted through the PBM portal.

Paste confirmation number/appeal ID on Pharmacy Marketplace.

Update opportunity “APPEAL WAS SUBMITTED”

Appeal successfully updated through Pharmacy Marketplace.

Primary Communication Method

● Secure messaging within the CVS Caremark Provider Portal

● Email notifications alert the pharmacy when a new portal message is available Finding Responses on PBM Portal

● Appeal approvals, denials, and reimbursement updates are posted inside the secure portal inbox ● Home page of CVS Caremark Provider Portal

○ ‘Secure Message’ in the top banner

■ Message

○ New page will load showing the internal ‘inbox’

● Determination will be listed under ‘Outcome’ part of the message.

● Note: You cannot reply to this ‘message’ through the inbox.

Documentation & Tracking

● Appeal communications and supporting documentation may be uploaded and maintained within the Pharmacy Marketplace PBM Appeal Tool

● PBM response documentation is not required for internal appeal tracking; however, supporting responses should be retained when escalation or external appeal review is anticipated

External Appeal Consideration

● External appeals commonly require submission of:

○ PBM appeal determination

○ Supporting invoices

○ Prior appeal documentation

● Pharmacies should retain CVS Caremark communications for inclusion with external review submissions.

Required Pharmacy Action

● Monitor portal inbox routinely and track email alerts tied to portal messages.

● Update status of appeal to ‘Record PBM Response’ in Pharmacy Marketplace.

Mark appeals as approved/rejected with the correct PBM response date.

Upload relevant documentation for internal tracking inside the ‘documents’ section for the claim in the Pharmacy Marketplace PBM Appeal Tool

Appeal successfully updated through Pharmacy Marketplace.