Fillable Instructions for Filing for and responding to Claims (Department of Technology and Information)

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Instructions for Filing for and responding to Claims (Department of Technology and Information)

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Instructions for Filing for and responding to Claims Arbitration under the Department’s
SB 227/Reg 1319 Arbitration Program
A Provider may request that a Department of Insurance Arbitrator review a claims
reimbursement decision made by an Insurance Carrier (see 18 DE Admin. Code § 1319) ONLY
if:
1. The reimbursement rate is less than the Medicare reimbursement for comparable
physician services;
2.
The patient’s health care plan is an SB 227-qualifying plan (it is an individual plan
issued pursuant to 18 Del.C. § 3342B or a group health insurance plan issued under
18 Del.C. § 3556A; and
3. The claim in dispute involves either primary care or chronic care management
services or both (payment for other services may be contested under other aspects
of the Department’s arbitration program – see the Department’s website for
additional information).
CRITICAL DEADLINES:
Provider application deadline
- within 60 days from the date the Provider receives
notice from the Insurer of a full or partial denial of reimbursement. Failure to
submit the application within the application timeframe will render the Insurer’s
reimbursement decision final.
Insurer response deadline - within 20 days of receipt of the Petition for Arbitration
from the Provider. Failure to do so will result in a summary decision in favor of the
Provider.
Use the checklist ON THE NEXT PAGE to ensure that you have completed each step of the
process. A Provider should submit a separate application for each date of service in
dispute.
Each application must be accompanied by a check or money order in the non-refundable
amount of $75.00. The check or money order must be made payable to “Delaware Insurance
Department.” On the check, list the full name of the insurance company as indicated on the
policy and include the Insurer’s NAIC number.
If you have questions, please call the Department toll free at (800) 282-8611 or for local calls
(302) 674-
7322. You can also send an e-mail to DOI-Arbitration@delaware.gov.
Delaware Insurance Department
Attn: Arbitration Secretary
1351 West North Street, Suite 101
Dover, DE 19904
Application and Response Checklist
SB 227/Reg 1319 Arbitration Program
Checklist for a Medical Services Provider to
petition for arbitration
Checklist for an Insurance Carrier
when responding to a petition for
arbitration
____ 1. Download Regulation 1319 – Form
A-Petition for Primary Care and Chronic
Care Management Services
Reimbursement Arbitration, and fill it out
COMPLETELY.
To find the insurance carrier’s NAIC number, log
on to insurance.delaware.gov, click “for
Business”, click “Active Companies List”, click
“list of
companies.” The NAIC number is listed
after the name of the insurance company.
____1. Download Regulation 1319 – Form B
Response to Petition for Primary Care an
d
C
hronic Care Management Services
Reimbursement Arbitration and fill it out
COMPLETELY.
____ 2. Determine whether the health
insurance plan is an SB 227-qualifying plan
as required in the yellow-highlighted box,
by referring to the notice of payment
determination from the Insurer or by
contacting the Insurer.
____ 2. Be sure to indicate in the yellow-
highlighted box whether the health
insurance plan is an SB 227-qualifying plan.
____ 3. Attach all supporting
documentation to Form A.
____ 3. Attach all supporting
d
ocumentation to Form B.
____ 4. Send one copy of completed Form
A with all supporting documentation to the
Insurer or Insurer’s representative by
certified mail, return receipt requested.
____ 4. Send one copy of completed Form B
with all supporting documentation to th
e
P
rovider or his or her authorize
d
r
epresentative by first class U.S. mail,
postage prepaid.
____ 5. Download and complete Regulation
1319 – Fo
rm C Proof of Service of Papers
Required for Primary Care and Chronic Care
Management Services Reimbursement
Arbitration.
____ 5. Download and complete Regulation
1319 - Form C Proof of Service of Papers
Required for Primary Care and Chronic Car
e
M
anagement Services Reimbursement
Arbitration.
___ 6. Send all of the following to the
Department at the below address:
• Th
e original and one copy of completed Form A
and all supporting documentation;
• The completed Form C Proof of Service; and
• A check or money order in the non-refundable
amount of $75.00 for each date of service in
dispute.
___ 6. Send all of the following to the
Department at the below address:
(the Department may return any non-
conforming Response to the carrier):
• The original and one copy of completed Form B
and all supporting documentation; and
• The completed Form C Proof of Service.
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Instructions for Filing for and responding to Claims (Department of Technology and Information)

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Completed 20 July 2020

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