Why Isn't My Claim Showing in My Appeals Dashboard?

If a claim isn't appearing in your appeals dashboard, don't worry! There are a few common reasons this happens, and most are easy to resolve. Work through the steps below to find out what's going on.

The dashboard defaults to the In Progress view when you first log in. Your claim may actually be there, just under a different status. Try switching the filter to New Eligible or Closed to see if it shows up there.

2. Check the invoice date

The invoice date must be on or before the date of fill. For example, if the invoice is dated 2/26 but the fill date is 2/25, the system sees this as the pharmacy purchasing the drug after it was dispensed, which doesn't meet the legal requirement for substantiating acquisition cost.

3. Confirm the purchase was made through your primary wholesaler

Only purchases made through your primary wholesaler are eligible. Claims tied to purchases from secondary or alternate suppliers won't appear in the dashboard.

4. Verify the RX is a commercial claim

Medicaid claims are not eligible for MAC appeals. This isn't a limitation of Pharmacy Marketplace; it's how the law is structured. MAC appeal rights under most state laws and PBM contracts apply specifically to commercially reimbursed prescriptions. If the RX was adjudicated under Medicaid, it falls outside the scope of what can be appealed through this process.

5. Check that your dispensing data includes both BIN and PCN

Your dispensing records need to include both the BIN and PCN for a claim to be identified and pulled into the dashboard. If one or both values are missing, the claim won't appear. This tends to come up more often for pharmacies using Pioneer. If you're on Pioneer and noticing missing claims, it's worth checking your dispensing export to confirm both fields are populated.

6. Confirm the claim is still within the appeal window

Claims will only appear if they are still eligible for appeal based on state-specific timelines (ex: 7 business days from date of fill in Tennessee).  If the appeal window has passed, the claim will not populate in the New Eligible section.

7. Verify NDC match between claim and invoice

The NDC on the invoice must match the NDC that was dispensed on the claim. If there is a mismatch (even if therapeutically equivalent), the system cannot validate acquisition cost and the claim will not appear.

8.  Verify the RX is with a supported PBM

Pharmacy Marketplace currently supports:

• Express Scripts (ESI)
• CVS Caremark
• OptumRx

Claims processed under other PBMs or discount programs will not appear.

9. Confirm the claim has synced into the system

There may be a delay between dispensing and when data is pulled into the dashboard.
Check the “Last Data Pull” timestamp to confirm your system has been updated. If the fill is recent, allow time for the next sync. Claims are updated every 24 hours. 

10. Check if the claim is already in progress or completed

If a claim has already been:

• Submitted
• Marked In Progress
• Closed

Use filters or search by RX number to locate it.

11. Review for reversals or rebills

If the claim was already reversed and rebilled, it may no longer qualify as a new eligible claim and could be categorized differently in the system. 

Still not seeing your claim?

If you've worked through the steps above and the claim still isn't showing, our support team is happy to help dig into it.

📧 support@pharmacymarketplace.com 📞 1 (800) 958-5540

When you reach out, please have the following ready so we can look into it quickly:

• RX number
• Date of fill
• Pharmacy name / NPI