Key points
- These three denials are paperwork or status problems, not decisions about your care. The fix is usually proof: of the date the claim was sent, of your other insurance, or of your coverage dates.
- A denial based on a finding that you do not meet the plan's eligibility requirements is not eligible for federal external review. Your options are the plan's appeal, your employer or the Marketplace, and a regulator complaint.
- Often the provider or the employer, not you, has to act first. Ask them in writing and keep the dates.
Three kinds of denial look alike on a letter and are fixed in different ways. “Filed too late” is about the date a claim reached the plan. “Another insurer is primary” is about which plan pays first. “Coverage not active” or “not eligible” is about whether you were covered on the date of service. None of them asks whether you needed the care.
What this means
Filed too late (timely filing). Plans set a window for claims to arrive after the date of service. The plan document says how long. In most cases the provider sends the claim, so the provider’s billing office has to prove when it did. The Arthritis Foundation advises asking for proof of the date the claim was submitted, and says a late-filing error by an in-network provider is not yours to pay for. Ask the provider whether its contract with your plan says anything about late filing.
Another insurer is primary (coordination of benefits). When you have two plans, one pays first and the other pays after. A plan may deny or pend a claim until it knows which is which. The fix is to give both plans the other’s details and the primary plan’s explanation of benefits. See the guide on two plans and continuation coverage under the Consolidated Omnibus Budget Reconciliation Act (COBRA) for the common cases.
Coverage not active (eligibility). The plan says you were not covered on the date of service. The cause may be a missed premium, a change in your job or hours, a waiting period, a late enrollment, or a mistake. Federal external review does not cover a denial based on a finding that you do not meet the plan’s eligibility requirements. The plan’s internal appeal and the regulator are still open to you.
Who acts first. For timely filing, the provider. For coordination of benefits, you (to tell the plans) and sometimes the provider. For eligibility, you and your employer or the Marketplace.
What to do
- Read the denial for which of the three it is. Note the date of service and the date the plan says the claim arrived or your coverage ended. (You.)
- For timely filing, ask the provider for proof of the submission date. Ask for a clearinghouse record, a fax record or a portal confirmation. Ask the billing office to send it to the plan with a request to reprocess. Use the timely filing appeal letter if the plan will not. (The provider, then you.)
- For coordination of benefits, call both plans. Ask each which one it considers primary and why. Give each the other’s details and send the primary plan’s explanation of benefits to the secondary plan. (You.)
- For eligibility, gather proof of coverage. Collect enrollment confirmations, premium payment records, your insurance card and pay stubs that show deductions. Ask your employer’s benefits office for the dates it reported to the plan. Ask the plan for the date and reason it says coverage ended and for the notice it sent you. (You and your employer.)
- File the plan appeal. Employer and non-grandfathered individual plans must allow at least 180 days after you receive the denial. Check the date on your notice, which controls. (You, or the provider with your permission.)
- Complain to the regulator if the plan will not move. For an insured plan, the state insurance department. For a self-funded employer plan, the federal Department of Labor. (You.)
- Ask the provider to hold the bill while you resolve it. (You.)
What the plan may say, and what to say back
“The claim was received after our filing limit.” Ask for the filing limit in the plan document and the date it says it received the claim. Ask the provider for proof of the earlier submission and send it.
“Another plan is primary.” Ask which plan and what information it holds. Ask the other plan to confirm in writing. Send each plan the other’s explanation of benefits.
“You were not eligible on the date of service.” Ask for the date and reason coverage ended and for the notice it sent. Send your proof of payment and enrollment. If the plan cancelled coverage back to an earlier date, see when coverage is cancelled retroactively.
The rule
A denial based on a finding that the person does not meet the plan’s eligibility requirements is not eligible for the federal external review process. 29 Code of Federal Regulations (CFR) 2590.715-2719
Watch for
- Marketplace eligibility is a separate appeal. A decision about enrollment or premium tax credits is appealed to the Marketplace, generally within 90 days of the eligibility notice. See the Marketplace eligibility appeals guide.
- Medicaid eligibility. The state must generally send notice at least 10 days before it ends coverage. A few exceptions allow less time. The hearing deadline is a reasonable time not to exceed 90 days from the date the notice was mailed, so take the number from your notice. If you ask for a hearing before the action date, services generally continue. See the Medicaid appeals guide.
- Do not let the filing limit run on a corrected claim. Once a billing mistake is fixed, resubmit quickly.
What next
- Whose job is it to fix this?: who has to act on each kind of denial.
- Two plans and COBRA: how coordination of benefits works.
- When coverage is cancelled retroactively: if the plan went back in time.
- Billing and paperwork topic page: all related guides and letters.