Appealing a Health Plan ‘Filed Late' Denial in Arkansas | Arkansas Estate Planning | FastCounsel
Get Matched
AR Arkansas Estate Planning

Appealing a Health Plan ‘Filed Late' Denial in Arkansas

August 12, 2025 7 min read

Detailed Answer

When your health plan denies a claim for physical therapy because it says the claim was filed late, you have a series of steps you can take under Arkansas law and federal rules to try to get the claim paid. The exact process depends on whether your plan is governed by federal ERISA rules (common for employer-sponsored group plans) or by state insurance law (common for individual plans and some small‑employer plans). Follow these steps to preserve your rights and maximize the chance of overturning the denial.

1. Determine which law governs your plan

Look at your plan documents (Summary Plan Description or Evidence of Coverage) or ask your employer/plan administrator if the plan is an ERISA plan. ERISA plans follow federal rules and have specific appeal timing and procedural requirements. State‑regulated plans are subject to Arkansas insurance rules and the Arkansas Insurance Department (AID) consumer protections.

For information about federal ERISA claims and appeals rules, see the U.S. Department of Labor (EBSA) guidance: https://www.dol.gov/agencies/ebsa. For Arkansas insurance consumer resources, see the Arkansas Insurance Department: https://insurance.arkansas.gov/consumer/. You can also review Title 23 (Insurance) on the Arkansas Legislative website for the state insurance code: https://www.arkleg.state.ar.us/.

2. Read the denial notice and your plan’s appeals rules

The insurer must give a written denial (an Explanation of Benefits and an adverse benefit determination). That notice should state the reason (“timely filing”) and tell you how to appeal, including any deadlines, where to send the appeal, and what supporting information is allowed. Note the deadline and method (written, online portal, fax) and calendar the appeal deadline immediately.

3. Gather proof that the claim was filed on time

Collect everything that shows the claim was submitted within the insurer’s time limit:

  • Provider billing records and ledger entries showing date claim was submitted.
  • Electronic submission confirmation or clearinghouse acknowledgements (ANSI 277/999, transmission receipts).
  • Fax confirmation pages showing date/time of transmission.
  • Patient statements showing date of service and date of payment responsibility.
  • Any emails, portal messages, or correspondence with the provider or insurer about claim submission.

4. If you cannot prove timely submission, document why it was late

If the provider or you missed the insurer deadline, collect documentation of the reason. Common acceptable reasons include provider billing errors, administrative delays at the provider office, provider bankruptcy/closing, provider system outages, or the insurer’s failure to supply information required to file on time. Ask the provider to prepare a short affidavit or cover letter explaining the billing timeline and cause of delay.

5. File an internal appeal (first-level appeal)

Submit a written appeal to the plan or insurer following the appeal instructions in the denial notice. Key points:

  • Include claimant name, member ID, claim number, dates of service, provider name and NPI.
  • Explain why the claim should be considered timely (attach proof) or explain the excusable delay with supporting documentation from the provider.
  • Attach medical records or a letter from the treating therapist/physician showing medical necessity, if relevant.
  • Ask for a full reconsideration and specify the remedy you seek (payment of specific claim or reprocessing).
  • Send the appeal by certified mail or another method that creates a delivery record; keep copies of everything.

Timeframes for decisions vary:

6. If the internal appeal is denied, pursue external review or other remedies

After the plan denies the internal appeal, you may have one or more options:

  • State external review / independent review: For many state‑regulated health plans and ACA-compliant plans, you can request an external independent review through the Arkansas Insurance Department. The denial notice should explain whether you qualify and how to request review. Contact AID for details: https://insurance.arkansas.gov/consumer/.
  • Federal external review or ERISA litigation: If the plan is governed by ERISA, review the plan’s final internal decision for information about judicial remedies. If you exhaust administrative appeals required by ERISA, you may be able to file suit in federal court under ERISA § 502(a). For ERISA procedures and appeal rules see DOL/EBSA resources: https://www.dol.gov/agencies/ebsa and the claims-procedure regulation above.
  • File a complaint with the Arkansas Insurance Department: If you believe the insurer applied its timely‑filing rule unfairly or failed to follow Arkansas law, file a consumer complaint with AID: https://insurance.arkansas.gov/consumer/submit-a-complaint/.

7. Consider other practical options

If appeals and external review fail or will take too long, you may negotiate with your provider for reduced patient responsibility, a payment plan, or for the provider to re-bill under different codes or with corrected information. Some providers will absorb part of the cost if the insurer’s timely-filing rule is applied despite clear evidence of good-faith submission.

Example timeline (hypothetical)

Imagine you had a physical therapy session on April 1 and the provider mailed the claim on April 30. The insurer’s timely‑file rule requires claims submitted within 90 days of service and denies a claim on August 1 for late filing. You obtain your EOB and plan documents, gather the provider’s mailing log and a fax confirmation dated April 28, and file an internal appeal by August 20 with that proof. The insurer must review and respond under its stated appeal deadline; if denied again, you request external review through AID or pursue ERISA remedies depending on plan type.

When to get an attorney

Consider talking with a lawyer if:

  • The insurer repeatedly refuses to follow its own appeals rules.
  • You have an ERISA plan and the final denial could justify a federal lawsuit for wrongful denial.
  • The claim is for a large sum and internal/external appeals fail.

An attorney experienced with health-plan appeals or ERISA litigation can advise on procedural strategy and, if needed, represent you in court. If you want help finding counsel in Arkansas, the Arkansas Bar Association lawyer referral service can help you find a suitable attorney.

Important links

Helpful Hints

  • Act immediately. Appeal deadlines can be short. Calendar every deadline and confirm delivery.
  • Keep originals and make multiple copies of all paperwork, medical records, and transmission receipts.
  • Get written statements from the provider explaining when and how they submitted the claim. A provider affidavit or billing supervisor note can be persuasive.
  • Use certified mail, tracked courier, or a submission method that gives you proof of delivery for every appeal step.
  • If you have an ERISA plan, follow the plan’s appeal procedures exactly. Failure to exhaust required internal appeals can block later court claims.
  • Consider asking the provider to re-bill with corrected data (e.g., correct insurer address, member ID, or procedure code) if the denial was due to a technical error.
  • If the denial is part of a pattern (multiple claims denied as late without clear reason), file a complaint with the Arkansas Insurance Department and keep records of all denials.

Disclaimer: This article explains general principles and common procedures under Arkansas and federal rules. It is educational only and is not legal advice. For advice about your specific situation, consult a licensed attorney or the Arkansas Insurance Department.

The information on this site is for general informational purposes only, may be outdated, and is not legal advice; do not rely on it without consulting your own attorney.