I hate telling people sometimes of what goes on as a claims examiner.. many times the difference between paying and denying a claim came down to the mood I was in and the easiness level. Most may not know but examiners are rated on not just quality but production, it was not unheard of to take your daily batch's and break out the easy claims to process first and leave the crap for overtime or after you hit your daily production. The longer you have been there and the better your stats the more administrative authority you had and the higher payment threshold.. for example I was at USLife (now AGI) for 9 years, I had a payment threshold of $75,0000 without going to quality check. Only random claims would go to Quality check and they could be $50 claims. LOL We also had mandatory overtime, so the more we were forced to work the faster we pushed out claims and that would often mean applying something we were taught.. "IF in doubt.. Knock it Out" (claims examiner talk to deny the claim and worry about it on appeal.) I know it's horrible. Not justifying it or excusing it but goes on and I think that's why I've been successful on the other side because I do know these little things. In regards to late filing, again, if the claim had to be looked up, researched and it required a lot of work, I had the administrative authority to deny it based on timely filing, but many times I would go back to some of these claims after my production was hit and then pay a lot of them.. again, it depended on the day!