When an insurance company is not paying your claims, first find out which of three things is happening: the payer never received a clean claim, the payer is holding it for information, or the payer has simply missed its deadline. Medicare and most states set legal deadlines for paying clean claims, and many require interest or penalties when they are missed. Check the claim's status, fix anything that made it unclean, and then escalate in writing, using the payer's own appeal process and, where it applies, the state regulator.
Step 1: confirm the payer actually has a clean claim
- Was it accepted? Check your clearinghouse acceptance report. A claim rejected at the clearinghouse never reached the payer.
- Is it pending for information? Check the payer portal or send an electronic claim status inquiry. Requests for records or coordination-of-benefits updates are often sent by letter and missed.
- Was it sent to the right payer? Plan changes, carve-outs and separate behavioral health or imaging vendors send claims to the wrong place.
- Was the provider effective with that payer on the date of service?
Prompt pay rules generally protect clean claims only, so this step decides whether the clock is even running.
How long payers have to pay a clean claim
| Payer or state | Payment deadline for clean claims |
|---|---|
| Original Medicare | Paid or denied within 30 days of receipt, with interest after that. Medicare also may not pay during a waiting period of 13 days for electronic claims and 26 days for paper claims. |
| New York (state-regulated plans) | 30 days for claims sent by internet or electronic mail, 45 days for paper or fax. Interest applies to late payments. |
| Texas (HMO and PPO plans) | 30 days for electronic clean claims, 45 days for non-electronic, with statutory penalties after the deadline. |
| Florida (health insurers) | Pay, deny or contest within 20 days for electronic claims and 40 days for paper claims. |
| New Jersey (state-regulated carriers) | Pay or deny within 30 calendar days for electronic claims and 40 calendar days for other claims. |
State prompt pay laws apply to state-regulated plans. Self-insured employer plans are generally outside them; New Jersey's regulator, for example, lists self-insurance among the plans its prompt pay rules do not cover. Know the plan type before you escalate.
Step 2: escalate in the right order
- Call and document. Get a reference number, the representative's name and the stated reason.
- Send a written payment appeal or reconsideration request, with proof of receipt of the original claim.
- Use the formal appeal route for denials: for Medicare, a redetermination within 120 calendar days of the initial determination.
- Contact your provider representative for patterns across many claims; contracted providers often have escalation paths in the agreement.
- File a complaint with the state regulator for state-regulated plans that miss prompt pay deadlines, with copies of the claims and proof of receipt.
Eligibility verification (EV), benefits verification (BV), prior authorizations, and denial management at no cost for your first 30 days.
30-Day Free TrialSigns the problem is on your side
- Many claims stuck with the same payer after a plan or address change.
- Claims for a new provider all pending or denying.
- Repeated requests for the same documentation.
- Clearinghouse rejections that nobody is reviewing.
These are fixed upstream, with eligibility checks, credentialing and claim follow-up, not with louder appeals.
What to track every week
- Claims with no payer response after the payer's deadline, by payer.
- Claims pending for information, with the date requested and date sent.
- Late payments where interest or penalties were owed but not paid.
- Appeals filed and their deadlines.
How Sterling Global Solution LLC gets claims paid
We check acceptance on every claim the day it is sent, follow up with each payer on a schedule tied to its deadline, answer information requests the same week, and escalate late clean claims in writing through the payer's appeal route, with proof of timely filing. Old balances that have already aged go through our AR recovery process, and denials through our denial management service. Start with our 30-Day Free Trial.
Frequently asked questions
Why is an insurance company not paying my claims?
How long does Medicare have to pay a clean claim?
Do state prompt pay laws apply to every insurance plan?
What can I do when a commercial plan pays late?
Can you follow up on our unpaid claims?
Sources
Centers for Medicare & Medicaid Services, Medicare Claims Processing Manual, chapter 1, sections 80.2.1.1 (payment ceiling) and 80.2.1.2 (payment floor).
New York Insurance Law, section 3224-a: payment within 30 or 45 days and interest.
Texas Department of Insurance, Prompt Pay FAQ: Texas Insurance Code 843.338 and 1301.103 payment deadlines and penalties.
Florida Statutes, section 627.6131: 20 and 40 day action deadlines.
New Jersey Department of Banking and Insurance, Prompt Pay FAQs: N.J.A.C. 11:22 deadlines and excluded plans.
Code of Federal Regulations, 42 CFR 405.942: Medicare redetermination filing.
Rules differ by plan type and contract. This is general billing information, not legal advice. How we verify this guidance.
Related reading
- AR recovery services. Recovering balances that have already aged.
- Medical billing for New Jersey practices. New Jersey prompt pay appeals in detail.
- Why are insurance claims denied?. When the claim was processed and refused.
- Cutting days in AR. Keeping claims from aging.
Get your claims followed up
Eligibility verification (EV), benefits verification (BV), prior authorizations, and denial management at no cost for your first 30 days.
30-Day Free TrialNo setup fee. No long-term contract.