Notes on payer behavior
Appeal deadlines at Florida's major payers: the working table (2026)
Every denial play starts with the same question: is the claim still alive? Here's the working table we use for contracted providers at Florida's major payers, with the caveats the subject requires. Payer manuals are inconsistent. Contracts can shorten windows. And the deadline printed on the EOB is the one that counts.
Read this first: verify every window against your own participation agreement and the remittance in hand. The printed deadline on the EOB or provider remittance advice controls over anything in this table, and contracts may shorten these windows (UnitedHealthcare's guide says so explicitly).
The working table: contracted providers, days to dispute
| Payer | First step | Second step | Confidence note |
|---|---|---|---|
| Florida Blue | Reconsideration: 1 year from the remittance date (prerequisite for appeal) | Administrative appeal inside the same 1-year window | High on the clock: the manual and the October 2023 form both say one year from the remittance date. The manual says one review level; the form makes reconsideration a prerequisite. Clinical and coding appeals use a different form and P.O. box. The Florida Blue profile |
| UnitedHealthcare | 12 months from the EOB/PRA date, a combined window: reconsideration and appeal must both land inside it | High (admin-guide language) | |
| Aetna | Reconsideration: 180 days from the initial decision (underpayments route here too) | Appeal: 60 days from the reconsideration decision (one appeal level only) | High |
| Cigna | 180 days from initial payment or denial | Single internal level; the next stop is arbitration per contract | High |
| Humana | ~120 days from remittance | 60 days from the level-1 decision | Medium. The 120 is a working assumption from a regional document; national number unconfirmed, so read your contract |
| Medicare FFS | Redetermination: 120 days from receipt of the remittance (+5-day mail presumption) | QIC reconsideration: 180 days → ALJ: 60 days | High (federal regulation) |
| Workers' comp (all carriers) | DFS petition: 45 days from receipt of the EOBR (one state regime, not a payer appeal) | High; see the WC note | |
Two payer-specific traps. Cigna is one shot. The single internal appeal has to be complete, because there's no second bite before arbitration. And UHC's combined window means a slow reconsideration eats the appeal clock behind it.
Medicare reopenings: the underpayment workhorse
Separate from the appeals ladder, Medicare contractors can reopen a determination: within one year for any reason, within four years for good cause, and any time for clerical-error corrections. For fee-for-service underpayments this path survives long after the 120-day redetermination window closes. It's the standing route for stale Medicare shortfalls.
Medicare Advantage splits by contract status. Contracted disputes follow the payer's contract and manual (the rows above). Non-contracted providers get the federal track: 60 days from receipt, with a signed waiver-of-liability form.
The statutory backstop
For underpayments (paid-but-short claims, as opposed to denials) Florida law adds a floor no contract can remove: 12 months from the payment date on fully-insured business, with 12% interest, under §627.6131 and §641.3155. That window outlives the Aetna, Cigna, and Humana rows above. Which is why stale short-pays get positioned as statutory claims rather than late appeals. Full treatment in the 12-month rule note; the surrounding clocks are in the prompt-pay guide.
What the table implies for triage
- Denials older than ~4 months are already dead at Humana and dying at Aetna and Cigna, but still alive at UHC and Florida Blue. Work the soonest-expiring dollars first.
- Underpayments on fully-insured business stay alive 12 months everywhere; Medicare FFS underpayments a year via reopening.
- Timely-filing denials are their own discipline. The date math and the proof hierarchy are in the CO-29 note.
- Workers' comp never waits: 45 days from EOBR receipt, then the petition path closes.