Appeal: filed too late
Asks your plan to accept a claim it called late, by showing when it was first sent, quoting the plan's own filing rule, and asking it to apply any exception it contains.
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- A template, not legal advice
This one is for a specific kind of coverage
It is written for the coverage tagged above. If you have a different kind (for example Medicare or Medicaid instead of a job-based or individual plan), it may cite the wrong rules. Check what kind of coverage you have and use the letter written for it.
When to use this, and what it is not
When to use this. Use this when your plan denied a claim as filed after its deadline. The federal sources used here set no filing deadline and no good-cause test, so this appeal depends on your proof of when the claim was sent, on what caused the delay, and on the plan's own wording.
This is a template, not legal advice. Read it, change anything that is not true for you, and send it only when you are satisfied. Your notice and your plan document control.
Fill in the letter
Your letter
[Your name] [Your address]
13 November 2026
[Name and address of the plan's appeals department]
Re: Appeal: filed too late Plan: [Name of the health plan] Member ID: [Member ID] Claim or reference number: [Claim or reference number]
To the reviewer:
I am appealing the decision dated [Date on the denial notice] on claim [Claim or reference number], which denied [The care or drug that was denied] ([Date of the care], [Doctor, hospital or pharmacy]) because the claim was filed too late. I ask you to reverse that decision and process the claim on its merits under [Name of the health plan], member ID [Member ID].
The plan gave this reason: [The reason the plan gave] The plan's filing deadline reads: [The plan's filing deadline, as the plan document words it]
The claim was first sent to the plan on [Date the claim was first sent to the plan]. The proof is: [What proves the claim was sent on that date] The claim was treated as late because: [Why the claim reached the plan after the deadline, or was treated as late]
I ask the plan to do three things. First, tell me the date and the way it says it first received the claim, and send me that record. Second, identify the plan provision it relied on. Third, apply any good cause, exception or extension provision in the plan documents, and accept the claim if the delay came from the plan's own error or from information the plan gave.
Under the federal claims and appeals rules, including Title 29 of the Code of Federal Regulations (CFR), sections 2560.503-1 and 2590.715-2719 (for individual coverage, 45 CFR 147.136), a denial notice must state the specific plan provisions relied on, and I am entitled to a full and fair review. I ask that someone who was not involved in the first decision, and who is not that person's subordinate, decide this appeal and give no deference to the first decision. Please consider every document and comment I send, including anything that was not before the first reviewer.
Please send me your decision in writing within the time the rules allow. If you uphold the denial, I will pursue every further review available to me, including a complaint to the agency that regulates my plan.
Enclosures: 1. Copy of the denial letter or Explanation of Benefits 2. Proof of the date the claim was first sent 3. Letter from the provider's billing office, if I have one 4. Notes of my calls with the plan, if I have them
Sincerely, [Your name]
Before you send it
Send it to the appeals address printed on your denial notice, by a method that proves delivery, such as certified mail with a return receipt or the plan's online portal with a saved confirmation page. Send a copy of the same letter to the provider's billing office. Keep a complete copy of the letter and everything you enclose, and write down the date and the method you used.
What to enclose
- Copy of the denial letter or Explanation of Benefits
- Proof of the date the claim was first sent
- Letter from the provider's billing office, if I have one
- Notes of my calls with the plan, if I have them
What happens next
- Ask the provider's billing office for proof of the first submission now, if you do not have it. Ask them to hold the bill while you appeal.
- Your plan must decide within 60 days after it receives an appeal of a claim for care you have already had. If your plan has two appeal levels, each level gets 30 days. Check the date on your notice, which controls.
- External review covers decisions that involve medical judgment, so a filing deadline denial may not qualify. If the plan says no again, ask the plan, in writing, whether external review is available, and complain to the agency that oversees your plan.
- If you are writing for someone else, tick "I am writing for someone else". The plan may require its own authorization form. See the letter "Name someone to act for you".
The rule behind this
Sources
Denial reasons this answers
- Denial reason
Filed too late
The plan says the claim reached it after its filing deadline. If your provider was supposed to file it, the late filing is usually the provider's problem to fix. Ask for proof of when the claim was sent.