Delaware — How to Appeal a Physical Therapy Claim Denial for “Late Filing” | Delaware Probate | FastCounsel
Get Matched
DE Delaware Probate

Delaware — How to Appeal a Physical Therapy Claim Denial for “Late Filing”

August 12, 2025 8 min read

How to appeal a denied physical therapy claim that your health plan says was filed late (Delaware)

Short answer: First determine whether your plan is governed by federal ERISA rules (common for employer-sponsored plans) or by Delaware insurance law (more common for individual and fully insured group plans). Gather proof that you filed the claim on time (date-stamped forms, certified-mail receipts, portal timestamps, provider billing records). Then follow the plan’s written appeal process immediately. If the plan denies your internal appeal, ask about an external review or file a complaint with the Delaware Department of Insurance. If the plan is ERISA-governed, you may be able to sue under ERISA §502 only after you exhaust internal remedies. This article explains each step and the rules that typically apply.

Disclaimer

This is educational information and not legal advice. I am not a lawyer. If you need legal advice about your specific situation, consult a licensed attorney.

1. Determine which law governs your plan: ERISA (federal) vs. Delaware (state)

Which procedures and rights you have depends on whether your health plan is an ERISA-governed employee benefit plan or a state-regulated insurance policy:

2. Collect and preserve evidence proving timely filing

Before you appeal, assemble every piece of evidence that shows the claim was filed on time:

  • Claim forms or bill sent to the insurer and the date (print or screenshot of the claim portal timestamp).
  • Proof of mailing: certified mail receipts, FedEx/UPS tracking, or postmark on the envelope.
  • Provider billing statements showing date of service and submission date.
  • Any electronic acknowledgments, claim numbers, or EDI interchange confirmations from the insurer.
  • Medical records showing when treatment occurred and any reason you couldn’t file earlier (if applicable).

3. Read your plan documents closely

Locate the Summary Plan Description (SPD), Evidence of Coverage (EOC), or policy wording. These documents explain the insurer’s claim-submission deadlines, the appeal process, and whether the insurer accepts late claims for “good cause.” Note the exact timelines and required forms or addresses for appeals. If you cannot find the SPD or EOC, ask your employer’s plan administrator (for ERISA plans) or your insurer (for individual policies).

4. Follow the plan’s internal appeal procedure immediately

Most plans require you to file an internal appeal before seeking other remedies:

  • For ERISA-governed plans, federal rules require a meaningful internal appeal process and specific notice content for adverse benefit determinations. ERISA regulations typically require that an adverse benefit determination include the reasons for denial and a description of the plan’s appeal procedure. See 29 C.F.R. §2560.503‑1 for the specific notice and timing rules: https://www.ecfr.gov/current/title-29/subtitle-B/chapter-xxv/part-2560/section-2560.503-1.
  • File the appeal in writing within the plan’s deadline. For ERISA plans the regulation generally requires that you be given a reasonable time to appeal; many plans set 180 days for an appeal of an adverse benefit determination (confirm the SPD/EOC). If your case involves urgent care, the appeal timetable is shorter under the regulation.
  • Include all supporting evidence proving timely filing and a clear statement asking the plan to reverse the late‑filing denial. Ask for a copy of any internal notes, the claim file, and the insurer’s basis for concluding the claim was late.

5. Argue common legal and factual bases to overturn a “late filing” denial

When you appeal, consider raising these points (tailor them to your facts):

  • Proof the claim was submitted on time (show receipts, portal timestamps, provider submission logs).
  • Dispute the insurer’s receipt date if its own records are inconsistent or lack supporting evidence.
  • Point to plan language that allows late filing for reasons beyond your control or for “good cause” (for example, incapacity, provider delay, or insurer misdirection).
  • For ERISA plans, require the plan to comply with 29 C.F.R. §2560.503‑1 notice requirements — an unclear or unsupported denial can be invalid under ERISA procedures.
  • Ask for equitable relief if the insurer contributed to the delay (for instance, wrong address or poor instructions).

6. If internal appeal fails: external review, state complaint, or ERISA lawsuit

Next steps depend on plan type:

  • External review: If your policy is subject to the Affordable Care Act’s external review rules or Delaware’s external review procedures, you may be eligible for an independent external review of the denial. Ask the insurer and the Delaware Department of Insurance whether an external review is available for your case.
  • Delaware Department of Insurance complaint: For state‑regulated policies, you can file a consumer complaint with the Delaware Department of Insurance. They can investigate unfair claim handling and may assist in resolving disputes: https://insurance.delaware.gov/consumers/.
  • ERISA litigation: For ERISA-governed plans, after you exhaust internal appeals you generally may bring a civil action under ERISA §502(a) (29 U.S.C. §1132(a)) to challenge the denial in federal court. See 29 U.S.C. §1132: https://www.law.cornell.edu/uscode/text/29/1132. Note that ERISA has special procedural rules and legal standards; courts often review the plan administrator’s decision under either a de novo or an abuse-of-discretion standard depending on the plan terms.

7. Time is critical — act quickly

Appeal deadlines and opportunities for external review are limited. Preserve all evidence and submit your appeal well before any deadline the plan sets. If you plan to file a state complaint or a lawsuit later, early documentation strengthens your case.

8. Practical checklist (what to file with the appeal)

  • A clear written appeal letter stating the denial date, claim number, date(s) of service, and that you contest the late-filing determination.
  • Copies of the claim submission proof: certified mail receipts, provider submission confirmations, screenshots of portal timestamps, and EDI confirmations.
  • Provider statements or medical records showing treatment dates and billing/transmission dates.
  • Any correspondence from the insurer indicating receipt or earlier communications that suggest the insurer had knowledge of the claim.
  • Contact information and a request for expedited handling if treatment is ongoing or urgent.

9. Sample appeal request points (short checklist for your letter or form)

  1. Identify yourself and the patient, plan name, claim number, dates of service.
  2. State the adverse action you are appealing (denial for late filing).
  3. Summarize evidence showing timely filing.
  4. Request specific relief (e.g., reversal of denial and payment to provider or re-processing of claim).
  5. Request copies of the claim file and any internal notes relied on to deny the claim.

10. When to get a lawyer

Consider consulting an attorney if:

  • You cannot get your insurer to reconsider the claim after you present proof of timely filing.
  • The claim denial involves a large amount of benefits or ongoing, medically necessary treatment.
  • You need help navigating ERISA rules or preparing a civil action under 29 U.S.C. §1132.

Helpful links (Delaware and federal)

Helpful Hints

  • Keep copies of everything you send and receive. Insurers sometimes lose paperwork — your copies matter.
  • Whenever possible, use certified mail or an insurer’s online portal that shows a timestamp and keep screenshots.
  • If a provider filed the claim for you, get a written statement from that provider confirming the date they submitted the claim and how they transmitted it.
  • When you call the insurer, note the date, time, and the name of the representative and confirm by short follow-up email or certified letter summarizing the conversation.
  • Ask the insurer to place your appeal in an “urgent” or “expedited” queue if you have ongoing care dependent on the claim being paid.
  • If your plan is employer-sponsored, the employer’s HR/benefits office can sometimes help resolve administrative errors quickly.
  • File a complaint with the Delaware Department of Insurance if you suspect unfair claim handling by the insurer.

If you want, tell me (1) whether your plan is employer-sponsored or an individual policy, (2) whether you already filed an appeal and the insurer’s response, and (3) any proof you have of when the claim was filed. I can then suggest the next concrete steps and a short appeal outline you can adapt.

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.