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 is the working table we use for contracted providers at Florida's major payers — with the honesty 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 | Medium — no separate level-2 split confirmed; verify against the provider manual |
| 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 must be complete, because there is 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 is 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 are 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.