Detailed answer: what to do first and the full appeal process in Arizona

This section explains the practical steps you should take if a health plan denies a physical therapy (PT) claim because the plan says it was filed late. The guidance below assumes you start with no legal knowledge. It covers how to check whether your plan is regulated under state law or federal (ERISA), how to prepare an appeal, what evidence helps, and what to do if the internal appeal fails.

1. Identify what kind of health plan you have

Why it matters: Some employer group plans are subject to federal ERISA rules, while many individual and small-group plans are regulated by Arizona. The rules for appeals, deadlines, and external review differ depending on which law applies.

• Check your plan documents (Summary Plan Description or Evidence of Coverage). If the document says this is an ERISA plan or refers to a “plan administrator” under ERISA, federal rules likely apply.
• If your plan is a state-regulated individual or small-group policy (including many ACA marketplace plans), Arizona Department of Insurance rules and Arizona law generally govern appeal and external review rights.
• If you are unsure, contact your employer benefits administrator or the Arizona Department of Insurance: https://insurance.az.gov/.

2. Carefully read the denial letter

Insurers must provide a written denial that explains the reason for denial and how to appeal. Note all deadlines and appeal instructions in that letter. Keep the denial in your file.

3. Collect proof the claim was filed on time

Many late-filing denials stem from administrative errors, missing paperwork, or timing misunderstandings. Gather everything that proves timely submission:

• Provider billing records, claim submission confirmations, and transmission reports (electronic acknowledgements or clearinghouse receipts).
• Fax confirmations (with date/time stamps) or certified-mail tracking receipts.
• Patient portal messages, emails, or payment/attachment receipts showing when documents were uploaded.
• Medical records showing date of service and any urgent circumstances that affected timely filing.
• Notes from the provider’s billing office confirming when the claim was sent.

4. Ask the insurer to reopen or reconsider before filing a formal appeal

If you have evidence the claim was submitted on time, contact the insurer’s claims/billing department and request an immediate re-review or reopening of the claim file. Use written communication (certified mail or email if the insurer accepts it) and attach your proof. Keep copies of everything and record phone calls (note date, time, person you spoke with, and what they said).

5. File the insurer’s internal appeal if reopening does not work

Follow the appeal process and deadlines listed in the denial letter and in your plan documents. Typical steps:

• Submit a written appeal letter stating why the denial is incorrect and attach all supporting documents and statements from the provider explaining why filing was timely or why late filing should be excused (for example, provider error, system outage, or extraordinary circumstances).
• If the provider made the error, get a signed billing statement from the provider explaining the error and requesting reconsideration.
• Ask the plan for a copy of the claim file and any documentation they relied on. Under many rules you can review the insurer’s rationale and medical or billing reviews used to deny the claim.
• Submit the appeal within the plan’s stated deadline. If you need more time for a reason you can document (for example, hospitalization or disability), ask for an extension in writing and provide proof; insurers often grant extensions for documented good cause.

6. Argue exceptions and legal theories that may excuse late filing

Common reasons to ask the insurer to accept a late-filed claim:

• Provider error: The billing office submitted incorrectly or to the wrong insurer; include the provider’s attestation and submission logs.
• System or administrative failure: Electronic clearinghouse errors, insurer system outages, or lost mail. Provide technical logs, confirmation screenshots, or affidavits.
• Equitable estoppel or waiver: If the insurer misled you (for example, told you the claim was received when it was not) and you relied on that, you may ask the insurer to waive the deadline.
• Extraordinary circumstances: Hospitalization of the insured, natural disaster, or other factors that prevented timely filing.

7. If the internal appeal is denied: next steps in Arizona

For non-ERISA plans (Arizona-regulated): you may have a right to an independent external review or to file a complaint with the Arizona Department of Insurance. External review is a neutral medical review of the denial and can overturn the insurer’s decision if the reviewer finds the denial was not medically or contractually justified. For general consumer help and complaint submission, use the Arizona Department of Insurance: https://insurance.az.gov/.

For ERISA plans (most large employer plans): federal procedures apply. If the plan’s internal appeals are exhausted and the denial is upheld, your options typically are to request any available external review under the plan or to file a civil lawsuit under ERISA. You can also contact the U.S. Department of Labor’s Employee Benefits Security Administration for guidance: https://www.dol.gov/agencies/ebsa.

8. Time limits and acting quickly

Deadlines matter. If a plan’s denial letter sets an internal appeal period, file within that period or ask in writing for an extension with supporting facts. If you miss internal deadlines on an ERISA plan, courts can be strict about exhaustion rules. For state-regulated plans, Arizona’s rules and the Department of Insurance may provide relief or tolling in some situations. Contact the insurer and the Arizona Department of Insurance quickly to preserve rights: https://insurance.az.gov/.

9. When to get professional help

Consider contacting an attorney if:

• The insurer refuses to accept convincing proof of timely filing and the claim amount is significant.
• The plan is ERISA-covered and you face complex procedural hurdles after an adverse appeal.
• You believe the insurer committed fraud, bad faith, or willful misrepresentation.

If you are unsure whether your plan is ERISA or state-regulated, contact the Arizona Department of Insurance or the Department of Labor for direction: https://insurance.az.gov/ and https://www.dol.gov/agencies/ebsa.

Relevant Arizona resources

• Arizona Department of Insurance (consumer help and complaint filing): https://insurance.az.gov/
• Arizona Insurance Code (general insurance law): https://www.azleg.gov/arsDetail/?title=20
• U.S. Department of Labor, Employee Benefits Security Administration (ERISA guidance): https://www.dol.gov/agencies/ebsa

Important: This article explains the typical process in Arizona. Specific rights and procedures depend on your plan documents and whether federal ERISA rules apply.

Helpful Hints

• Start by making a single organized file (electronic + paper) with the denial letter, claim number, all submission confirmations, provider statements, and all communication notes.
• Ask your PT provider billing manager to take the lead on bill re-submission and to provide a written attestation of what was submitted and when.
• Use certified mail or email with delivery/read receipts when sending appeals or evidence; keep tracking numbers and screenshots.
• Request the insurer’s complete claim file and medical records it relied on; reviewing their file helps you spot weaknesses in their argument.
• If you are nearing an appeal deadline, submit the best evidence you have while you gather additional documentation and explain any ongoing efforts to obtain missing records.
• Keep a timeline of events (dates of service, submission attempts, denial, communications). A clear timeline helps the reviewer see the full story.
• File a complaint with the Arizona Department of Insurance for help with consumer issues: https://insurance.az.gov/.
• For employer-plan complications, contact the DOL EBSA regional office for guidance about ERISA procedures: https://www.dol.gov/agencies/ebsa.
• If you consider a lawyer, look for attorneys who handle health-insurance appeals or ERISA litigation; an initial consult can help you weigh cost vs. benefit.