How to Appeal a Physical Therapy Claim Denial for “Filed Late” in Colorado

Short answer: Treat the denial notice like an urgent deadline. Read the denial letter for the appeal deadline and the reason given, gather proof that the claim was timely filed (claims forms, date-stamped receipts, provider billing records, electronic submission confirmations), file a written internal appeal promptly, and—if your plan is state-regulated—request external review or file a complaint with the Colorado Division of Insurance if the internal appeal fails. If your plan is an ERISA (self-funded employer) plan, follow the plan’s appeal process and the federal rules that apply to ERISA plans.

Detailed Answer

1. Identify what type of health plan you have

Who administers your plan determines which rules apply:

• State-regulated insured plans (purchased through an insurer) are usually subject to Colorado’s insurance rules and the Colorado Division of Insurance (DOI) external review and complaint procedures. See Colorado Division of Insurance – Appeals and Complaints: https://doi.colorado.gov/consumers/health-insurance/appeals-and-complaints.
• Self-funded employer plans are often governed by the federal Employee Retirement Income Security Act (ERISA). ERISA plans follow federal claims-and-appeals rules and may not be subject to state external review in the same way; the U.S. Department of Labor explains how plan appeals work: https://www.dol.gov/ebsa. The federal regulatory text for claims procedures is at 29 C.F.R. § 2560.503-1: https://www.ecfr.gov/…/2560.503-1.

2. Read the denial letter carefully — it contains critical deadlines and instructions

Your insurer or plan administrator must give a written notice explaining why the claim was denied and how to appeal. That letter should state:

• The reason the claim was denied (e.g., “claim received after timely-filing limit”).
• How to submit an internal appeal or grievance (address, fax, online portal).
• The deadline to file that appeal and any special procedures for urgent/expedited reviews.

If the plan does not give a clear deadline or you think the deadline has passed, act immediately and document your attempts to appeal.

3. Gather documentation that the claim was timely filed

To dispute a late-filing denial you will need proof. Useful items include:

• Copies of the original claim form or billing submitted by your provider.
• Provider records showing when they billed the insurer and what method they used (electronic submit, paper with mailing date, fax confirmation, clearinghouse logs).
• Any electronic confirmations, receipts, or clearinghouse acknowledgments.
• Your explanation of benefits (EOBs) and any correspondence with the insurer.
• Date-stamped mail receipts or screenshots showing the insurer received the documents.

4. File an internal appeal promptly and clearly

Most plans require a written appeal. Keep it concise and include:

• Your name, policy/member ID, claim number, and a short statement that you appeal the denial as untimely.
• The facts that support timely filing (attach the proof you gathered).
• A request for a specific remedy (reprocess the claim, pay the PT provider, or apply a timely-filing exception).
• A request for any available peer-to-peer or clinician-to-clinician review if the denial raised medical-necessity or documentation issues as well.

Send the appeal by a method that gives proof of delivery (certified mail, portal upload with timestamp, or documented fax). Keep copies of everything.

5. Respond to the insurer and use escalation opportunities

If the insurer denies the internal appeal, the denial should explain your next steps. For state-regulated plans, that often includes external review by an independent review organization arranged through the Colorado Division of Insurance. For ERISA plans, the plan’s internal-appeal exhaustion rules and federal limits will control whether you can sue in federal court afterward.

External review and complaints:

• State-regulated plan holders can often request an external review or file a complaint with the Colorado Division of Insurance. Colorado DOI consumer information: https://doi.colorado.gov/consumers/health-insurance/appeals-and-complaints.
• If your plan is ERISA-covered, you typically must exhaust the plan’s internal appeal procedures before filing a lawsuit. For ERISA guidance see the Department of Labor: https://www.dol.gov and the federal regulation at 29 C.F.R. § 2560.503-1: https://www.ecfr.gov/…/2560.503-1.

6. Common defenses to a “late filing” denial you can assert

Arguments that sometimes succeed:

• The provider submitted the claim on time but the insurer lost it (ask insurer for their records of receipt).
• The plan’s timely-filing limit is ambiguous, inconsistent with your policy documents, or not applied uniformly.
• An exception applies (for example, you submitted during a period of incapacity, or the insurer gave incorrect instructions).
• The claim was filed electronically and the insurer’s portal/clearinghouse shows a timely timestamp.

7. If your appeal fails: external review, complaints, and litigation

State-regulated plans: You can often request an independent external review through Colorado’s process. Contact the Colorado Division of Insurance for instructions and forms: https://doi.colorado.gov/consumers/health-insurance/appeals-and-complaints.

ERISA plans: If you have an ERISA plan and you exhaust internal appeals, your next step may be to file a civil action under ERISA in federal court. Timing matters; read the plan’s appeal decision letter closely and consult an attorney about deadlines.

8. Practical timeline and actions to take now

1. Immediately find and read the denial letter to note the deadline for appeal.
2. Contact your PT provider and ask for certified copies of the billing submission and dates.
3. Assemble your written appeal and send it by trackable means before the deadline.
4. If denied on appeal, ask for the specific reason in writing and request information on external review or how to file a complaint with the Colorado Division of Insurance (if applicable).
5. Keep careful records of every call, email, and document.

Helpful Hints

• Do not rely only on verbal promises; always get confirmations in writing.
• Use certified mail or the insurer’s official portal and save timestamps to evidence timely filing.
• Ask your PT clinic to bill again or to submit an appeal on your behalf if they originally billed late due to their error.
• If your plan is ERISA-governed, understand that state insurance external review may not be available; contact your HR department or plan administrator to confirm plan type.
• File a complaint with the Colorado Division of Insurance if the insurer ignores Colorado consumer protections or fails to explain how to appeal: Colorado DOI – Appeals & Complaints.
• Preserve time-sensitive rights: if you suspect litigation may be necessary, contact an attorney experienced with health-insurance appeals or ERISA as soon as practical.

Disclaimer: This article explains general procedures under Colorado and federal rules. It is for educational purposes only and is not legal advice. Laws and deadlines vary by plan and fact pattern. If you need legal advice about your particular situation, consult a licensed attorney.