Short answer

If your insurer denied a physical therapy (PT) claim as “filed late,” act quickly: confirm who governs your plan (state-regulated vs. ERISA/self-funded), gather proof of timely submission, file the plan’s internal appeal (with a clear explanation and supporting documents), and, if needed, pursue external review or file a complaint with Connecticut regulators or a federal ERISA action. Connecticut has consumer help resources that can assist you through these steps.

Detailed answer — step-by-step

1. First: find out which rules apply to your plan

Plans fall into two basic groups:

• ERISA / self-funded employer plans: These are governed by federal ERISA rules. ERISA limits state regulation of claims procedures and gives you a federal route for litigation in some cases. See the U.S. Department of Labor for general ERISA guidance: https://www.dol.gov/agencies/ebsa. The federal claims-procedure regulation is at 29 C.F.R. §2560.503-1: https://www.ecfr.gov/current/title-29/subtitle-B/chapter-XXV/part-2560.
• State-regulated / fully insured plans: Connecticut insurance law and the Connecticut Insurance Department oversee these plans. If your plan is fully insured, you can use Connecticut regulatory complaint processes and state external-review options. File complaints or get consumer help through the Connecticut Insurance Department: https://portal.ct.gov/cid/Consumers/File-a-complaint, and you can also contact the Connecticut Office of the Healthcare Advocate for assistance: https://portal.ct.gov/oha.

2. Collect the documents you’ll need

Before you appeal, assemble everything that supports your claim:

• Explanation of Benefits (EOB) showing the denial code and insurer’s receipt/received date.
• The provider’s claim submission records (electronic submission logs, fax confirmations, certified mail receipts, billing portal timestamps).
• Copies of the claim form, superbill, and patient account statements.
• Clinical notes or therapy records showing dates of service and medical necessity.
• Your plan’s Summary Plan Description (SPD) or evidence of coverage that explains filing deadlines and appeal procedures.

3. Read the denial notice closely

Look for these key items on the letter:

• Exact reason for denial (e.g., “claim received after filing deadline”).
• Date the insurer says it received the claim and the deadline it used.
• Instructions for filing an internal appeal, including where to send it and the deadline for filing the appeal.

4. File the plan’s internal appeal promptly

Most plans require a written internal appeal as the first formal step. Make the appeal focused and document-based:

1. Identify yourself: name, member ID, provider name, claim number, date(s) of service.
2. State that you are appealing the denial and request that the insurer reconsider because the claim was timely filed (or, alternatively, that the insurer waive the filing deadline for good cause).
3. Attach supporting evidence: proof of submission, logs, medical records, and any communications with the provider or insurer that show timely filing or justify an exception.
4. Explain any good-cause reason for late filing if applicable (provider billing error, administrative mistake, serious illness, confusion caused by insurer, technical failure of the insurer’s portal, etc.).
5. Send the appeal by a method that creates a receipt (certified mail, courier with tracking, or a portal upload that gives a timestamp). Keep copies of everything.

Check your plan documents or denial letter for the appeal deadline. For ERISA plans, federal rules commonly allow up to 180 days to file an internal appeal for post-service claims — see 29 C.F.R. §2560.503-1 for details: https://www.ecfr.gov/current/title-29/subtitle-B/chapter-XXV/part-2560. State‑regulated plans will have their own timelines in the plan contract or state law.

5. What to expect after you file the internal appeal

Insurers have set timeframes to decide appeals. These timeframes vary (urgent claims move faster). If the plan is state‑regulated and you do not get a timely response, you can file a complaint with the Connecticut Insurance Department. If the plan is ERISA, the federal regulations specify the maximum response time for appeals — check the SPD or the regulator links above.

6. If the internal appeal is denied (or you get no response)

Your options depend on plan type:

• State-regulated plan: You can pursue external review or file a complaint with the Connecticut Insurance Department. The Insurance Department can review whether the insurer followed Connecticut rules and may order corrective action or mediation. File a complaint here: https://portal.ct.gov/cid/Consumers/File-a-complaint.
• ERISA plan: The external-review options state agencies offer may not apply. After exhausting the plan’s internal procedures, your next remedy may be to consult an attorney about filing a civil action under ERISA in federal court. Contact the U.S. Department of Labor or an ERISA attorney for guidance: https://www.dol.gov/agencies/ebsa.

7. Get help from Connecticut consumer resources

For state-regulated plans, the Connecticut Office of the Healthcare Advocate (OHA) helps consumers understand options, file appeals, and work with insurers: https://portal.ct.gov/oha. The Connecticut Insurance Department accepts complaints and enforces insurer practices: https://portal.ct.gov/cid/Consumers/File-a-complaint.

8. When to talk to an attorney

Consider legal help if:

• The amount denied is large or would cause significant financial hardship.
• Your appeal was denied and you face limited regulatory or administrative options (common with ERISA plans).
• The insurer clearly ignored its own rules or deadlines and internal appeals and regulator complaints don’t resolve the issue.

Helpful hints

• Act immediately. Preserve evidence of when the claim was submitted and when you learned of the denial.
• Always request an appeal in writing and keep copies. Use certified mail or upload to the insurer’s portal if possible.
• If the provider billed late, ask the provider to send a corrected claim and a written statement explaining why it was late.
• Document any communications with the insurer or provider: dates, names, and a short summary of what was said.
• Use consumer resources. The Connecticut Office of the Healthcare Advocate can help you prepare appeals and contact the carrier: https://portal.ct.gov/oha.
• If your plan is employer-sponsored, ask HR for the Summary Plan Description (SPD) and whether the plan is self-funded (ERISA) or fully insured.
• Request a written acknowledgement from the insurer that it received your appeal.
• Ask for a “good cause” or equitable exception if circumstances beyond your control delayed filing (medical emergency, system outages, provider error).

Sample points to include in your appeal letter

• Member name and ID number, provider name, claim number(s), and date(s) of service.
• Brief statement: “I request review of the denial that states the claim was filed late. Attached is proof the claim was submitted on [date] or an explanation of the delay.”
• List of attached documents (submission confirmation, bills, notes, provider statement).
• Request that the insurer either process the claim or waive the filing deadline for good cause.
• Contact information for follow-up and request for a written decision and explanation of rights to further appeal or external review.