Short Answer

In North Carolina, you typically start with an internal appeal to your health plan and then, if the plan is state-regulated, you may request an independent external review through the procedures your plan provides. Deadlines are short and strictly enforced. To overturn a “filed late” denial, you must show the claim was timely or that there is a good-cause exception under the plan, supported by proof (for example, submission receipts or provider attestations).

How North Carolina Law Applies

North Carolina law gives many consumers in fully insured health plans the right to a multi-step appeal process. Your plan documents control the exact steps and deadlines. A denial for “timely filing” usually argues the claim wasn’t submitted within the plan’s filing window (for example, 90–180 days). You can challenge that by showing the claim was filed on time (clearinghouse confirmations, fax/email logs, or insurer portal screenshots), or by explaining a valid reason for late filing that your plan recognizes (such as insurer or provider error, missing information the plan failed to provide, or events beyond your control).

Map it to your situation: if your physical therapy provider billed, ask for their proof of submission and rejections. If you filed yourself, gather your transmission receipts. If the plan’s denial letter doesn’t cite the exact plan provision or doesn’t explain how it calculated the deadline, request those plan terms and a detailed explanation in writing.

Key Requirements

• Know your plan type: fully insured (regulated by the North Carolina Department of Insurance) or self-funded (governed by federal law; appeal rights still apply but differ).
• Get the “adverse benefit determination” letter; it should state the specific reason for denial and the appeal deadlines.
• File a written internal appeal on time (often within 180 days of the denial) and include evidence that counters the “late filing” reason.
• If you lose the internal appeal on a state-regulated plan, request an external, independent review within the deadline stated in your plan (commonly short—act fast).
• Preserve a complete record: claim forms, PT notes, referrals/prescriptions, submission logs, EOBs, insurer portal screenshots, and correspondence.

Process & Timing

1. Request documents: Ask your plan for the Summary Plan Description (SPD), the full plan certificate/policy, and any utilization review or timely-filing rules it relied on.
2. Collect proof of filing: From your PT provider and any clearinghouse, obtain claim transmission reports, re-submission logs, insurer portal confirmations, and denial codes/explanations.
3. Internal appeal (first level): Submit a concise written appeal by the deadline stated in the denial (often 180 days). Explain why the claim was timely or why a plan-approved exception applies. Attach evidence.
4. Second-level internal appeal (if offered): Many plans offer another internal review. Use it if available and add any missing documents.
5. External review (if eligible): For many state-regulated plans, you can request an independent external review after the final internal denial. The request window is short (often around 120 days in many plans). Follow your plan’s instructions precisely and include the complete record.
6. Agency help: If your plan is fully insured, you can also contact the North Carolina Department of Insurance Consumer Services for help understanding procedures and options. If your plan is self-funded through an employer, federal remedies may apply.
7. Consider legal options: If administrative avenues are exhausted and the amount at issue is significant, speak with an attorney about next steps, including potential litigation deadlines.

What the Statutes Say

• North Carolina Insurance Code (Chapter 58): Sets statewide rules for state‑regulated health plans, including claims processing and consumer grievance rights. Your specific appeal rights and deadlines depend on your exact plan type and policy language.
• Note: Employer self-funded plans are primarily governed by federal law. Procedures and deadlines can differ from state-regulated plans. Always follow the appeal instructions in your denial letter and plan documents.

Exceptions & Pitfalls

• Missed deadlines: Appeal windows are short. If you miss them, your claim may be barred. File early and keep proof of delivery.
• Provider vs. member submissions: Sometimes the provider must appeal on your behalf. Coordinate so only one complete, timely appeal is sent with all evidence.
• Incomplete records: External reviewers and courts rely on the written record. Include all documents with your appeal; don’t assume reviewers will “look it up.”
• Vague denials: If the denial lacks the exact plan section or calculation used, write and request a detailed explanation and the governing plan terms before your appeal deadline runs.
• Good-cause exceptions: Plans may allow exceptions to timely-filing rules for documented reasons (e.g., insurer system errors, lack of required information, or events outside your control). You must ask and prove it.
• Wrong forum: Some plans require you to finish internal appeals before an external review or lawsuit. Jumping ahead can get your case dismissed.

Helpful Hints

• Ask your PT clinic for clearinghouse and insurer-portal proof that the claim was submitted and for any rejection/no-response reports.
• Request claim histories and call logs from the insurer; keep your own call notes with dates, names, and reference numbers.
• Send appeals by a trackable method and keep copies of everything you submit.
• If the denial letter is missing details, promptly request the specific plan language and how the insurer calculated the filing deadline.
• If you have a fully insured plan, the North Carolina Department of Insurance Consumer Services can explain procedures and help you understand options.

Talk to a Personal Injury Attorney

If you’re dealing with a “filed late” health insurance denial for needed physical therapy, our firm has experienced attorneys who can help you understand your options and timelines. Call us today at 919-313-2737.

Disclaimer: This article provides general information about North Carolina law based on the single question stated above. It is not legal advice for your specific situation and does not create an attorney–client relationship. Laws, procedures, and local practice can change and may vary by county. If you have a deadline, act promptly and speak with a licensed North Carolina attorney.