Express Scripts Appeal Submission Guide

Watch the Video. 

● Click ‘Open Portal’ on opportunity in Pharmacy Marketplace
● Log into the ESI Provider Portal

Once on home screen
● Appeals (will send you to another screen)
● New Appeals Button
○ Top right of screen

Enter Claim Information
● Benefit Provider (dropdown)
○ Express Scripts/Cigna
● Rx Number*
● Date of service*
*You will be able to copy and paste listed information from Pharmacy Marketplace.

Add Claim
● The page will update with ‘Appeal ##--Claim# xx’ below the pharmacy's information box.
○ Expand
● The portal will automatically include your pharmacy’s information and claim information
● Acquisition Cost (ACQ) per unit*
● Desired Reimbursement per unit*
*You will be able to copy and paste listed information from Pharmacy Marketplace.
● Reason for Pricing Inquiry (dropdown)
○ ‘Reason Not Listen’
● Next Button (new screen will populate)

Upload Invoice
● Appeal ID/Claim ID will be available
● Document Upload Button
○ Upload invoice available from Pharmacy Marketplace
● Once uploaded there will be a ‘check mark’ appear

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.

Express Scripts (ESI) — Appeal Communication Process

Primary Communication Method
● ESI Provider Portal notifications
● Automated email confirmations of appeal submission and appeal resolution

Finding Responses on PBM Portal
● Final appeal outcome available within the ESI provider portal
● Home screen of Express Scripts Provider Portal
○ Appeals (will send you to another screen)
○ Bottom of the page, pharmacy can search for an appeal by
■ Appeal number (must include the ‘APMM-’
■ Date of submission
■ Date of Service
○ Status of appeal will be listed on the right
■ In Progress
■ Completed
○ Select appeal (opens new window)
● Resolution of appeal will be explained at the top of the page

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
● 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.

Express Scripts PBM Update – New Batch Appeal Submission Available
Express Scripts has introduced a Batch Appeal Submission option within its portal. This new feature allows pharmacies to submit multiple reimbursement appeals in a single file upload rather than submitting each appeal individually.

Pharmacies may continue using the existing single-appeal process or choose the new batch upload option, depending on which best fits their workflow. Both submission methods remain available.
To support pharmacies using this new feature, we have prepared a step-by-step guide outlining the batch submission process, including completing the Excel template, uploading the batch file, monitoring appeal status, and attaching the required invoices after the appeals have been created.

As with any new workflow, pharmacies should understand the operational differences between the batch and individual submission methods to ensure all required documentation is submitted and appeals are completed successfully.

Express Scripts Batch Appeal Upload Guide

Step 1: Download the Appeals Template
Log in to the Express Scripts appeal portal and select New appeals by file upload.
Download the required Appeals Template Excel file.

Step 2: Complete the Excel Template
Enter one appeal per claim line.

Required fields:
1. Pharmacy NPI
Enter the pharmacy’s 10-digit NPI.
2. Rx Number
Enter the prescription number as 12 digits. Add leading zeros if needed.
3. Date of Service
Enter the claim’s date of service.

Recommended fields to include:
4. Unit Acquisition Cost
Enter the pharmacy’s acquisition cost per unit.
5. Desired Reimbursement
Enter the reimbursement amount the pharmacy is requesting.
6. Reason
Use: MAC Unit Below Cost

Pharmacies can use the claim information shown in the Pharmacy Marketplace PBM Appeals Tool to complete the batch appeal template.

Step 3: Upload the Completed Excel File

Before uploading, check the required box confirming:

“I have read the appeals instructions. My appeals template is ready for upload.”

Upload the completed Excel file.

Once the upload is successful, a confirmation notification will appear. An Appeal ID is not provided
immediately at this stage.

Step 4: Review File Upload History

Go to File Upload History to view pending or successfully uploaded batch files.

Select View All Appeals to see the status and details for the uploaded file.
Once processed, the details will show as successfully submitted.

Step 5: Review Individual Appeals
Each claim will be separated by Rx number and assigned its own confirmation number.

Step 6: Upload the Invoice
Under Actions, upload the supporting invoice for each appeal.
After the invoice uploads, a check mark will appear. The check mark may disappear shortly after upload.

Batch vs. Individual Appeal Submission
Express Scripts now offers pharmacies the option to submit reimbursement appeals individually or through a batch upload process. The choice of submission method is entirely up to the pharmacy.
While the batch upload can reduce the time required to enter appeal information, it also introduces
additional workflow steps that may increase the opportunity for errors. Unlike individual appeal
submissions, pharmacies do not receive an appeal confirmation number immediately after uploading the batch file. Each appeal must first be processed by Express Scripts before a confirmation number is assigned.

Because supporting invoices cannot be attached until the individual appeals are created, pharmacies must return to the portal after the batch file has been processed to upload an invoice for each claim separately. Express Scripts does not currently provide a clear confirmation that an invoice has been successfully attached to an appeal, making it more difficult to verify that all required documentation has been submitted. If an invoice is not attached, the appeal may ultimately be considered incomplete or invalid.

Although completing the Excel template is relatively quick, the overall process may require additional administrative time due to the delay between the batch upload and appeal creation, followed by the need to revisit each appeal individually to upload supporting invoices. Pharmacies should consider these workflow differences when deciding whether the batch or individual submission process best fits their operations.