Filed too late

What it means

Plans set a time limit for receiving a claim. The plan says yours came after it. The limit is not set in the federal rules this site relies on. It appears in your plan document and, for an in-network provider, in the provider’s contract with the plan. Ask the plan in writing for the limit, the date it received the claim, and where it states the rule.

Late filing is usually decided on dates and records, not on medical facts. That makes proof the main thing.

Who has to act first

If an in-network provider filed the claim, the provider has to act. The Arthritis Foundation advises asking for proof of the submission date, and says the error is not the patient’s to pay for. Triage Cancer says late claims are often the in-network provider’s responsibility. Whether the provider may bill you at all depends on its contract and your plan, so ask both in writing before you pay anything.

If you filed the claim yourself, for example for care from an out-of-network provider, the proof is yours to gather.

If the plan sent a denial notice, you have at least 180 days after you receive it to appeal, for a job-based plan or a non-grandfathered individual plan (check the date on your notice, which controls). Medicare, Medicaid, TRICARE, Veterans Affairs and federal employee plans have different, often shorter, deadlines. Do not let the provider’s talks with the plan run past that date.

Arguments that work

• Proof the claim was sent in time. An electronic acceptance report, a clearinghouse confirmation, a fax confirmation, or a certified mail receipt with a date.
• An earlier version was sent in time. If the first claim went in on time and was rejected for an error, ask whether the plan counts the date of that first submission.
• The delay was not the sender’s fault. If you or the provider were waiting on the plan or on another insurer, say so and ask whether the plan allows exceptions. The other insurer problem has its own page.
• The plan’s own words. The notice must name the plan provision it relied on. Ask for the exact wording and the date it received the claim.
• The provider’s responsibility. Ask the plan and the provider in writing whether the provider’s contract bars billing you for a claim it filed late.

Evidence to gather

• The denial notice or Explanation of Benefits (you).
• The plan’s filing limit and its record of the date received (the plan, in writing).
• The provider’s submission records and acceptance reports (your provider).
• Your own proof if you filed: copies and receipts (you).
• Records of any delay by another insurer or the plan (you).
• Your call log (you).

What to send

Ask the provider’s billing office to send the plan its proof of the submission date with an appeal, and to copy you. If you filed yourself, send your own appeal with your proof. Ask the plan to reprocess at in-network rates if the provider is in network, and ask the provider in writing to hold the bill until the plan answers; it is not required to, and an unpaid bill can go to collections, so ask before you withhold any payment.

When this is not worth an appeal

If you sent a claim yourself long after the plan’s limit, with no record of when you sent it and no reason for the delay, an appeal has little to work with. Ask the provider about a self-pay price and hospital financial assistance, and ask whether the plan will make an exception.